BEDSIDER IN HEALTH CENTERS /
From 2012-2013, Power to Decide (formerly The National Campaign to Prevent Teen and Unplanned Pregnancy) collaborated with the National Family Planning and Reproductive Health Association (NFPRHA) and American Congress of Obstetricians and Gynecologists (ACOG) to fund clinics and providers to explore how Bedsider.org may improve the operation of family planning health centers and patients’ contraceptive use. Sites used a range of methodologies to explore and evaluate the implementation of Bedsider. Below are highlights from those projects and project descriptions from each site.
While the research methodologies for many of the studies don’t allow for determinations of causality, many clinics saw improvements during the period they implemented interventions with Bedsider.
- No-show rates: The Center for Health and Prevention of San Luis Obispo County’s Center for Health and Prevention, a NFPRHA site who used Bedsider for method and appointment reminders, found their no-show rates were 3.6%, compared to 13% for the same quarter the previous year. HCCMS Family Health Services in Iowa saw a declining no-show rate from 21% to 15% after Bedsider implementation.
- Use of and interest in LARC: Cincinnati Health Department Reproductive Health and Wellness Program, a NFPRHA site, found that only about 30% of the sample was using LARC before the visit, and more than 60% of the sample was using LARC after the visit in which they were introduced to Bedsider. At Health Imperative sites in Boston, more women requested a LARC during the Bedsider intervention, compared to the same period the previous year. And ACOG fellows at Wake Forest Baptist Health found that more women indicated they were interested in LARC after postpartum contraceptive counseling using Bedsider than before the intervention.
- Reductions in exam times: At Flathead Community Health Center, the average patient spent 57 minutes during an initial physical exam, compared to 69 minutes before the use of Bedsider.
- Patient and provider reactions: All sites that included patient focus groups or surveys found that patients responded favorably to Bedsider. Multiple sites reported that women felt Bedsider was easy to access, presented positive, helpful information, and found the content empowering and reliable.
The Center for Health and Prevention of San Luis Obispo County’s Center for Health and Prevention (CAPSLO) (San Luis Obispo, CA)
The Center for Health and Prevention began using Bedsider at two clinic sites in order to improve contraception continuation and decrease the number of missed appointments. CAPSLO created Bedsider information cards and established kiosks in the check-in area where patients could interact with Bedsider. CAPSLO introduced Bedsider through clinic information cards at a range of community events—including outreach to local colleges, drug and alcohol services, and a local farmer’s market. Clinicians or medical assistants taught patients one-on-one how to use Bedsider for method and appointment reminders either on the clinic kiosks or their own web-enabled devices.
CAPSLO surveyed patients who had been introduced to Bedsider at the clinic and found that 60% had used Bedsider. Of those who visited Bedsider, 97% created an account and 89% used the reminder system for appointments, methods, or both.
CAPSLO compared appointment no-show rates for the period they implemented Bedsider and found rates were lower—3.6% no shows, compared with 13% for the same period the previous year. Staff felt that Bedsider likely contributed to the decline, and found Bedsider was particularly helpful for patients returning for 3-month STI recheck visits.
Cincinnati Health Department Reproductive Health and Wellness Program (Cincinnati, OH)
Cincinnati Health Department (CHD) promoted the use of Bedsider in their Federally Qualified Health Centers in conjunction with services provided by its Title X funded program. They provided iPads to patients to explore Bedsider and utilized paper versions of a Bedsider catalogue that included descriptions of contraceptive methods. CHD trained a nurse practitioner and a medical assistant to use the Bedsider catalog with patients. Staff explained the services available from Bedsider, and then assisted patients with setting up appointment and method reminders.
CHD surveyed patients after their visit to ask about their use of the Bedsider materials during the visit. 87% of participants said they used some of the materials, with the majority using the catalog provided by clinic staff. 80% of participants said the materials were helpful. Only about 30% of the sample was using Depo Provera, Implant or an IUD before the visit, and more than 60% of the sample reported using one of those methods after the visit. Although it is difficult to attribute causality to Bedsider, staff believed that access to information on Bedsider was helpful in encouraging contraception use.
