Non-adherence to oral contraception regimens can have serious consequences: oral contraception misuse or discontinuation is often caused by forgetfulness, and results in over 1 million unwanted pregnancies in the US each year. Due to its simplicity and habitual nature, taking the Pill can be easily incorporated into a daily routine. However, technology-based interventions aimed at improving adherence only focus on just-in-time reminders and taking the Pill at a specified time; the routine aspect of the task is neglected. We argue that technology that facilitates the creation of sustainable habits and supports women when their routine changes could reduce forgetfulness and would be more effective at reducing non-adherence than existing reminder-based solutions

Cox, AL

Stawarz, KM

UCL Discovery

         EPSRC Programme Grant EP/G059063/1 Public Paper no. 197 How Technology Supporting Daily Habits could Help Women Remember Oral Contraception  Katarzyna Stawarz & Anna Cox  Stawarz, K., & Cox, A. L. (2013).  How technology supporting daily habits could help women remember oral contraception.  Paper presented at the Workshop on Habits in HCI at BCS-HCI 2013, London, September 2013. PP release date: 3 October 2013 file: WP197.pdf  1 How technology supporting daily habits could help women remember oral contraception Katarzyna Stawarz and Anna L. Cox University College London Gower Street, London WC1E 6BT k.stawarz@cs.ucl.ac.uk, anna.cox@ucl.ac.uk Non-adherence to oral contraception regimens can have serious consequences: oral contraception misuse or discontinuation is often caused by forgetfulness, and results in over 1 million unwanted pregnancies in the US each year. Due to its simplicity and habitual nature, taking the Pill can be easily incorporated into a daily routine.  However, technology-based interventions aimed at im-proving adherence only focus on just-in-time reminders and taking the Pill at a specified time; the routine aspect of the task is neglected. We argue that technology that facilitates the creation of sustainable habits and supports women when their routine changes could reduce forgetfulness and would be more effective at reducing non-adherence than existing reminder-based solutions.  Habits. Technology. Forgetfulness. Oral contraception. 1. INTRODUCTION The contraceptive pill (the Pill) is one of the most popular and easily available contraception methods in the UK (Robinson, 2012). With just one pill to take each day, its regimen is simple and easy to follow. However, its effectiveness depends heavily on regular use (Matter & Meier, 2008), which makes women responsible for the quality of their own protection against unwanted pregnancies. Since remembering to take the Pill every day can be easily disrupted, this protection can fail.   Each year, approximately 20% of 3.5 million un-wanted pregnancies reported in the US are caused by medication non-adherence (Rosenberg & Waugh, 1999). That figure has not changed much in the past 15 years and irregular use and discontinuation are still the main causes of oral contraception non-adherence (Black et al., 2010, Smith & Oakley, 2010). Nearly a half of women who conceived whilst using the Pill as their main method of contraception reported memory issues: they did not remember to take it every day; took it at irregular times; forgot to pack the pills when travelling; or did not remember to order refills on time (Jones et al., 2002).  Despite the prevalence of forgetfulness, adherence interventions appear to only focus on intentional non-adherence and educating women about the risks of irregular use (Halpern et al., 2011). However, even women who understand the need to take the Pill every day and the consequences of forgetting, still make this error.   Interventions aimed at reducing forgetfulness are few and far between, and tend to focus on just-in-time reminders alerting women to take the Pill at a specified time. Such reminders often require an immediate action after the alert goes off so that the action is not forgotten (Cramer, 1991). This seems to disregard the fact that oral contraception regi-mens can become habitual tasks that could easily be incorporated into a daily routine. In this paper, we demonstrate the weaknesses in existing tech-nologies that aim to support Pill taking, and argue that by taking advantage of the habitual nature of the Pill regimen by facilitating the creation of daily routines, technology could be more effective than just-in-time reminders. 2. TAKING THE PILL There are two main oral contraception regimens that depend on the type of the pill: a combined hormone pill and a single hormone pill (Robinson, 2012). A combined pill needs to be taken every day at the same time for 21 days followed by seven pill-free days before a new pack can be started. Women can take this pill up to 12 hours late without compromising its effectiveness. A single hormone progestogen-only pill does not require any breaks: it has to be taken every day, ideally within a 3-hour window if it is to remain effective. Even though this regimen is stricter, its continuous nature and the How technology supporting daily habits could help women remember oral contraception Stawarz & Cox 2 lack of breaks make it easier to remember than the combined pill (Aubeny et al., 2004).  