Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To evaluate the effectiveness of interventions using social networking sites to promote the uptake and adherence of contraception in women of reproductive age.
Background
Description of the condition
Contraception is a key public health intervention due to the negative impact of unwanted pregnancies on women's and children’s health (Cleland 2012). Appropriate use in the population can play a key role in reducing the rates of maternal mortality and abortion, as well as improve perinatal outcomes and child survival (Cleland 2012). Unplanned pregnancy can increase the risk of adverse family socioeconomic outcomes and family dysfunction (Boden 2015).
Globally rates of contraception usage vary; the United Nations (UN) reported that an average of 64% of married or in‐union women of reproductive age use some form of contraception. The rates of contraception use are highest (75%) in North America and the lowest (33%) in Africa. The UN identified that around one in 10 married or in‐union women worldwide are estimated to have an unmet need for family planning (UN 2015). Of particular note, the unmet need in the adolescent age group results in teenage pregnancies complicated by increased levels of morbidity and mortality, higher rates of abortion and “set the pattern for the rest of an individual’s life” (WHO 2004). Contraception use and adherence in this age group is varied; a USA study found an average delay of approximately one year between the onset of "coital activity and the use of modern contraceptives" (McCauley 1995). Resolving this unmet need for women who do not want to have children but are not using contraception is therefore a vital global public health measure (Alkema 2013; Gold 2011).
Reports from the USA show that 74% of internet users use social networking sites (SNSs), with 18 to 29 year olds being both the heaviest users and more likely to use SNSs on their mobiles (Pew Research Center 2013). Similarly, in the UK 81% report using social media daily, with 44% of 16 to 24 year olds visiting sites more than 10 times a day (Ofcom 2015). Globally, SNS usage continues to grow with worldwide internet users spending 106 minutes daily (Statista 2015). Their use as a health intervention has become increasingly championed (Gold 2011; Guse 2012), and the popularity, widespread accessibility and ease of use makes them a key vehicle for health interventions.
Description of the intervention
With the rapid expansion of social networking sites (SNSs), SNSs are now considered a component of daily life (Gold 2012; Xu 2012). Boyd 2007 defined SNSs as web‐based services that allow individuals to construct a public or semi‐public profile within a bounded system. They can be used to articulate with a list of other users with whom they share a connection, and view and traverse their list of connections and those made by others within the system (Boyd 2007).
There are a variety of SNSs with the focus ranging from social utility, such as Facebook; microblogging, such as Twitter; to business, such as LinkedIn. Facebook is considered the most popular (Gold 2012), and is the third most popular webpage worldwide with Twitter, LinkedIn and Instagram also in the top 25 (Alexa 2016). The definition of social media is broad and can include a diverse set of platforms; for this review we will focus on SNSs that are unique in that they require the creation of a social profile within a bounded system that allows users to share connections (Boyd 2007) .
SNS interventions are run in various ways, with many studies using them as an add‐on to the standard treatment. Whilst their use is highly advocated by some (Gold 2012; Korda 2013), others argue that social media is insufficient as a stand‐alone for health promotion and pose a risk of providing misleading or inaccurate information (Balatsoukas 2015). A study on contraception used a Facebook account as an adjunct to in‐office counselling and found improved participant contraceptive knowledge and increased preference for long‐acting reversible contraceptives (Kofinas 2014). Another study that aimed to reduce the display of risky sexual behaviour sent a physician email to targeted Myspace users and showed a reduction in reported risky sexual behaviour (Moreno 2009). A large multidisciplinary study called the The FaceSpace Project used fictional interactive characters to present sexual health promotion messages (Nguyen 2013).
How the intervention might work
Interventions run on SNSs can be broadly categorised as follows.
Interventions that create an account that participants chose to interact with. This can be an account created with the aim of health promotion. Generally we would expect this to be an open account that users choose to follow or receive ongoing posts or discussions.
Interventions that create an account and directly contact participants through private messages or ‘emails’. In this approach the intervention would actively recruit participants and use private messaging or in‐app email to directly target users of the SNSs.
Interventions that create character accounts that participants can chose to follow or interact with. These interventions will pose as an active account that generate a following, or interact with users in live‐time to deliver the intervention.
Interventions that do not use an intervention account to deliver health promotion. By discussion or sharing information in groups or networks the intervention may be carried out without any direct user contact and rely on peer‐effect instead.
Interventions run on SNSs may work in isolation to educate or counsel participants or in adjunct to other interventions. They should aim to initiate or improve uptake of contraception methods and/or improve adherence.
In understanding how the intervention might work, the motivational theory is commonly used to describe the use of social media with intrinsic motivation characterised by the "hedonic" enjoyment of using it, in addition to the extrinsic motivations of utilitarian gratification and perceived usefulness (Xu 2012). The extrinsic motivations were expanded on to explain that the network externality came from the number of members, number of peers and perceived similarity, which all interplay in the continued use of social media (Lin 2011). Thus use of SNS is a complex interplay of network externalities, usefulness and enjoyment (Lin 2011).
