Missed opportunities in contraceptive counselling: findings from a European survey-based study with simulated patient consultation

Figures & data

Figure 1. Annotated schematic showing each step in the counselling simulation. The simulation was designed to elucidate the step-by-step decision-making process HCPs go through when making contraceptive recommendations to their patients. *Please see Table 1 for the list of predefined questions. HCP: health care professional; IUD: intrauterine device; IUS: intrauterine system; OC: oral contraceptive.

Table 1. Patient characteristics and counselling questions.

	Patient X	Patient Y	Patient Z
(A) Brief patient profile
Reason for consultation	‘I come today for a regular check-up and to renew my contraceptive prescription’	‘I come today for a regular check-up and to renew my contraceptive prescription’	‘I come today for a regular check-up and also want to re-evaluate my contraceptive options’
Age (years)	23	24	28
Relationship status	Stable relationship	Stable relationship	Stable relationship
Parity status	No child	No child	No child
Occupation	First job after college	First job after college	Sales person
Contraceptive eligibility	Eligible for all methods	Eligible for all methods	Eligible for all methods
Contraceptive history	Started COCs at 17 years old and has used the same pill (EE/LNG, 21/7-day regimen) for the past 3 years	Started COCs at 20 years old and has used the same pill (EE/LNG, 21/7-day regimen) for the past 2 years. Previously using condoms	Started COCs at 18 years old and has used the same pill (EE/LNG, 21/7-day regimen) for the past 6 years
(B) Full patient profile
Family planning
‘If you want to become pregnant, when do you plan to become pregnant?’	‘Definitely not before I am 30 years old’	‘Maybe in 6 years…but it’s not that fixed in my mind. I just see myself still doing a lot of other things before becoming a mother’	‘Perhaps in 6 or 7 years’
‘How important is it not to become pregnant until then?’	‘Very important, I don’t even want to think about that happening’	‘Very important, I don’t even want to think about that happening’	‘Very important, I don’t even want to think about that happening’
Menstrual experience
‘Do you experience any pain alongside menstruation?’	‘Not too much, just the usual, I guess…’	‘I have more headaches than before and I guess it may be related to the pill, but I am not sure. Besides that, I sometimes experience a bit of pelvic pain’	‘Not too much, just the usual, I guess…’
‘How intense and how long are your periods?’	‘Quite regular. Normal, I guess’	‘Quite regular. Normal, I guess’	‘Thanks to the pill, my cycle was regular and my bleeding was reduced’
‘How many days does your period last in total?’	‘About 4-5 days’	‘About 4-5 days’	‘About 4-5 days’
‘Does the duration/intensity or amount of bleeding during your menstruation disturb you and your routine?’	‘No. It is normal’	‘No. It is normal’	‘No. It is normal’
‘Would you prefer to have less or less intense menstruation?’	‘Yes, that would be great’	‘Yes, that would be great’	‘Yes, that would be great’
‘Would it be acceptable to have longer, more intense menstruation?’	‘Definitely not!’	‘Definitely not!’	‘Definitely not!’
‘Would you be ok not having your period every month?’	‘Yes. But how would I know I am not pregnant then?’	‘I know that if I take my pill the right way I should not get pregnant’	‘Yes. But how would I know I am not pregnant then?’
Lifestyle and awareness
‘Would you say your daily routines allow for regular and timely intake of a pill?’	‘I guess so…’	‘Yes’	‘Yes’
‘Which methods are you aware of?’	‘Pill, condom, ring, but most of my friends use the pill’	‘Pill, condom, injection and IUD’	‘IUD, condom, pill, ring, temperature method, natural cycles app, diaphragm…’
‘Have you ever heard about long-acting methods which do not require having to think about it every day?’	‘Now that you mention it. But all my friends use the pill. I have honestly never considered any option besides that’	‘Yes, I have. But all my friends use the pill. I have honestly never considered any other option besides that’	‘Yes, I know there are several ones, and the long protection sounds interesting as I don’t want to be pregnant within the next years’
‘Would it be a critical issue for you if the option available to meet your need is not reimbursed or has a higher cost to you?’	‘Well, I’m happy with what I’ve got, but I’m open to suggestions if you think there’s something better for me’	‘It is good if I do not need to pay, but I’m open to suggestions if you think there’s something better for me’	‘I obviously don’t want to pay a ton of money for my contraception, but if a hormone-free option costs a bit more, I would be willing to pay that for better health’
Current contraceptive use
‘Do you want to change your current contraceptive method for any reason?’	‘No, I am fine’	‘I think I am fine with my current method’	‘Yes, after exposing my body to hormones for 10 years, I think it’s time to change to a hormone-free option’
‘Is it difficult for you to use oral contraception?’	‘It is not hard’	‘No! It’s OK.’	‘The daily intake is no problem whatsoever, but the daily hormones? I don’t really know how tough that is on my body…’
‘How many times did you forget to take the pill over the last 3 months?’	‘Maybe once or twice…’*	‘Not that often’	‘Not very often, perhaps once or twice per year’
‘How concerned have you been, when you forgot to take the pill?’	‘I was very concerned, but thankfully my period came eventually’	‘It does not happen that often, so not very’	‘Not that concerned’
‘Are you OK with your pill?’	‘It’s OK. It has done its job so far’	‘It’s OK. It has done its job so far’	‘No, I want to stop it’
‘With your current pill, do you experience anything you are not happy with?’	‘No’	‘I have more headaches than before and I guess it may be related to the pill, but I am not sure’*	‘Only that I really don’t feel like myself while I’m on it’
Contraceptive preference
‘What is important to you when choosing a contraceptive method?’	‘Efficacy. I am not a fan of hormones, but it’s more important to me that I do not get pregnant’	‘I absolutely need to be sure I will not get pregnant. Aside from that it is also important to me not to have side effects and risk thrombosis’	‘I need to be sure I will not get pregnant and I don’t want hormones. I’m convinced they are not good for my body’*
‘Do you have already any idea what would be a good contraceptive option and method for you?’	‘I am OK with my current one’	‘I am OK with my current one. My concerns are more about its side effects and the risk of thrombosis’	‘A non-hormonal option’
‘What are concrete and specific concerns you have about hormonal contraception?’	‘I have never had any issues, but I hear a lot about the risks, and that sounds quite scary to be honest’	‘You mean besides the usual side effects of it and the risk of thrombosis? I hear a lot of other things, but I am not sure if it really causes cancer or something like that. And supposedly there may be an impact on my libido… I would prefer to avoid that if I can’	‘I heard that hormones are bad for you. I don’t want to take something every day that messes with my body!’
‘What exactly bothers you about ‘taking hormones’?’	‘I may not want to have kids now, but definitely later. I don’t want these hormones to get in the way of that’	‘I am concerned that taking it may cause side effects and that it is impacting my general well-being’	‘I don’t know…Exposing your body to this many hormones on a daily basis, it just cannot be good for you, right, doctor?’
‘Would you prefer a daily or non-daily method? OR do you prefer a specific intake regimen (daily, weekly, monthly, 3 years, 5 years)?’	‘All of my friends use the pill. I have never considered any other options besides that to be honest’	‘Actually I prefer daily intake to be in control’	‘As long as it’s good for my wellbeing and a convenient option, I guess it doesn’t really matter’
‘Do you have any additional need or expect any specific positive effect from your contraceptive?’	‘No’	‘No’	‘No’

