Contraceptive methods (CMs) vary widely in formulations and indications (ie, menstrual cycle regulation) beyond pregnancy prevention [1-3]. Adolescents and young adults (AYAs) seeking contraceptives face numerous considerations (eg, weight gain and pain with long-acting CM insertion) that are often overlooked by health care providers due to competing priorities and a lack of adequate contraceptive information, which can lead to CM misuse or nonuse and undesirable outcomes. AYAs also often rely on social media for contraceptive information [4-8]. AYAs from racial and ethnic minority groups are more likely to report mistrust in contraceptive use and to forego or discontinue a method [4]. Furthermore, AYAs with a nonconforming sexual orientation, gender identity or form of expression (SOGIE) are less likely to receive contraceptive counseling that meets their needs outside of a gender-affirming care clinic (eg, counseling regarding menstrual suppression) [9,10]. Therefore, developing a culturally and developmentally tailored intervention to support AYAs’ unique contraceptive indications and decisional needs is critical.

The American Academy of Pediatrics recommends a patient-centered approach to contraceptive counseling to improve method uptake and prevent early discontinuation and adverse outcomes [1]. Shared decision-making (SDM)—the process of involving patients in health decisions about treatment options, benefits, and harms—enables patients to make evidence-informed choices that align with what matters most to them [11,12]. This approach reduces decisional conflict and enhances patients’ knowledge, treatment adherence, and health outcomes [11-13]. SDM is considered the pinnacle of patient-centered care and is standard practice for adult women’s contraceptive counseling [11,14,15]. Although several contraceptive decision support tools have been shown to improve contraceptive knowledge among AYAs, their effectiveness in supporting AYA contraceptive choice, methods use, and treatment satisfaction remains unclear [16,17]. Furthermore, few of these tools meet the patient decision aid (DA) standards set by the International Patient Decision Aid Standards (IPDAS), and many have not been designed to address the unique needs of a diverse AYA population, including individuals who identify as nonbinary [17,18]. Finally, few have been rigorously evaluated, tested in diverse AYA populations, or successfully implemented in clinical practice following clinical trials (for a summary of existing contraceptive decision support tools, refer to Multimedia Appendix 1) [16-29]. To address these gaps, we aimed to develop a web-based DA that addresses the unique contraceptive decisional needs of AYAs from diverse backgrounds, following an evidence-based framework for web-based DA for patients and the IPDAS [18,30].

Twenty-four participants, including clinicians (n=10), cisgender female AYAs (n=9), and AYA-AFABs with nonconforming SOGIE (n=5), aged 16 to 24 years, most of whom identified as White, Asian, Hispanic or Latino, or Black, contributed to our DA through 2 user testing cycles from February 2023 to June 2024 (Table 2). User testing cycle 1 included 3 focus groups comprising health care providers (n=5), cisgender female AYAs (n=4), and AFABs with nonconforming SOGIE (n=3). User testing cycle 2 involved 4 focus groups, comprising 2 health care provider groups: group 1 (n=3) and group 2 (n=2), plus 1 group of cisgender female AYAs (n=5) and 1 group of AYA-AFABs with nonconforming SOGIE (n=2). Participants’ characteristics are summarized in Table 2.

Key findings from the user testing analysis prompted the following changes between our first and second digital prototypes, available in Multimedia Appendix 5: (1) content refinement through the use of nongendered language throughout the app; (2) reduced emphasis on heteronormative indications for contraceptives; and (3) the inclusion of medical contraindications in the decision algorithm, along with relevant patient facing cardiometabolic screenings (BMI, BP, and smoking status), according to the US Medical Eligibility Criteria for Contraceptive Use [31,32]. Other changes included shortening the DA content to include only information that health care providers and youth participants considered most relevant and improving the end user experience by adding navigation buttons. Clinicians found the DA to be comprehensive because it addressed all the important aspects they wanted to discuss during an encounter and felt that it would save time and effectively support SDM between patients and health care providers during a visit if the health care provider summary view interfaced with the electronic health record (Multimedia Appendix 5). This iterative process improved the clarity and relevance of the DA’s information, design, and usability, resulting in a functional prototype, MyPlanMyChoice (Figure 2).

