A scoping review of the format, content, effectiveness and acceptability of reproductive life planning tools
1UCL Institute for Women’s Health, Reproductive Health Research Department, Sexual and Reproductive Health Research Team
2UCL Division of Biosciences, Faculty of Life Sciences
3UCL Institute for Global Health, Faculty of Population Health Sciences
4Guy’s & St Thomas’s NHS Foundation Trust, Community Sexual and Reproductive Health
*Corresponding author; email: jennifer.hall@ucl.ac.ukAbstract
Introduction
A Reproductive Life Plan (RLP) is a set of questions that encourage patients to reflect on their reproductive goals and the actions needed to achieve them. This scoping review of the published and grey literature aims to map the evidence on currently available RLPs.
Methods
We searched four databases (Medline, Embase, PsycINFO and Scopus) and used Google to search the grey literature, the search terms were; “reproductive life plan$” OR “reproductive plans$” OR “pregnancy intention screening”. Data were extracted on target audience, format, content, behaviour change theory, features, effectiveness and acceptability.
Results
44 published papers and 18 grey literature sources were included. 21 RLPs were discussed in the published papers and 17 in the grey literature. Most RLPs came from the USA. Most RLPs in published papers were asked verbally, while all RLPs in the grey literature were self-completed; there were six digital RLPs. Most ask whether an individual wants children, some then ask about number and timing of children, and contraception. Grey literature RLPs also asked about lifestyle and health.
Discussion
The concept of developing an RLP is acceptable to people of reproductive age and healthcare professionals. There was a lot of consistency in the questions asked, however, there is limited data on effectiveness and only three tools, all digital, incorporated behaviour change theory.
Conclusion
A digital RLP that builds on the evidence for existing tools and integrates appropriate theory could result in the realisation of the potential that RLPs are theorised to deliver.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Clinical Protocols
Funding Statement
CS and JH are part-funded by an MRC Gap Funder Grant ref: MR/Y503320/1. The funders played no role in the review or decision to submit.
Introduction
“You’re either on contraception or you’re pregnant, and that middle step is missing”. So said one woman in our qualitative research (1), describing the gap that pregnancy intention screening (PIS) and reproductive life planning (RLP) is attempting to fill (see Box 1 for definitions). Arguably the decision of whether or when to have children is one of the most important decisions a person will make in their lifetime, with far reaching impacts for health and wellbeing across the lifecourse. Despite this there is very little reliable and evidence-based support available for people to make these decisions, whether that is from health professionals, educational settings, digital sources, or from peers.
Pregnancy intention screening (PIS): a way of identifying a person’s desire for pregnancy, within a set timeframe, usually a single question. In a clinical context, this can be used to determine which reproductive health services to offer or could precede a reproductive life planning discussion.
Reproductive life plan (RLP): a set of longer-term personal goals about having or not having children and how to achieve those goals, based on the person’s own values, goals, and resources.
Box 1: Definitions of pregnancy intention screening and reproductive life plans
Reproductive life planning is a concept developed in the USA and championed by the Centers for Disease Control and Prevention (CDC) (2). It is a set of questions that health care providers were encouraged to use to prompt their patients to reflect on their reproductive goals and the actions that they need to take to achieve them (Box 2). This could lead to advice on how to improve health before pregnancy (preconception care) to increase the chances of pregnancy (3) and reduce adverse birth outcomes (4,5), counselling on contraceptive choices, or support for those who are unsure or ambivalent about a future pregnancy, recognising that pregnancy planning is not a salient concept for some (6). Box 2: Questions in the RLP developed by Moos (2006) and adopted and adapted by the CDC (7).
- Do you plan to have any(more) children?
- How many children do you hope to have?
- How long do you want to wait until you become pregnant (again)?
- How much space do you plan to have between your future pregnancies?
- What do you plan to do to avoid pregnancy (until you are ready to become pregnant)?
- What can I do to help you achieve your plan?
