title: Assessing the Efficacy of an App-Based Method of Family Planning: The Dot Study Protocol.
abstract: BACKGROUND
  Some 222 million women worldwide have unmet needs for contraception; they want to avoid pregnancy, but are not using a contraceptive method, primarily because of concerns about side effects associated with most available methods. Expanding contraceptive options-particularly fertility awareness options that provide women with information about which days during their menstrual cycles they are likely to become pregnant if they have unprotected intercourse-has the potential to reduce unmet need. Making these methods available to women through their mobile phones can facilitate access. Indeed, many fertility awareness applications have been developed for smartphones, some of which are digital platforms for existing methods, requiring women to enter information about fertility signs such as basal body temperature and cervical secretions. Others are algorithms based on (unexplained) calculations of the fertile period of the menstrual cycle. Considering particularly this latter (largely untested) group, it is critical that these apps be subject to the same rigorous research as other contraceptive methods. Dynamic Optimal Timing, available via the Dot app as a free download for iPhone and Android devices, is one such method and the only one that has published the algorithm that forms its basis. It combines historical cycle data with a woman's own personal cycle history, continuing to accrue this information over time to identify her fertile period. While Dot has a theoretical failure rate of only 3 in 100 for preventing pregnancy with perfect use, its effectiveness in typical use has yet to be determined.
  
  
  OBJECTIVE
  The study objective is to assess both perfect and typical use to determine the efficacy of the Dot app for pregnancy prevention.
  
  
  METHODS
  To determine actual use efficacy, the Institute for Reproductive Health is partnering with Cycle Technologies, which developed the Dot app, to conduct a prospective efficacy trial, following 1200 women over the course of 13 menstrual cycles to assess pregnancy status over time. This paper outlines the protocol for this efficacy trial, following the Standard Protocol Items: Recommendations for Intervention Trials checklist, to provide an overview of the rationale, methodology, and analysis plan. Participants will be asked to provide daily sexual history data and periodically answer surveys administered through a call center or directly on their phone.
  
  
  RESULTS
  Funding for the study was provided in 2013 under the United States Agency for International Development Fertility Awareness for Community Transformation project. Recruitment for the study will begin in January of 2017. The study is expected to last approximately 18 months, depending on recruitment. Findings on the study's primary outcomes are expected to be finalized by September 2018.
  
  
  CONCLUSIONS
  Reproducibility and transparency, important aspects of all research, are particularly critical in developing new approaches to research design. This protocol outlines the first study to prospectively test both the efficacy (correct use) and effectiveness (actual use) of a pregnancy prevention app. This protocol and the processes it describes reflect the dynamic integration of mobile technologies, a call center, and Health Insurance Portability and Accountability Act-compliant study procedures. Future fertility app studies can build on our approaches to develop methodologies that can contribute to the evidence base around app-based methods of contraception.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT02833922; https://clinicaltrials.gov/ct2/show/NCT02833922 (Archived be WebCite at http://www.webcitation.org/6nDkr0e76).
authors.affiliation: Institute for Reproductive Health, Georgetown University, Washington, DC, United States.
authors.forename: Rebecca G
authors.identifier: http://orcid.org/0000-0003-3516-4585
authors.initials: RG
authors.lastname: Simmons
authors.affiliation: Institute for Reproductive Health, Georgetown University, Washington, DC, United States.
authors.forename: Dominick C
authors.identifier: http://orcid.org/0000-0002-8524-8149
authors.initials: DC
authors.lastname: Shattuck
authors.affiliation: Institute for Reproductive Health, Georgetown University, Washington, DC, United States.
authors.forename: Victoria H
authors.identifier: http://orcid.org/0000-0003-4963-1930
authors.initials: VH
authors.lastname: Jennings
keywords: contraception; family planning; fertility; fertility awareness; mHealth; mobile health apps; natural family planning; reproductive health; study protocol