Flathead Community Health Center/Family Planning Services (Kalispell, MT)
Flathead Family Planning integrated Bedsider materials into the clinic by providing iPads in the exam room and during patient intake and education sessions. Medical assistants showed patients Bedsider.org and encouraged them to browse the site before meeting with the Nurse Practitioner. The clinic educator also utilized Bedsider.org during intake and when discussing birth control choices. Over 90% of patients who used Bedsider reported their use of Bedsider helped them feel more prepared for their visit with the Nurse Practitioner.
Staff compared outcomes from the period in which Bedsider was implemented to the same period the previous year and found:
- 89% of women who had not been using a form of birth control started using one, compared to 83% the previous year.
- The average patient spent 57 minutes during an initial physical exam, compared to 69 minutes the previous year.
- 67% of patients returned for their follow-up birth control supply appointments, compared to 61% the previous year.
HCCMS Family Health Services (Harlan, IA)
HCCMS Family Health Services implemented use of the Bedsider.org website with the goal of increasing long acting reversible contraception (LARC) use and clients’ knowledge about available contraceptive methods. They promoted Bedsider.org through posters and handouts at the clinic and provided iPads to patients in order to set up text message and email-based birth control reminders. They used the Method Explorer on the website to promote contraceptive methods counseling.
While the clinics did not see significant changes in women’s selection of more effective methods of contraception, they did see an improvement in no-show appointment rates. In the six months before using Bedsider, the clinic had a no-show rate of 21%, declining to 15% during the Bedsider intervention. Clients who signed up for Bedsider said the appointment reminders helped them keep their appointments.
Planned Parenthood Association of Utah (Salt Lake City, UT)
Planned Parenthood of Utah provided patients with iPads with access to Bedsider at two clinics. Additionally, they installed televisions in the waiting room that ran video and content from Bedsider on a continuous loop. Patients were surveyed on a range of factors related to birth control and satisfaction with the clinic visit. Fifty seven percent of patients responded that the website was extremely helpful in their decision of what birth control method to use. The clinics didn’t find significant changes in women’s selection of effective contraception, except for teens who visited the clinic for an abortion. The clinic found that LARC use for this group increased from 36% in the previous quarter to 50% for the quarter when the clinic was using Bedsider.
Health Imperatives (Brockton, MA)
Health Imperatives implemented Bedsider at nine clinic sites by integrating an introduction to the Method Explorer as part of their clinic visits. Sites introduced patients to Bedsider during the initial appointment scheduling and offered a text reminder when the appointment was scheduled. When women arrived to their appointments, staff provided an iPad that allowed them to visit the Bedsider Method Explorer. At the end of the exam, staff offered text reminders for follow-up appointments and for birth control reminders, if appropriate. All clinic sites saw an increase in requests for LARC from the same quarter the previous year—148 women requested a LARC, compared to 104 the previous year.
Planned Parenthood of Southern New England (PPSNE) (Old Saybrook, CT)
PPSNE referred patients to Bedsider’s Method Explorer when they called to set up their appointments, and provided iPads for patients to explore Bedsider in the clinic. Of the 43 women who were referred to Bedsider, eight signed up for appointment reminders, and 17 signed up for birth control reminders.
PPSNE found that many of their young adult patients were already satisfied with their current method of birth control, and the majority in need of contraceptive counseling were young women, ages 15 to 17. Rather than introduce teens to Bedsider, staff referred them to StayTeen, which includes more age-appropriate contraceptive information. Staff reported that teens found the website helpful and expressed interest in more StayTeen materials.
University of Rochester Medical Center (Rochester, NY)
Investigators: Sarah Betstadt and Amy Harrington
Researchers at University of Rochester Medical Center studied how exposure to Bedsider changes women’s knowledge of emergency contraception (EC) knowledge compared to an educational pamphlet. Fifty women were randomly assigned to either the pamphlet or use of Bedsider on an iPad. Both groups completed pre- and post-intervention surveys of their knowledge and attitudes about EC. While both educational interventions significantly improved women’s knowledge, Bedsider was more effective at increasing women’s knowledge.