As the implementation of reproductive life planning has been developed it has increasingly been emphasised that it should be used in a way that supports patient autonomy, is not judgemental, and is patient-centred i.e. focusing on the patient’s priorities and not what the healthcare professional thinks those should be, particularly when it comes to contraceptive choice (6). Consequently, five key attributes of reproductive life planning have been defined: goal-orientated; personalised; collaborative but person-centred; fluid; and health promotion-focused (8). Pregnancy intention screening is an antecedent to reproductive life planning (8), often a single question in a clinical encounter which seeks to establish a person’s current attitude towards pregnancy, and which may begin the process of reproductive life planning, resulting in the formulation of a reproductive life plan. Throughout this paper we use RLP to refer to both the process and the output of reproductive life planning.
To date there has been no attempt to implement pregnancy intention screening or reproductive life planning in the United Kingdom. However, in 2023 it was recommended as the entry point for holistic care across the reproductive life course in primary care in England (1). There are a range of potential tools and it is not clear which would be best in any given setting. Furthermore, women and healthcare professionals have expressed preferences for a digital approach, or one that integrates digital and in-person modalities (1, 9, 10), and the evidence for this needs to be explored.
This scoping review of the published literature, and a review of RLPs available in the grey literature, aims to map out what is currently available and describe the content and format of existing RLPs, as well as synthesise any information on their effectiveness or acceptability, with a particular focus on digital tools.
Methods
We conducted a scoping review of the published and grey literature (11). The search protocol was pre-registered with OSF (DOI 10.17605/OSF.IO/S26CV). We searched four databases: Medline; Embase; PsycINFO; and Scopus, accessed via the Ovid and Scopus interfaces, and used Google to search the grey literature. After extensive testing we created a parsimonious search strategy of keywords, as there were no suitably focused MeSH terms, of “reproductive life plan$” OR “reproductive plans$” OR “pregnancy intention screening”. The search was limited to peer-reviewed studies, in humans, published from 1 January 2015, when the first digital RLPs began to appear, to 24th October 2023. Observational and intervention studies were included. The full electronic search strategies are included in S1. We searched Google on 15/11/2023 using the search strategy “reproductive life plan$” OR “reproductive plan$ tool$”, extracting the first 50 results. Additional inclusion criteria were that the study focused on people of reproductive age, or health professionals serving them, and was about any reproductive life planning or pregnancy intention screening tool. Studies were excluded if they were not in humans, not available in English or not a primary study. The same criteria were applied for both papers and grey literature.
Database search results were extracted and uploaded to Rayyan where duplicates were removed, and title/abstract screening was managed. The list of papers selected for full text review was uploaded to Endnote. To minimise bias and increase objectivity, reviewers worked in parallel for all screening rounds, blind to each other’s decisions. Any discrepancies were resolved by a third reviewer. Reviews were excluded after references were checked for additional studies meeting the inclusion criteria. References and citations of included studies were screened to identify additional studies. Data items extracted into an Excel spreadsheet designed for this review included meta data about the studies, target audience, format, content, including any associated behaviour change theory, features, effectiveness and acceptability of the PIS/RLP. Findings were synthesised within each of these categories with differences between tools, settings and formats considered.
We contacted authors of any papers that did not include the wording of the PIS or RLP content in the paper. Of the three authors contacted (12–14) only one replied (14).
Results
The database searches yielded a total of 432 publications: 135 were duplicates; 235 were removed on title and abstract review; and 62 full-text papers were retrieved. Thirty-one of these were excluded, mostly because they were not about PIS/RLP. Thirteen additional publications were identified from forward and backward citation searching. From the grey literature search, eighteen results were retained; most results were excluded as they were a research paper that had been identified in the database search (n=17). The PRISMA flowchart is shown in Figure 1 and checklist is in S2.
Included studies
Ultimately, 44 papers were included in our review and are described in Table 1 (6, 12–54). Although published between 2015-2023, data were collected between 2012-2021. The majority of papers came from the USA (n=33) followed by Sweden (n=6) and Eswatini (n=2). Pilot studies, qualitative analyses and randomised controlled trials were the joint most common studies (n=8). Most studies took place in clinical settings: either primary/community health services (n=27) or secondary clinic/hospital (n=10). Within the grey literature sources most were published by health care services in the USA and are described in Table 2 (55–72).