This study describes the development process of the DA, MyPlanMyChoice, designed to address the unique contraceptive and noncontraceptive indications of AYA-AFABs. This approach enabled us to incorporate the perspectives of a diverse group of stakeholders, including AYA-AFABs with a nonconfirming SOGIE, racial and ethnic minority groups, and adolescent health care providers, to guide the development and refinement of the DA content. This approach enabled us to prioritize aspects crucial to AYAs’ contraceptive choice, including but not limited to using inclusive language and illustrations throughout the DA, as well as presenting concerns about contraceptive side effects (ie, weight gain and unscheduled bleeding), alongside contraceptive and noncontraceptive indications (Figure 2; Multimedia Appendix 3), which health care providers may view as less critical than pregnancy prevention. However, undisclosed side effects or benefits can lead to contraceptive misinformation, lack of trust, failure to choose a CM, method dissatisfaction, and early discontinuation of CMs [4,5]. Additionally, our user testing led to the inclusion of a frequently asked questions tab to address common concerns and misconceptions (eg, infertility) and the lack of reliable sources of information, which often leads AYAs or the parents of AYAs to rely on social media as a source of information [6-8]. Furthermore, this process addressed health care providers’ perspectives on the implementation of the DA, resulting in an improved health care provider summary view that incorporates the patient’s medical history and relevant cardiometabolic risk factors, such as BMI, BP, and smoking, as well as the importance of integrating the health care provider summary view into the electronic health record in future versions of our DA to facilitate SDM during a medical encounter. Our multistage collaboration with expert advisors ensured that the proposed changes from user testing were supported by clinical evidence. Finally, the iterative nature of our testing process allowed us to refine the content, enhancing the functionality and fidelity of our DA prototype before conducting pilot testing in clinical settings.

Although we aimed to include diverse viewpoints in the development of our DA, we acknowledge several factors that limited our ability to achieve adequate representation among our user testing participants. First, we had a slightly lower proportion of AYA participants from racial and ethnic minority groups who self-identified as Black (n=2) or Hispanic or Latino (n=3) than those who identified as White (n=4) or Asian (n=4). Additionally, our sample size was relatively small, and the age distribution was skewed toward older AYAs with a median age of 19 (16-25) years (Table 2). Finally, our DA prototype was available only in English, which limited the enrollment of non–English-speaking participants to test the app and provide feedback. Nevertheless, to address these limitations, we plan to partner with AYAs from our hospital youth advisory group to inform our recruitment strategy for the next phases of our DA evaluation.

In summary, SDM is regarded as the gold standard of patient-centered care and is standard practice for adult women’s contraceptive counseling [11-15]. Although several available contraceptive decision support tools have been shown to improve contraceptive knowledge among AYAs, most have focused on pregnancy prevention, even though contraceptives have a wide range of indications. Few have involved the perspectives of AYAs from diverse SOGIE, racial, and ethnic backgrounds and their decisional needs in their design; undergone rigorous evaluation; or addressed implementation strategies. Therefore, their use in clinical settings beyond pilot testing and their effectiveness in supporting the AYAs remain unclear [17,29]. This study outlines a patient-centered approach to developing a DA that addresses the contraceptive decisional needs of AYA-AFABs from diverse racial, sexual orientation, and gender identity backgrounds. This process resulted in the development of a functional DA, MyPlanMyChoice, that presents a comprehensive range of CM options, including noncontraceptive indications and method side effects. This enables progress toward pilot and feasibility testing [35]. In the next phase of our study, we plan to assess the acceptability and feasibility of our DA intervention among AYAs and health care providers in a clinical setting and to explore its preliminary efficacy beyond pregnancy prevention, such as improving cardiometabolic awareness and informing on contraceptive choice. To accomplish this, we plan to administer evidence-based acceptability and decision quality scales and contraceptive knowledge preinterventional and postinterventional surveys. Additionally, we plan to follow the Consolidated Framework for Implementation Research to identify barriers and facilitators among patients and health care providers through semistructured interviews, thereby informing the development of implementation strategies and a future hybrid effectiveness-implementation trial [36].