Since 2017, people in Canada have had the choice between medical and surgical options for early abortion care. The options are comparably safe and effective, but differ on other attributes. We developed an online patient decision aid (PtDA) to support evidence-based, values-aligned choice between medical and surgical care for early abortion.
We followed recommendations for the inclusion of users in the development of PtDAs and the International PtDA Aid Standards Collaboration systematic development process. The initial prototype was based on Canadian clinical practice guidelines and expert review. The prototype was refined according to two initial phases of user testing involving 30-60 minute interviews with assigned-female-at-birth participants. Interviews were subjected to thematic analysis and the results were used to iteratively revise the PtDA. In the third phase of user testing, assigned-female-at-birth community members and health professionals involved in abortion care evaluated the PtDA online using an online survey that assessed its comprehensibility, appropriateness, and usability. Survey questions included the System Usability Scale (SUS), a usability questionnaire adapted from our previous reproductive health PtDA studies, and open- and close-ended questions to identify strategies for implementing the PtDA.
Phase 1 user testing included 7 participants who were 31-37 years old, Hispanic, Black, Chinese, Southeast Asian, or White, college or university educated, and parous. Key changes included shortened format, resources links, and updates of user-important attributes (e.g., pain, travel time). Phase 2 user testing included 4 participants with a history of abortion who were 26-38 years old, White, and college or university educated. Key changes included support to find an abortion provider, and personalised information based on contraindications and values. Phase 3 user testing included 25 community members of whom 20% disclosed a previous abortion, and 25 health professionals who were primarily family physicians or nurse practitioners. The mean SUS score was 86.06 (SD=8.61) among community members and 79.38 (SD=11.95) among health professionals, indicating excellent and good usability respectively. Whereas community members generally found the PtDA to be concise, comprehensive, and easy to understand, a minority of health professionals felt that it would be complex for users. All participants recommended including additional information about locating an abortion provider, anticipated costs of methods, psychological supports available, and follow-up care. In both participant groups, 92% felt that the tool would be appropriate for use before meeting with a health care professional. The resulting PtDA included: screening questions for contraindications, a grid comparing options, explicit and interactive values clarification, the 4-item SURE test to screen for decision conflict, and a summary page to facilitate shared decision making. We also added a “Leave” button to ensure that users could leave the PtDA quickly to protect their privacy.
Community members and health professionals considered the online PtDA a usable tool for choice of method of early abortion. Future research will examine the implementation of the PtDA into the care pathway and whether its use leads to improvement in decision quality for people seeking early abortion.Kate Wahl PtDA poster