Findings
We extracted and synthesised the evidence relating to the PIS/RLP’s target audience, format, content including any associated behaviour change theory, features, effectiveness and acceptability of the PIS/RLP. Findings were synthesised within each of these categories with differences between different RLPs, settings and formats considered.
PIS/RLP
Twenty-one different PIS/RLPs were discussed in the 44 studies (Table 3).
Some PIS/RLPs were mentioned in multiple papers, e.g. One Key Question (OKQ) (n=14); CDC/Moos (n=6); FPQ/RepLI (n=3); and PATH (n=2), although were not always in the same format.
The 18 grey literature sources discuss 17 different RLPs, though there was a lot of commonality and many were based on the CDC/Moos RLP.
Target audience
In the published literature, the main target audience was cis-gender females of reproductive age, although the age range varied; only one paper specifically focused on men (16). A few studies focused on women with cancer (29) or chronic mental illness (25), but most did not mention specific medical conditions.
In the grey literature, the target population was often unclear, however, eight stated the target audience was female and seven appeared to be for both males and females. Age was not specified in most cases, but two mentioned people of reproductive age (63, 64) and two were focused on adolescents/teens (65, 69).
Format
The majority of PIS/RLPs were employed verbally during clinical encounters (15 RLPs in 27 papers) (6, 16, 17, 22, 24, 25, 28–36, 38–42, 44, 45, 48, 49, 52–54), five were self-completed (written) RLPs studied in seven papers (14, 15, 21, 37, 46, 47, 50) and six were digital RLPs (13, 19, 20, 26, 43, 51), although one was designed to be used/completed with a midwife (26) and one was linked to primary care (51). Several PIS/RLP were implemented in different formats, for example, the OKQ, FPQ/RepLI and Moos were all asked both verbally during clinical encounters and self-completed (written). All PIS (apart from OKQ) were only used in clinical encounters, while the RLPs were used in clinical encounters, were self-completed and were digital. While the method of recording PIS/RLP was not stated for most of the papers, the electronic medical record was the most frequently identified location (n=9).
All of the RLPs in the grey literature were designed to be self-completed, although one was connected to clinical encounters. Twelve of the 17 RLPs in the grey literature were PDFs and six were within blogs/websites.
Content – questions
Most of the RLPs, whether in the published or the grey literature, started with a question like the options shown in Box 3. For those who answer yes to having children, most RLPs go on to ask how many children an individual would like, when they would like to have those children, and what method of contraception will be used to prevent pregnancy until the desired time. Some of the longer RLPs also asked about/mentioned preconception health e.g. asking about health behaviours, health problems or medications, however this was rare for RLPs in the published literature (n=5) (14, 19, 20, 43, 51). For those that answer no, most RLPs ask how an individual will prevent pregnancy. For those who are unsure, most RLPs ask individuals what their thoughts on having children/getting pregnant are and how they will prevent pregnancy until they have decided what they want. Details of the specific topics covered by each RLP, the format of the RLP and its features can be found in Table 3 (55–72).
Box 3: Word tree of the most common wording of opening questions in RLPs
The RLPs in the grey literature tended to be longer, e.g. My Life My Plan was 12 pages long (69). This was because they also asked about other life goals, such as education and career aspirations, lifestyle, health (mental and physical) and family health history, relationships (e.g. partner’s thoughts, support, abuse) as well as questions about wider reproductive health (e.g. sexually transmitted infections) and previous obstetric experiences.
The PIS questions tended to ask an individual about their thoughts/feelings about becoming pregnant, rather than ‘having children’ and focused on a shorter time frame such as a year. Some had answer options, for example the OKQ has ‘Yes’, ‘No’, ‘I’m not sure’, ‘OK, either way’, but most were open-ended in line with the verbal format. Some PIS were focused on the reproductive health services an individual wanted and were therefore only applicable to clinical encounters (31, 32, 38, 48, 49, 54).
