Chatbots That Deliver Contraceptive Support: Systematic Review.

BACKGROUND: A chatbot is a computer program that is designed to simulate conversation with humans. Chatbots may offer rapid, responsive, and private contraceptive information; counseling; and linkages to products and services, which could improve contraceptive knowledge, attitudes, and behaviors. OBJECTIVE: This review aimed to systematically collate and interpret evidence to determine whether and how chatbots improve contraceptive knowledge, attitudes, and behaviors. Contraceptive knowledge, attitudes, and behaviors include access to contraceptive information, understanding of contraceptive information, access to contraceptive services, contraceptive uptake, contraceptive continuation, and contraceptive communication or negotiation skills. A secondary aim of the review is to identify and summarize best practice recommendations for chatbot development to improve contraceptive outcomes, including the cost-effectiveness of chatbots where evidence is available. METHODS: We systematically searched peer-reviewed and gray literature (2010-2022) for papers that evaluated chatbots offering contraceptive information and services. Sources were included if they featured a chatbot and addressed an element of contraception, for example, uptake of hormonal contraceptives. Literature was assessed for methodological quality using appropriate quality assessment tools. Data were extracted from the included sources using a data extraction framework. A narrative synthesis approach was used to collate qualitative evidence as quantitative evidence was too sparse for a quantitative synthesis to be carried out. RESULTS: We identified 15 sources, including 8 original research papers and 7 gray literature papers. These sources included 16 unique chatbots. This review found the following evidence on the impact and efficacy of chatbots: a large, robust randomized controlled trial suggests that chatbots have no effect on intention to use contraception; a small, uncontrolled cohort study suggests increased uptake of contraception among adolescent girls; and a development report, using poor-quality methods, suggests no impact on improved access to services. There is also poor-quality evidence to suggest increased contraceptive knowledge from interacting with chatbot content. User engagement was mixed, with some chatbots reaching wide audiences and others reaching very small audiences. User feedback suggests that chatbots may be experienced as acceptable, convenient, anonymous, and private, but also as incompetent, inconvenient, and unsympathetic. The best practice guidance on the development of chatbots to improve contraceptive knowledge, attitudes, and behaviors is consistent with that in the literature on chatbots in other health care fields. CONCLUSIONS: We found limited and conflicting evidence on chatbots to improve contraceptive knowledge, attitudes, and behaviors. Further research that examines the impact of chatbot interventions in comparison with alternative technologies, acknowledges the varied and changing nature of chatbot interventions, and seeks to identify key features associated with improved contraceptive outcomes is needed. The limitations of this review include the limited evidence available on this topic, the lack of formal evaluation of chatbots in this field, and the lack of standardized definition of what a chatbot is.

Chatbots to Improve Sexual and Reproductive Health: Realist Synthesis.

BACKGROUND: Digital technologies may improve sexual and reproductive health (SRH) across diverse settings. Chatbots are computer programs designed to simulate human conversation, and there is a growing interest in the potential for chatbots to provide responsive and accurate information, counseling, linkages to products and services, or a companion on an SRH journey. OBJECTIVE: This review aimed to identify assumptions about the value of chatbots for SRH and collate the evidence to support them. METHODS: We used a realist approach that starts with an initial program theory and generates causal explanations in the form of context, mechanism, and outcome configurations to test and develop that theory. We generated our program theory, drawing on the expertise of the research team, and then searched the literature to add depth and develop this theory with evidence. RESULTS: The evidence supports our program theory, which suggests that chatbots are a promising intervention for SRH information and service delivery. This is because chatbots offer anonymous and nonjudgmental interactions that encourage disclosure of personal information, provide complex information in a responsive and conversational tone that increases understanding, link to SRH conversations within web-based and offline social networks, provide immediate support or service provision 24/7 by automating some tasks, and provide the potential to develop long-term relationships with users who return over time. However, chatbots may be less valuable where people find any conversation about SRH (even with a chatbot) stigmatizing, for those who lack confidential access to digital devices, where conversations do not feel natural, and where chatbots are developed as stand-alone interventions without reference to service contexts. CONCLUSIONS: Chatbots in SRH could be developed further to automate simple tasks and support service delivery. They should prioritize achieving an authentic conversational tone, which could be developed to facilitate content sharing in social networks, should support long-term relationship building with their users, and should be integrated into wider service networks.

A Systematic Review of Apps using Mobile Criteria for Adolescent Pregnancy Prevention (mCAPP).