Researchers also introduced OBGYNs and other providers in the University of Rochester MedicalCenter system to Bedsider and the educational pamphlet. Ninety-nine percent of providers found Bedsider helpful (compared to 80% of providers who read the pamphlet), and 87% would recommend Bedsider to patients (compared to 69% for the pamphlet).
Wake Forest Baptist Health (Winston-Salem, NC)
Investigator: Jennifer Bromley
At Wake Forest Baptist Health, researchers studied how Bedsider might improve postpartum contraceptive counseling. Thirty-nine women were counseled about contraception using Bedsider on an iPad after their delivery and were counseled on the risks of short inter-pregnancy intervals. The patients completed a survey in the hospital before the counseling and were asked to complete a second survey at their 6-week postpartum visit.
After the counseling with Bedsider, 72% of women indicated they were interested in LARC, compared to only 33% before the counseling. Only 36% of patients returned for their follow-up visit 6-weeks after delivery, but 100% of those returning women chose a LARC. Unfortunately, not all of the women had insurance and some were unable to afford LARC.
The researchers found that contraceptive counseling was challenging with postpartum patients because they were busy with their newborn, and recommended including counseling in routine prenatal visits and improving access to LARC methods for immediate postpartum placement in the hospital prior to discharge.
Bridgeview Women's Health (Portland, OR)
Investigator: Carrie Frederick
Bridgeview originally planned to utilize Bedsider as part of their contraceptive counseling. While the practice’s providers initially agreed to use Bedsider, once the project was ongoing, only one of the physicians and the nurse practitioner actually used Bedsider for contraceptive counseling with their patients with 15 women during the six-month study period. Although their LARC placement rates increased compared to the previous six months (37 LARC compared to 30), the small number of women exposed to the Bedsider make it difficult to attribute the change to exposure to Bedsider. Providers did not use Bedsider in many of the visits because patients were already well informed about different methods and were coming to the office to obtain a specific method. Generally, the providers who used the website felt it was a useful tool and patients were glad to find a trustworthy source of information about contraceptive methods.
Women's Center at Yale–New Haven Hospital (New Haven, CT)
Investigator: Greg Gressel
Researchers utilized focus groups with separate groups of providers and patients from an urban, Medicaid-based clinic that cares for an at-risk population of young women. The focus groups indicate that patients and providers may have conflicting opinions about Bedsider. Generally, patients reported that the website was informative, interactive, and easy to use. They identified with the “real stories” and videos and found the content empowering and reliable.
Staff and providers in the clinic were less optimistic about the ability of the website to meet the needs of patients. Although many providers liked the visual appeal of the website, they were concerned that the website was too complicated for patients, used too much slang, and was written at too high of a reading level. Furthermore, they felt the website did not empower women but rather provided “racy” material.
The researchers concluded that the most noteworthy finding was that providers may be out of touch with patients and their contraceptive counseling needs. The discrepant perspectives between patients and providers regarding the legitimacy, appropriateness, usability, applicability, and empowerment of Bedsider may be an indication that while providers’ intentions are good and they believe they are providing adequate information in a professional way, that this may not be what patients want or need.
Johns Hopkins Bayview Medical Center (Baltimore, MD)
Investigator: Roxanne Jamshidi
Researchers at Johns Hopkins conducted a study to test the effect of exposure to Bedsider during a clinic visit on contraceptive choice. Women who were visiting the clinic for gynecologic care were randomly assigned to either receive a tablet with Bedsider or Google search as the home page. Women in both groups were given a Bedsider information card. One month after the visit, patients completed an online survey about their use of Bedsider and contraceptive choices. Although only half of the women were randomized to the Bedsider home page group, at the follow-up, over 95% of all the patients had actually visited Bedsider. This is likely because the printed materials about Bedsider that patients received may have encouraged women in the control group to visit the website as well. As a result, researchers were unable to determine if exposure to the Bedsider website influence contraceptive choices. Researchers are conducting a follow-up study to test their original hypothesis where the control group will not be given any Bedsider materials.