Content – topics covered
Thirty-three papers discussed information/advice that was provided alongside the RLP; most provided information about health behaviours, lifestyle, fertility and contraception, with folic acid supplementation mentioned in both published and grey literature. For those that were used verbally during clinical encounters (especially the PIS) some stated the information/advice that should go alongside the RLP/PIS but it is impossible to know what discussions individual healthcare professionals actually had with their patients. From the grey literature, ‘My Life My Plan’, which is specifically targeted at teenagers, included topics relevant to this demographic, such as being ready for sex, relationships and teen pregnancy, as well as providing information (and links) specific to teenagers (69).
Features
Five of the digital RLPs included features such as being interactive (19, 51), providing individualised information (19, 43, 51), creating to-do lists(43), and allowed the RLP to be revised (19, 26) or printed/saved/shared (19, 20, 26, 51). Other features included providing assistance such as directions to nearest provider/pharmacy/GP, or incorporated action planning into the RLP.
Of the 12 RLPs that were PDFs in the grey literature, nine had features including goal setting (56, 58, 59, 62, 65, 69, 70), tracking goals (56, 58, 70), to-do lists (58, 62, 70), action planning (62, 67, 68, 69), ability to review/revise(56, 69, 70) or print/save/share (62, 67, 69, 69).
Behaviour Change
Of the 44 included papers, 32 made no mention of any underpinning behaviour change theory and there was no explicit mention in the grey literature of behaviour change theory. Studies focused on implementation in a clinical setting often mentioned the importance of taking a patient-centred approach, ensuring shared decision-making and balanced counselling, and aspects of motivational interviewing, which is a recognised behaviour change technique. The web-based ‘My New Options’ RLP incorporated action planning (19). This encourages a person to think in advance how to implement the desired behaviour and how to address challenges, reducing the cognitive load when these situations are faced (73).
The development of three RLPs, all of which were digital, was said to be informed by specific behaviour change theories: Fishbein’s reasoned action approach to health promotion (43); the health promotion model (13); and self-determination theory (51, 74).
Batra et al (43) hypothesised that their RLP ‘MyFamilyPlan’ would increase preconception discussion with HCP via an increase in self-efficacy, a component of Fishbein’s theory (75). The intention was that the pre-consultation use of MyFamilyPlan, which provided actionable, specific preconception health recommendations and encouragement to discuss them with a physician, would empower patients to initiate discussions of reproductive health.
The health promotion model was utilised by Jagoda et al (13) as their conceptual framework. This model concentrates on three major categories: individual characteristics and experiences, behaviour-specific cognitions and affect; and the behavioural outcomes (76). It has previously been applied to reproductive health and showed that social support, perceived benefits and perceived barriers were the most important predictors of health promoting behaviour (77).
Finally, Callegari et al (51) implemented self-determination theory, a personality theory that focuses on the motivations behind decisions in their web-based RLP ‘MyPath’ (78). It focuses on intrinsic motivation i.e. engagement in the activity is valued rather than valuing the outcome. This theory suggests that there will be improved health behaviours and outcomes where health care meets individuals’ psychological needs for autonomy, competence, and relatedness (feeling understood and cared for by others). MyPath was designed to build competence through knowledge and self-efficacy, autonomy by encouraging reflection on reproductive desires and goals, and relatedness by promoting patient-centred communication among clinicians.
Effectiveness
Twenty-six out of 44 studies (59.1%) measured effectiveness as a study outcome, however there were several different ways that effectiveness was conceptualised. The most common effectiveness outcome was contraceptive use (14/26, 53.8%). One study described a significant increase in long-acting reversible contraceptive (LARC) use, but not pill or injection, following RLP implementation whilst controlling for ethnicity and education (aOR 1.635, 1.03, 2.61) (12), and another, using the MyNewOptions tool, noted no differences in contraception use between intervention and control arms (19). The remaining studies described either stable contraception use or did not report contraception use pre-intervention as a comparator.