Why it is important to do this review
The unmet need for contraception is unresolved especially in young women where unplanned pregnancy is associated with significant socioeconomic implications (Cleland 2014; UN 2015; WHO 2004). Women use SNSs more often and more extensively than their male counterparts (Ofcom 2015). The value of SNSs as a health intervention has been highlighted (Gold 2012; Guse 2012), and a comprehensive meta‐analysis that explored the effect of SNS health interventions on non‐communicable diseases found a positive effect on health related behaviour outcomes (Laranjo 2015). Gold 2011 reviewed the link between SNSs and sexual health promotion and found a positive response.
We have not found any literature that explored the impact of SNS interventions on the uptake of contraception specifically, and we argue that the breadth of sexual health promotion is too wide a topic to be able to adequately assess interventions. We will focus on SNSs as opposed to the umbrella term of social media as it can encompass a variety of platforms with various accessibility and target audiences. By narrowing the scope and focusing solely on SNSs we can assess the impact of SNS interventions on the use and adherence of contraception and comment on the needs for future research.
Objectives
To evaluate the effectiveness of interventions using social networking sites to promote the uptake and adherence of contraception in women of reproductive age.
Methods
Criteria for considering studies for this review
Types of studies
We will consider interventional studies including randomised controlled trials (RCTs) and non‐randomised studies (NRS) to include non‐RCTs. We expect limited evidence from RCTs that utilise a social networking site (SNS) as an intervention; hence the inclusion of NRS will broaden the evidence base to enable us to review the topic more thoroughly.
Types of participants
We will include women of reproductive age in this review without any geographical restrictions. Participants may be initiating contraceptive use, switching to a different method, or continuing use of the same method. Participants may also include women who are postpartum or post‐abortal.
Types of interventions
We will include studies where the intervention was delivered either solely via named SNS, or in adjunct with another method. The purpose of the intervention must be to improve use of, or adherence to, contraception compared to standard delivery of care or another intervention.
The included interventions should seek to fulfil one of the following aims.
To improve uptake of contraception.
To promote use of specific contraceptive method.
To improve adherence to contraception.
Interventions may be targeted at both current and potential contraception users. Interventions must be delivered through named SNSs where the participant has a personal account that allows them to accesses the intervention. Although it is not an exclusion criteria, we would expect selected SNSs to have a way for participants to interact with each other as well as the intervention. We will exclude any intervention delivered by an app or website where a personal account is not required, where the intervention can only be utilised when downloaded, or if participants cannot interact with the intervention directly. We will include SNSs available in a downloadable form only if they also have an open‐access website.
Types of outcome measures
Primary outcomes
Contraception use (for three months after the intervention was initiated), to include the following.
Initiation of a new method.
Improved adherence to a method.
Increased uptake of long‐acting reversible methods.
Contraception use can be assessed in various ways and we will accept the method used by the trial investigator.
The time frame for assessment will be three months or more for the initiation of a new method, improved adherence and continuation of an existing method.
Secondary outcomes
We will include outcomes regarding a change in attitude or knowledge about contraception. Also we will include outcomes regarding attitudes towards the use of SNSs as an intervention, the format of the intervention and how trustworthy participants felt it was.
Search methods for identification of studies
Electronic searches
We will search for eligible studies in the following databases. Searches will start from 1997, which is when the first SNS (according to the definition we outlined earlier) was created (Boyd 2007). Please refer to the search strategies for the complete list of search terms (Appendix 1).
Medical databases
The Cochrane Central Register of Controlled Trials (CENTRAL).
MEDLINE.
Embase.
Multidisciplinary databases
Cumulative Index to Nursing and Allied Health Literature.
Web of Science.
Computing databases
Association for Computing Machinery (ACM).
DBPL computer science bibliography.
Trial registers
US National Institutes of Health register http://www.clinicaltrials.gov.
The World Health Organisation International Trials Registry Platform search portal http://www.who.int/trialsearch/Default.aspx.
Searching other resources
We may write to the contact investigators of identified and included studies to request additional information about the study or, where appropriate, to identify any additional trials. We will hand search reference lists of relevant trials and systematic reviews retrieved by the database searches. We will review abstracts of key sexual and reproductive health conferences. We will contact national organisations and topic experts, where appropriate, to obtain information about trials not identified by the search strategy.
Data collection and analysis
Selection of studies
We will assess for inclusion all titles and abstracts identified during the literature search. We will export the search results into a bibliographic citation management software programme and we will remove duplicates. Two review authors will independently screen the titles and abstracts of studies retrieved. We will retrieve full‐text articles for further assessment if the information given suggests that the study meets the following criteria.