BACKGROUND: Adolescents in the United States and globally represent a high-risk population for unintended pregnancy, which leads to high social, economic, and health costs. Access to smartphone apps is rapidly increasing among youth, but little is known about the strategies that apps employ to prevent pregnancy among adolescents and young adults. Further, there are no guidelines on best practices for adolescent and young adult pregnancy prevention through mobile apps. OBJECTIVE: This review developed a preliminary evaluation framework for the assessment of mobile apps for adolescent and young adult pregnancy prevention and used this framework to assess available apps in the Apple App Store and Google Play that targeted adolescents and young adults with family planning and pregnancy prevention support. METHODS: We developed an assessment rubric called Mobile Criteria for Adolescent Pregnancy Prevention (mCAPP) for data extraction using evidence-based and promising best practices from the literature. mCAPP comprises 4 domains: (1) app characteristics, (2) user interface features, (3) adolescent pregnancy prevention best practices, and (4) general sexual and reproductive health (SRH) features. For inclusion in the review, apps that advertised pregnancy prevention services and explicitly mentioned youth, were in English, and were free were systematically identified in the Apple App Store and Google Play in 2015. Screening, data extraction, and 4 interrater reliability checks were conducted by 2 reviewers. Each app was assessed for 92 facets of the mCAPP checklist. RESULTS: Our search returned 4043 app descriptions in the Apple App Store (462) and Google Play (3581). After screening for inclusion criteria, 22 unique apps were included in our analysis. Included apps targeted teens in primarily developed countries, and the most common user interface features were clinic and health service locators. While app strengths included provision of SRH education, description of modern contraceptives, and some use of evidence-based adolescent best practices, gaps remain in the implementation of the majority of adolescent best practices and user interface features. Of the 8 best practices for teen pregnancy prevention operationalized through mCAPP, the most commonly implemented best practice was the provision of information on how to use contraceptives to prevent pregnancy (15/22), followed by provision of accurate information on pregnancy risk of sexual behaviors (13/22); information on SRH communication, negotiation, or refusal skills (10/22); and the use of persuasive language around contraceptive use (9/22). CONCLUSIONS: The quality and scope of apps for adolescent pregnancy prevention varies, indicating that developers and researchers may need a supportive framework. mCAPP can help researchers and developers consider mobile-relevant evidence-based best practices for adolescent SRH as they develop teen pregnancy prevention apps. Given the novelty of the mobile approach, further research is needed on the impact of mCAPP criteria via mobile channels on adolescent health knowledge, behaviors, and outcomes.

Mobile Phone Apps for the Prevention of Unintended Pregnancy: A Systematic Review and Content Analysis.

BACKGROUND: Over 50% of pregnancies in the United States are unintended, meaning that the pregnancy is mistimed, unplanned, or unwanted. Unintended pregnancy increases health risks for mother and child, leads to high economic costs for society, and increases social disparities. Mobile phone ownership is rapidly increasing, providing opportunities to reach at-risk populations with reproductive health information and tailored unintended pregnancy prevention interventions through mobile phone apps. However, apps that offer support for unintended pregnancy prevention remain unevaluated. OBJECTIVE: To identify, describe, and evaluate mobile phone apps that purport to help users prevent unintended pregnancy. METHODS: We conducted an extensive search of the Apple iTunes and Android Google Play stores for apps that explicitly included or advertised pregnancy prevention or decision-making support in the context of fertility information/tracking, birth control reminders, contraceptive information, pregnancy decision-making, abortion information or counseling, sexual communication/negotiation, and pregnancy tests. We excluded apps that targeted medical professionals or that cost more than US $1.99. Eligible apps were downloaded and categorized by primary purpose. Data extraction was performed on a minimum of 143 attributes in 3 domains: (1) pregnancy prevention best practices, (2) contraceptive methods and clinical services, and (3) user interface. Apps were assigned points for their inclusion of features overall and for pregnancy prevention best practices and contraceptive information. RESULTS: Our search identified 6805 app descriptions in iTunes and Google Play. Of these, 218 unique apps met inclusion criteria and were included in the review. Apps were grouped into 9 categories: fertility trackers (n=72), centers and resources (n=38), birth control reminders (n=35), general sexual and reproductive health (SRH) information (n=17), SRH information targeted specifically to young adults (YA) (n=16), contraceptive information (n=15), service or condom locators (n=12), pregnancy tests (n=10), and games (n=3). Twelve apps scored at least 50 points (out of 94) for overall number of features and at least 15 points (out of 21) for contraceptive information and pregnancy prevention best practices. Overall, 41% of apps did not mention any modern contraceptive methods and 23% mentioned only 1 method. Of apps that did mention a modern contraceptive method, fewer than 50% of these apps provided information on how to use it. YA SRH apps had the highest percentage of pregnancy prevention best practices in each app. Demographic and interface evaluation found that most apps (72%) did not target any race and only 10% explicitly targeted youth. Communication interface features were present in fewer than 50% of apps. CONCLUSIONS: This review identified several useful, evidence-based apps that support the prevention of unintended pregnancy. However, most apps miss opportunities to provide users with valuable information, interactive decision aids, and evidence-based interventions for unintended pregnancy prevention. Further, some apps in this space may increase the likelihood of unintended pregnancy due to the low effectiveness of the contraceptive methods promoted.