Most of the seven studies (35, 45, 46, 48, 52, 54) reporting documentation of reproductive counselling measured a significant increase after implementation of the RLP with intervention arm rates ranging from 58.4% in a study of the OKQ (54) to a maximum of 93.1% in a study of the MyPath tool (51). Knowledge and awareness also appeared to increase across the seven studies measuring this outcome. One study of the OKQ reported 77% of women had received new information and general fertility awareness increased from a mean score of 4.6 to 5.5 out of 12 (p=0.004) (16).
Medication reviews and use of folic acid were less commonly measured outcomes of effectiveness. Results of the impact of the RLP on folic acid use were inconsistent across two studies: a study of the Moos/CDC tool showed a statistically significant increase in folic acid use prior to pregnancy after RLP implementation (22) whilst a study using the MyFamilyPlan tool showed no difference between intervention and control (43). The Healthy Start tool, implemented as part of a program serving urban low-income African-American women, was found to result in a medication review in 75% (437/580) of cases of which 8% (35/437) were identified as including potentially teratogenic medications (14).
Five of the six studies using digital tools evaluated effectiveness (13, 19, 26, 43, 51). Digital RLPs were shown consistently to increase reflection (13), discussion and advice provision (26, 43), and to sometimes increase self-efficacy (51) but there was limited evidence of the translation of this into contraception or preconception behaviour change (19, 43, 51). A cluster randomised controlled trial of 292 women, showed that participants completing the MyFamilyPlan health education module prior to a well-woman visit were significantly more likely to report discussing reproductive health with their physicians (OR 1.97, 95%CI 1.22-3.19), though there was no impact on folate use before pregnancy (43). This tool was based on Fishbein’s reasoned action approach and aimed to improve self-efficacy to improve these outcomes, though they did not show an improvement in self-efficacy as measured in the study. Self-efficacy and knowledge were measured in the study of MyPath demonstrating a greater increase in both domains in the intervention arm versus the control arm, as well a significantly increased discussion of pregnancy and/or contraceptive needs (93.1% vs 67.9%, p=0.02) (51). There were non-significant increases in underpowered secondary outcomes of participants reporting the highest confidence that their contraceptive method was right for them the intervention versus control group (33.3% versus 7.4%, p = 0.11) and in the proportion of participants reporting the lowest level of decision conflict about their contraceptive decision (23.3% versus 7.1%, p=0.09).
Acceptability to users
Acceptability to users was assessed in 25 studies in the USA (n=18), Sweden (n=4) and one each in Iran (22), Eswatini (21) and Australia (53). Users were overwhelmingly positive about being asked about reproductive life planning across countries, settings and tools, commonly appreciating the opportunity to discuss their reproductive health and stating that PIS/RLPs should be routine. One study that looked at men only (16) showed that most (76%) found being counselled about their RLP in sexual health clinics in Sweden to be a positive experience. Negative reactions were extremely rare: 3.1% of respondents in another Swedish study found the experience ‘fairly negative’ and none thought it was very negative (36); in the well-baby setting only three out of 55 declined to discuss the issues raised by the RLP (including one who had a tubal ligation) (44); and one participant said that mental health professionals should not ask RLP questions (25).
Qualitative findings showed that RLPs were a valuable prompt for women to think critically about pregnancy intentions and related actions (17, 23) as they were hesitant to raise the topic themselves (15, 17, 23) and therefore preferred providers to raise the issue (17, 23). However, it was vital that providers did this, and gave the subsequent advice, in a non-judgemental, unbiased way that respected autonomy (17, 23, 32). This was particularly important for those with lower agency due to perceived shame, for example where their desires may not conform with society’s expectations of who should become a mother and when, whether that related to teenage pregnancy (23) or being childless by choice (38).