Includes participants that are women of reproductive age and users, or potential users, of contraception.
Has an intervention delivered by a SNS as a stand‐alone intervention or as an adjunct with another method.
Compares the intervention to routine standard of care or another intervention.
If there is any doubt regarding these criteria from the information in the title and abstract, we will retrieve the full‐text article for clarification. Two review authors will assess the full‐text articles of potentially eligible studies. We will resolve any discrepancies by discussion or by consulting the third review author. We will list all studies that we exclude after full‐text assessment in a 'Characteristics of excluded studies' table with their reasons for exclusion. We will construct a PRISMA diagram to illustrate the study selection process.
Data extraction and management
Two review authors will independently extract data from each of the included trials. We will create a 'Summary findings' table using GRADEproGDT 2014 and import it into RevMan 2014 upon completion. The 'Summary findings' table will record general information about the included studies as well as the study characteristics, the SNSs the studies used, the risk of bias (described further below) and outcomes. We will focus on the primary and secondary outcomes for this review and we will resolve any discrepancies through discussion.
Assessment of risk of bias in included studies
We will assess the risk of bias in each included study in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For RCTs we will examine sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other potential biases. For NRS we will use the GRADE 'Risk of bias' framework (Guyatt 2011), which will report on the eligibility criteria, measurement of exposure, measurement of outcome, confounding and attrition rates.
Two review authors will independently assess the risk of bias of each included study. We will resolve any disagreement through discussion.
Measures of treatment effect
For dichotomous outcomes we will determine the odds ratios and 95% confidence intervals (CIs). For continuous variables we will calculate the means difference with 95% CIs.
Unit of analysis issues
The unit of analysis will be the individual female of reproductive age. In cluster‐randomised studies we will assess whether the study authors have appropriately adjusted for clustering.
Dealing with missing data
Due to the varied nature of possible interventions we do not expect all included studies to have addressed all the outcomes we are examining, nevertheless in case of missing data, we will contact the primary study investigators to request this. If we are unable to access the data we will assume the data is missing at random. Where we make any assumptions about missing data, we will report the potential impact in the ’Discussion’ section of the review.
Assessment of heterogeneity
The studies are likely to be of variable designs so it is very unlikely we will be able to conduct a meta‐analysis. We will visually examine heterogeneity by comparing study design, target population and primary outcome measure.
Assessment of reporting biases
We aim to minimise reporting bias by using a comprehensive search strategy. If an included study insufficiently reports on an outcome measure, we plan to contact the study authors to obtain this information. If there is a sufficient number of studies for any outcome, we will use a funnel plot to identify possible reporting biases.
Data synthesis
We expect high heterogeneity in the studies so it is very unlikely we will be able to conduct a meta‐analysis. We will construct a 'Summary of findings' table for the different types of studies and assess the risk of bias based on the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For RCTs and for NRS we will use the GRADE approach to assess the quality of the evidence (Guyatt 2011).
Subgroup analysis and investigation of heterogeneity
We will conduct subgroup analyses based on study type (randomised or non‐randomised). Heterogeneity will be examined visually as described above.
Sensitivity analysis
We will undertake any analysis as appropriate, including repeating the analyses excluding unpublished or low‐quality studies if there are sufficient number of trials.