The brief patient profile (part A) was presented to the HCPs at the start of the simulated discussion (all patients and their profiles are fictional). HCPs could access all the information presented in the full patient profile (part B) during the simulated discussion by asking the relevant questions. HCPs were able to continue to question their patient until they were satisfied that they had sufficient information to make an informed recommendation. The full list of questions and answers was presented to HCPs at the end of the simulated discussion.

*Indicates the most direct way of uncovering the hidden need for each patient.

COC: combined oral contraceptive; EE: ethinylestradiol; HCP: health care professional; IUD: intrauterine device; LNG: levonorgestrel.

Table 2. HCP demographics/characteristics.

Characteristic	BEL	CHE	DEU	ESP	FIN	ITA	NLD	POL	SWE	UK
	(n = 40)	(n = 40)	(n = 100)	(n = 100)	(n = 26)	(n = 100)	(n = 75)	(n = 50)	(n = 30)	(n = 100)
Sex, %
Male	30	40	53	42	15	51	49	54	0	19*
Female	70	60	47	58	85	49	51	46	100	80*
Speciality, %
OB/GYN	100	100	100	100	100	100	0	100	0	0
GP	0	0	0	0	0	0	84	0	0	100
Midwife	0	0	0	0	0	0	16	0	100	0
Years practicing medicine^†
3–10	18	8	4	22	15	40	19	28	7	26
11–20	50	48	41	43	31	22	41	36	64	54
21–30	25	33	47	33	31	26	33	22	20	17
31–35	8	13	8	2	23	12	6	14	10	3
Setting, %^†
Hospital	61	41	12	56	54	55	4	27	7	3
Office	36	43	87	36	39	38	95	69	90	97
Other	3	16	2	8	6	6	1	4	4	0
WoRA seen in last month, %^†
40–80	10	10	0	4	33	24	25	20	30	29
81–120	8	18	8	10	46	26	21	26	40	24
121–200	33	38	21	27	13	29	29	32	27	31
200+	50	35	71	59	8	21	25	22	3	16

*One HCP did not identify as either male or female. ^†Percentages may not total 100 owing to rounding.

BEL: Belgium; CHE: Switzerland; DEU: Germany; ESP: Spain; FIN: Finland; GP: general practitioner; HCP: health care professional; ITA: Italy; NLD: Netherlands; OB/GYN: obstetrician/gynaecologist; POL: Poland; SWE: Sweden; UK: United Kingdom; WoRA: women of reproductive age.

Figure 2. Identification of women’s needs during contraceptive counselling. (A) Proportion of HCPs who identified their patient’s hidden need during contraceptive counselling. *Women’s needs were often not identified but were more likely to be identified when the patient actively requested a review of her contraceptive method. (B) Identification of patient hidden needs according to HCP age. (C) Identification of patient hidden needs according to HCP sex. (D) Mean number of questions asked by HCPs. HCPs who uncovered hidden needs were more likely to be younger (B), female (C) and ask more questions (D) than those who did not. *N values represent the number of HCPs who were assigned that patient’s profile. ^†Significantly higher than ‘Did not uncover’ at 95% CI. ^‡Significantly higher than ‘Uncovered’ at 95% CI. ^§Females accounted for 46–100% of respondents per country; in 7/10 countries, more respondents were female than male. CI: confidence interval; HCP: health care professional.

Figure 3. Proportion of HCPs recommending a prescription change before and after seeing the full patient profile. HCPs were more likely to recommend a change in prescription after obtaining a better understanding of their patients’ needs. HCP: health care professional.

Figure 4. Number of questions asked during the simulated discussion, according to patient type. In total, 438, 444 and 440 HCPs were assigned to patients X (A), Y (B) and Z (C), respectively. HCP: health care professional.

Data availability statement

The datasets used and/or analysed during the current study, where not included in this published article and its supplementary information files, are available from the corresponding author on reasonable request.