The four studies of digital RLPs’ acceptability (19, 20, 43, 51), found them to be an acceptable format, including in one study that included men (20). Respondents described an interactive, web-based format as easy to use and ‘desirable’ (19) with the majority reporting that they liked the online format (e.g. 75.3% in 43). Comments related to specific tools included ‘user friendly’ with ‘interesting content’ (20). High levels of completion (97.9% of intervention participants completely reviewed MyFamilyPlan (43)), recommendation (e.g. 93.3% would recommend MyPath to other women Veterans (51)), and retention (follow up rates over 3 years of 94-95% (18)) are further evidence of acceptability. For this format it was important that it was seen as a trustworthy and reliable source (20), that struck the right balance between brevity, ease of understanding and comprehensive content, for example by having ‘click here to read more’ options (20, 43, 51) and that was inclusive i.e. not too heteronormative (20).
Across different settings and populations, the FPQ/RepLI (29, 30), RH-SAT (15), PATH (25), FPQ (50) and OKQ (37, 50) were all shown to help participants talk to their provider about their reproductive goals, or to lead to an overall increase in satisfaction (from 81% to 97%, p=0.04) and communication (from 77% to 94%, p=0.06) (37). Where comparisons were made between tools, PATH (25), FPQ (50) and questions about reproductive service needs (32, 49) were preferred to OKQ.
Acceptability to HCPs
HCP opinions were assessed in seventeen studies, including nurses (n=3), midwives (n=5), primary care physicians (n=8), obstetric and gynaecology doctors (n=2), psychiatrists (n=1), paediatricians (n=1) or support staff (e.g medical assistants, medical students, or administrative staff) (n=3), or a mentor mother (n=1). Data came from Sweden (n=4), the USA (n=11), Eswatini (n=1) and Australia (n=1).
Overall, across the countries, professionals, formats and tools there was general support for the implementation of PIS/RLP as a good way of raising an important topic, that was generally a positive experience for the HCP (20, 26, 34, 39). HCP’s views on two online tools were positive (20, 26, 51), with most HCPs agreeing that women using MyPath prior to clinic attendance had helped users make informed decisions about pregnancy planning/timing (71.4%) and contraception (100%). There were no specific concerns with any of the approaches used, though more recently there has been growing evidence that, in the context of a clinical encounter, a question asking about service needs may be more acceptable to HCPs (30, 48). Lack of training (30) or time (39, 45, 47) was raised, though some felt it was time-efficient (39, 46, 51) and while empirical evidence suggested an additional 1-5mins was the norm (44, 48, 53), even this could be unmanageable in a busy clinic. In relation to this, several studies showed support for self-complete options (26, 46, 51).
Eight papers considered the acceptability of the OKQ, either alone or in comparison with other RLPs: five were as part of a clinical consultation (30, 31, 45, 52, 53); three were in a self-complete format (46, 47, 50); and all but one (52) were in primary care. Where OKQ was considered alone (45–47, 52, 53), providers generally found it easy to use, especially when related to the patient’s reason for presenting (53) and a helpful reminder to consider reproductive goals (45, 46) and get the conversation started (52, 53), though some felt overwhelmed by existing clinical reminders (46).
When compared with other tools, Madrigal et al (30) found OKQ was the least-preferred option (15%) in comparison with FPQ/RepLI and a screening question for reproductive service needs (which was the preferred option). A screening question focused on service needs was highly acceptable to support staff in primary care in another USA study (48). Conversely, in Baldwin et al’s comparison of OKQ and FPQ (50), fewer providers agreed the FPQ tool helped to focus their counselling, though this was not statistically significant (FPQ 16/43, 37.2% versus OKQ 18/36, 50%; p=0.25).
Awareness
Three studies considered awareness of RLPs: one each in Australia (18), the USA (27) and Iran (22). Most people were unaware of RLPs, whether or not they were currently planning a pregnancy. A survey of women in Australia, for example, found 90.2% were unaware of RLP, with no statistically significant difference between active planners (desire pregnancy in the next year) and non-active planners (1-5 years) (18). There was slightly higher awareness (24%) amongst college students in the USA, but only 4.2% had been asked about RLP by an HCP (27). Despite low awareness, most (62.9%) agreed developing an RLP was important and 68.7% wanted to receive information about RLP before attempting pregnancy, from either primary care or an obstetrician/gynaecologist. Awareness of RLPs amongst midwives in Sweden increased from 68% in 2012 (41) to 96.2% in 2018 (26).