Remembering to take the Pill therefore relies on prospective memory, i.e. a set of cognitive pro-cesses responsible for completing actions at some point in the future (Ellis, 1996). There are two main types of prospective memory tasks: time-based tasks that need to be completed at a specified time (e.g. take medication at 9am) or after a set period of time has elapsed (e.g. take antibiotics every 8 hours); and event-based tasks, where the task is linked to an existing event, e.g. taking the Pill with breakfast. Depending on individual circumstances, an oral contraception regimen can be classified as either of these tasks. However, event-based tasks are more effective in preventing forgetfulness: they are easier to remember and the presence of a rou-tine guides the behaviour and provides more con-textual cues, increasing the adherence to a medical treatment (Park & Kidder, 1996), e.g. the act of eating breakfast serves as a cue to take the Pill 2.1 Study 1: Remembering strategies To better understand how technology could support women who take the Pill, first we needed to learn how women usually try to remember it. Therefore, we conducted an online survey that explored women’s strategies for remembering their Pill, how often they forgot, and to what extent they rely on technology. The survey resulted in 971 complete responses. 76% of respondents were women aged 18-25 years old – an age group that is most likely to experience an unwanted pregnancy as a result of an oral contraception failure (Rasch, 2002). Women in this group are also likely to download smartphone apps, as 66% of 16-24 year olds in the UK own a smartphone (Ofcom, 2012).  The preliminary results confirm that women do indeed forget to take their Pill: nearly a half of respondents admitted completely missing the Pill at least once during the month preceding the survey, and during the same period, three quarters took it later than they should. 61% of women taking the Pill said that it was part of their daily routine and 52% said they simply “tried to remember” (there was a 50% overlap between these two groups). Therefore, it does not come as a surprise that the most common causes of forgetting were changes in the daily routine, being busy or distracted, and gen-eral forgetfulness. Yet, women who relied on their routine forgot less often: in the routine group 41% of women (N=589) completely forgot the Pill at least once in the past month and 69% were late, compared to 56% and 86% respectively amongst those that did not mention daily routines (N=382).  Interestingly, only 25% of women mentioned using some sort of technology, predominantly their phone’s alarm clock, as a reminder. Only 5% (N=45) used medication reminder apps and among them only eight used dedicated smartphone contra-ception reminder apps. In addition, nearly a quarter of women who used technology to support their memory also said that the pill taking was a part of their routine, which suggests that technology might have been used as a backup reminder.  Our initial findings show that women rely mainly on routines and this strategy increases their adher-ence. They also tend not to use technology to sup-port this task.  In the next section we explain why it is rational to rely on routines to support medication regimens. 3. ROUTINES AND MEDICATION TAKING One of the reasons that women may favour using routines to support their Pill taking behaviour may be due to the habitual nature of the oral contracep-tion regimen. The regimens for both the combined and single hormone Pill can be thought of as habit-ual tasks: they need to be taken regularly and within a particular period of time, leading to a grad-ual learning of patterns of behaviour and associa-tions between the task and the environment (Wood & Neal, 2007). As the frequency of repetitions of the task strengthens the association between the goal and the action (Aarts & Dijksternuis, 2000), the pill taking behaviour becomes automatic and rele-vant cues or the environment can trigger it without requiring conscious thought.  3.1 Benefits of a routine The importance of habits and patterned behaviour in medication taking is emphasised in the Medica-tion Adherence Model (Johnson, 2002). Johnson argues that good habits are established by the development of a routine and the use of reminders. As timing (e.g. breakfast time) and the location (e.g. kitchen) are key elements of a routine, each one is unique for each individual and reflects their lifestyle and daily activities which, in return, makes it more memorable, meaningful and reliable (John-son, 2002). However, while routines make repeti-tive tasks easier, they can turn them into automatic behaviour that can be completed mindlessly, which may be dangerous when the task requires deliberation (Reach, 2005).  