Acknowledgements
We thank Potenza Atiogbe for her help in creating the search strategy.
Appendices
Appendix 1. Search strategies
| Search strategy | |
| Search terms | |
| CENTRAL | |
| 1 | CONTRACEPTION/ EXP |
| 2 | CONTRACEPTION BEHAVIOUR/ EXP |
| 3 | CONTRACEPTIVE AGENTS/ EXP |
| 4 | CONTRACEPTIVE DEVICES/ EXP |
| 5 | FAMILY PLANNING SERVICES/ EXP |
| 6 | Contracept* |
| 7 | Condom* |
| 8 | Contraceptive agent |
| 9 | Barrier contracepti* |
| 10 | Family planning |
| 11 | Emergency contracept* |
| 12 | Intrauterine contracept* device* |
| 13 | Postcoital contracept* |
| 14 | Or 1‐13 |
| 15 | SOCIAL MEDIA/ |
| 16 | Social Media |
| 17 | Social network* |
| 18 | |
| 19 | |
| 20 | |
| 21 | Snapchat |
| 22 | Myspace |
| 23 | Or 15‐22 |
| 24 | 14 AND 23 |
| MEDLINE | |
| 1 | CONTRACEPTION/ EXP |
| 2 | CONTRACEPTION BEHAVIOR/ |
| 3 | CONTRACEPTIVE AGENTS/ EXP |
| 4 | CONTRACEPTIVE DEVICES/ |
| 5 | FAMILY PLANNING SERVICES/ |
| 6 | CONDOMS/ |
| 7 | Contracept* |
| 8 | Condom* |
| 9 | Contraceptive agent |
| 10 | Barrier contracepti* |
| 11 | Family planning |
| 12 | Emergency contracept* |
| 13 | Intrauterine contracept* device* |
| 14 | Postcoital contracept* |
| 15 | OR 1‐14 |
| 16 | SOCIAL MEDIA/ EXP |
| 17 | SOCIAL NETWORKING/ EXP |
| 18 | Social Media |
| 19 | Social network* |
| 20 | |
| 21 | |
| 22 | |
| 23 | Snapchat |
| 24 | Myspace |
| 25 | OR 16‐24 |
| 26 | 15 AND 25 |
| Embase | |
| 1 | CONTRACEPTION/ EXP |
| 2 | CONTRACEPTIVE/ |
| 3 | CONTRACEPTIVE AGENT/ |
| 4 | CONTRACEPTIVE BEHAVIOUR/ |
| 5 | CONTRACEPTIVE DEVICE |
| 6 | FAMILY PLANNING/ |
| 7 | Contracept* |
| 8 | Condom* |
| 9 | Contraceptive agent |
| 10 | Barrier contracepti* |
| 11 | Family planning |
| 12 | Emergency contracept* |
| 13 | Intrauterine contracept* device* |
| 14 | Postcoital contracept* |
| 15 | OR 1‐14 |
| 16 | SOCIAL NETWORK/ |
| 17 | SOCIAL MEDIA/ |
| 18 | Social Media |
| 19 | Social network* |
| 20 | |
| 21 | |
| 22 | |
| 23 | Snapchat |
| 24 | Myspace |
| 25 | OR 16‐24 |
| 26 | 15 AND 25 |
| CINAHL | |
| 1 | CONTRACEPTION/ EXP |
| 2 | REPRODUCTIVE CONTROL AGENTS/ EXP |
| 3 | CONTRACEPTIVE DEVICES/ EXP |
| 4 | Contracept* |
| 5 | Condom* |
| 6 | Contraceptive agent |
| 7 | Barrier contracepti* |
| 8 | Family planning |
| 9 | Emergency contracept* |
| 10 | Intrauterine contracept* device* |
| 11 | Postcoital contracept* |
| 12 | OR 1‐11 |
| 13 | SOCIAL NETWORKING/ |
| 14 | SOCIAL MEDIA/ |
| 15 | Social Media |
| 16 | Social network* |
| 17 | |
| 18 | |
| 19 | |
| 20 | Snapchat |
| 21 | Myspace |
| 22 | OR 13‐21 |
| 23 | 12 AND 22 |
| Web of Science | |
| 1 | TS=contracept* |
| 2 | TS=contracepti* agent* |
| 3 | TS=emergency contracepti* |
| 4 | TS=postcoital contraception |
| 5 | TS=contracept* devices* |
| 6 | TS=condom |
| 7 | TS=barrier contraception |
| 8 | TS=family planning |
| 9 | OR 1‐8 |
| 10 | TS=Social Media |
| 11 | TS=Social network* |
| 12 | TS=Facebook |
| 13 | TS=Twitter |
| 14 | TS=Instagram |
| 15 | TS=Myspace |
| 16 | TS= Snapchat |
| 17 | OR 10‐16 |
| 18 | 9 AND 17 |
| Association for Computing Machinery | |
| 1 | Contracept* |
| 2 | Condom* |
| 3 | Contraceptive agent |
| 4 | Barrier contracepti* |
| 5 | Family planning |
| 6 | Emergency contracept* |
| 7 | Intrauterine contracept* device* |
| 8 | Postcoital contracept* |
| 9 | OR 1‐8 |
| 10 | Social Media |
| 11 | Social network* |
| 12 | |
| 13 | |
| 14 | |
| 15 | Snapchat |
| 16 | Myspace |
| 17 | OR 10‐16 |
| 18 | 9 AND 17 |
| DBPL computer science bibliography | |
| 1 | Contracept* |
| 2 | Condom* |
| 3 | Contraceptive agent |
| 4 | Barrier contracepti* |
| 5 | Family planning |
| 6 | Emergency contracept* |
| 7 | Intrauterine contracept* device* |
| 8 | Postcoital contracept* |
| 9 | OR 1‐8 |
| 10 | Social Media |
| 11 | Social network* |
| 12 | |
| 13 | |
| 14 | |
| 15 | Snapchat |
| 16 | Myspace |
| 17 | OR 10‐16 |
| 18 | 9 AND 17 |
Contributions of authors
All authors contributed to drafting the review protocol.
Sources of support
Internal sources
None, Other.
External sources
-
University of Southampton, UK.
Dr Alwan is employed by the University of Southampton
Declarations of interest
AJ, IJ, and NA have no known conflicts of interest.
New
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