University Health Service (UHS) (Madison, WI)
Investigator: Mary Landry
The aim of this study was to improve access to contraception by using Bedsider to help students learn about birth control options and help with their decision-making prior to seeing a contraceptive counselor. UHS included a link to Bedsider on their website accessible to all visitors. They also emailed the link to all patients who had a contraceptive services appointment, and gave patients who were scheduled for an IUD insertion to have an “electronic” consultation directing them to Bedsider, or an in-person consultation. Finally, any student who didn’t review Bedsider in advance of their contraceptive appointment was given an opportunity to explore the site on a tablet in the exam room.
Generally, the clinic saw a substantial increase in the number of contraceptive service visits (846 visits in the fall of 2012 vs. 557 visits the previous fall), which may be the result of having Bedsider on the clinic’s website. The clinic also increased the rate of IUD consultations (13% of contraceptive visits compared to 8% the previous year). Although women who made appointments were sent information about Bedsider in advance of their appointments, only 25% went to the website before their appointments. However, during or after their appointment 74% of women had visited the site.
Seven providers completed an online survey about their experiences using Bedsider were patients and all of them said the website was helpful for improving practice, particularly for patients selection of a method, motivating patients to use contraception, education on potential side effects, and how to use a method. All of the providers recommended that other college health services implement Bedsider in their practices.
NYU/Bellevue Hospital (New York, NY)
Investigator: Amitasrigowri Murthy
Researchers at NYU/Bellevue hospital conducted focus groups to determine how Bedsider might be used for Spanish-speaking populations. While the researchers were challenged to recruit participants for the focus group, the resulting groups did provide valuable information in informing how the website might be adapted and the most useful ways to improve uptake in Spanish-speaking populations. Generally, participants had very favorable attitudes towards the website. In particular, they liked the methods section; although they wished there was more information on side effects and would like to see more videos with Latino/as. They also wanted to see more content targeting men and agreed that a section about domestic violence would be helpful.
Indiana Department of Corrections (Indianapolis, IN)
Investigator: Ami Rice
This project evaluated the use of Bedsider.org with women prior to their release from the maximum security Indiana Women’s Prison (IWP). An OBGYN provided small group teaching sessions for the women, introducing them to Bedsider and related content to facilitate a discussion of contraceptive methods.
Although the majority of women who had release dates during the period of the study were able to participate in the educational classes, limited contraceptive supplies were available. A Title X clinic near the prison provides some limited contraceptive care, but there is often insufficient time and resources to meet the needs of the women prior to their release. In collaboration with prison staff and administrators, the investigators developed a plan to provide consistent services and expand options to include IUD placement, but the insurance provider for the prison offenders was not willing to cover the expense, viewing contraception as “non-essential” care.
Medical University of South Carolina (Charleston, SC)
Investigators: Ashlyn Savage and Angela Dempsey
Researchers at Medical University of South Carolina (MUSC) conducted a randomized control trial examining whether use of reminders was more effective if initiated by patients with clinic staff or if women signed up on their own. Women were randomly assigned to an intervention or control group. Both groups were introduced to Bedsider on an iPad during their initial visit to the clinic. Clinic staff discussed the specific sections of the website using a script, and all patients were given a Bedsider.org postcard with information about the site. In addition to the Bedsider orientation, the Intervention group received additional help from clinic staff to initiate the reminder tool for their specific method of birth control (the pill, patch, ring, or shot). At baseline, over 95% of participants felt Bedsider was easy to use and 98% felt it seemed helpful. Visits for women in the intervention group took, on average, 3 minutes longer to facilitate the reminder signup. Staff followed up by phone with both groups three months after their visit and found no differences between the groups in their satisfaction with contraceptive care or whether or not they accessed Bedsider since their initial visit. However, women in the intervention group who signed up for the reminders at their visit with the help of staff were significantly more likely to be receiving reminders three months after their visit (47%) compared to the Control group (28%).
Walter Reed National Military Medical Center (Bethesda, MD)
Investigator: Scott Martin Peterson
Project: Randomized trial comparing Bedsider with classroom-based contraceptive counseling
Boston University Medical Center (Boston, MA)
Investigator: Sarita Sonalkar
Project: Randomized trial to test whether Bedsider improves LARC uptake among women seeking abortion and provider focus groups to evaluate Bedsider as a counseling tool