3.2 Dangers of a routine While the ‘automaticity’ of a habit can be character-ised by its efficiency, it also brings a lack of awareness, un-intentionality and often uncontrolla-bility to the behaviour (Bargh, 1994). Even though habits are useful for reducing cognitive load and supporting everyday routines such us remembering daily medication, the automaticity of actions and the lack of thinking required when performing habit-How technology supporting daily habits could help women remember oral contraception Stawarz & Cox 3 ual tasks can have negative consequences (Reach, 2005): routines can “override” planned actions, leading to action slips (Heckhausen & Beckmann, 1989; Reason, 1990), especially omission and repetition errors (Einstein et al., 1998).   Technology has the potential to support daily rou-tines and minimise their risks. In the next section we explore current digital technologies that aim to support medication regimens. 4. MOBILE REMINDERS 4.1 Forgetfulness and mobile reminders Current adherence interventions aimed at reducing forgetfulness tend to focus on providing just-in-time reminders. For example, Hou et al. (2010) evalu-ated the impact of text-message reminders on adherence to oral contraception during a random-ised controlled trial with 82 women. For three months, text messages reminding women to take their Pill were sent once a day at a time chosen by the participant before the trial. The results showed that, despite the daily reminders, the intervention did not improve the adherence compared to the control group. Hou et al. also discovered that women who ended the trial with an excellent adher-ence record had felt at the beginning of the study that they would not need text-message reminders, which suggests that they either already used their own reminders or relied on a daily routine.   As 92% of adults in the UK own a mobile phone and 39% own a smartphone (Ofcom, 2012), text-message reminders are a reasonable choice of a reminder technology. However, they may not be flexible enough to support the Pill regimen in the context of a busy everyday life. Therefore, using smartphone apps may be a better solution, as they offer more control over the reminders, provide more complex functionality and are already being used to support remembering.  Recently, Dayer et al. (2013) have reviewed over 160 medication adherence apps available to smartphone users. Despite the fact that the effec-tiveness of the apps has not been formally evalu-ated yet, they concluded that smartphone apps can help with medication regimens and could be recom-mended by pharmacists to support the treatment. However, their study focused primarily on apps addressing intentional non-adherence. Therefore, a similar review of medication reminder apps was needed to understand what functionality they offer, how they support remembering, to what extent they support daily routines, and how useful and reliable users find them.  4.2 Study 2: Functionality review of mobile reminder apps We have reviewed 229 medication reminder apps (including 25 dedicated Pill reminders) available for iPhone and Android smartphones and have discov-ered that even though the apps often offer features that can make remembering the Pill easier, such as customisable reminder alerts or time zone support, they focus primarily on just-in-time reminders and require immediate action as postponing the remind-er is often not possible. The apps are designed to encourage women to rely on the app’s reminder rather than to try to remember their Pill themselves, even though the apps are not always reliable. The analysis of customer reviews highlighted users’ frustration that sometimes reminders do not work, other apps can interfere with the alerts, or software updates can break the app. All this can result in missed reminders and missed pills.  These results suggest that the existing technolo-gies are not fit for purpose, as they do not support women in developing sustainable routines that enable them to take the Pill regularly.  This may explain the low adoption rate of existing smart-phone apps that we identified in Study 1. 5. CONCLUSIONS Due to their portability and increasing popularity, mobile technologies, and smartphones in particular, have the potential to support daily routines and pre-vent dangers of automatic behaviour. Yet, despite the fact that habit formation is supported in apps designed to change behaviour, e.g. promoting physical activity by providing regular feedback  (Rabin & Bock, 2011), existing medication reminder apps focus primarily on just-in-time reminders and do not provide any functionality supporting the creation of sustainable habits.   Based on the premise that oral contraception regi-mens are habitual tasks and incorporating pill tak-ing into a daily routine reduces forgetfulness, we argue that technology facilitating the creation of reliable routines or supporting the existing ones would be the most effective in reducing oral contra-ception non-adherence. However, if that technology is to successfully support daily routines, it must also take their dangers into the account and provide failsafe mechanisms for situations where the routine is disrupted or where the automaticity of the behaviour makes it unclear whether the Pill has already been taken. 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