Discussion
Our review has shown that the published and grey literature on RLP/PIS is dominated by the USA. While awareness of RLPs and their value is low amongst the public, there is consistent evidence of acceptability across countries, settings, tools, formats, users and providers. There was a great deal of consistency in the types of questions asked to help a person develop an RLP, with many plans based on the 2006 Moos RLP that was adopted by the CDC (7), and the topics covered, though those used outside a clinical encounter tended to be more holistic and less focused on reproductive health service needs. RLPs in the grey literature were more comprehensive, likely because they were not constrained by the time limits of a clinical encounter. Given the small number of digital RLPs, there is a scarcity of evidence on these tools, however where they have been developed, they are more likely to have underpinning theories and to have conducted more detailed effectiveness evaluations.
Despite finding 44 studies, there is limited data of effectiveness beyond changes in knowledge or recording of discussion of reproductive health in consultations. While important, these outcomes are a step away from the behaviour change outcomes on which we would wish to judge effectiveness, such as reduced unplanned pregnancies, increased use of folic acid before pregnancy or reduced contraception discontinuation. Part of the gap is that many studies did not look at effectiveness in terms of behaviour change or other outcomes, and another part is due to the heterogeneity of outcomes measured. Even where effectiveness was considered the evidence is still limited and conflicting. There are several possible reasons for this. Firstly, very few tools have been developed with due consideration to relevant behaviour change theory. This omission may be why tools have shown limited impact beyond increased knowledge and discussion. Where behaviour change theory has been utilised, precursors, such as self-efficacy have been focused on, without perhaps considering the other steps in the theory of change required to lead to impact. Secondly, the choice of outcome measure could also be a factor, and considering patient-centred measures, such as satisfaction with contraception, rather than efficacy-based outcome measures such as LARC use which reflect health system targets, may be better aligned to the concept of patient-centred RLPs (79). Thirdly there is potential selection bias in that those most likely to engage with an RLP might be the healthiest and least in need of change, resulting in a high baseline that is hard to affect. Fourthly, it is also important to consider that an individuals’ preferences and choices might be constrained by other factors, such as access to services and the (opportunity) cost of contraception which an RLP focusing on individual behaviour change may be unable to affect. Examination of the implementation context and facilitators and barriers in each setting and for each population group and tool is therefore also required. Finally, the digital RLPs developed may be too weak, lacking features such as personalisation, adaptive feedback and the ability to track behaviours which are known to facilitate engagement in mobile health apps (80, 81, 82).
Limitations
Due to our particular interest in digital tools, we focused on relatively recent literature. This could mean that we missed some RLPs, however given the consistency in the questions and topics covered in the identified RLPs this is unlikely to impact the overall findings of the review. We only searched in English, which would limit our ability to find studies or grey literature on RLPs in other languages. We excluded only one paper based on language (Hungarian) but did include an RLP in Swedish as the publications about it were in English.
Three papers did not include the questions that were asked as part of the RLP and only one author responded to our request for further information. Furthermore, some of the papers, particularly about the digital tools, only discussed the topics included within the RLPs. We were able to access some, but not all, meaning that we did not always have the specific wording of the questions used.
Conclusions
The concept of developing an RLP is acceptable to people of reproductive age and health care professionals, but awareness is low and evidence of how to effectively implement PIS/RLP is inadequate with none from the UK. New digital tools that are underpinned by behaviour change theories are emerging and though evidence of effectiveness is limited to date, it is promising. A digital RLP that builds on the existing tools, integrates appropriate theory, learns from other digital health interventions, has an appropriate implementation strategy and that supports person-centred care could facilitate reproductive choice and lead to the realisation of the potential that RLPs are theorised to deliver.
Supporting information
Data Availability
As a scoping review all data relate to the original publications referenced.
Funding
CS and JH are part-funded by an MRC Gap Funder Grant ref: MR/Y503320/1. The funders played no role in the review or decision to submit.