Reasons for delay in contraceptive clinic utilization

JOURNAL OF ADOLESCENT HEALTH 1991;12:225-232

Reasons for

iza

Adolescent Clinic and Nonclinic Populations LAURIE

S. ZABIN,

Ph.D.,

HEATHER

A. STARK, AND

Because delay in ascessing sontraceptive services is a serious obstacle to prevention of unintended pregnancy in adolescence, reasons for delay are probed in a iunior and s.?nior high school population and compared with results ob.tained amon 435 young black women previoidsly surveyed in 32 U.S. clinics, The 3F8 students B’.~: veyed before exposure tcrpregnancy prevention services ,arrecompared with 422 surveyed after 82 years expasure to a successfi~l educational/clinical intervention program. Particular attention is paid to reasons cited by those who never utiiized sen+e?: important reasons cited by all groups include fear that contraception is dangerous (cited by 40.0% at baseline), fear of parental discovery (30.5%3, and awaiting “closer” partner relationships (31.3%). The last reason was often cited a year or more after initiating coitus. That the perception of birth control as dangerous is a barrier TV contraception is confirmed by the large proportions who cited it among those who had never used clinical services. Programmatic implications of the findings are discussed.

RRYWORDS:

Contraceptive clinics Adolescents Pregnancy prevention

A serious obstacle to the prevention of unintended adolescent pregnancy is delay between first experience of intercourse and first attendance at a profes-

From the Dep&ment of PopulationDynamics, Johns Hopkins University School of Qgiene and Public Health, Baltimore, Mayland. Address reprint r.vuests to: Laurie S. Zabin, Ph.D., 61s N. Wolf;.’ Street,Baltimore, ML’ 21205. Manusccriptaccepted December12, 1990.

QSociety %rAdolescent

Compared MARK

R. EMERSON

sional facility to obtair! reliable contraception. The :Ghdion of that interval and reasons for the delay welt? explored severai years agq among patients who presented at such a facility for the first time (1). A median interval of almost a year was reported, and procrastination was the most frequent reason cited. Among whites, fear that parents would find out was an important reason; among black teenagers this was less frequently mentioned but ranked high nonetheless. Other studies have often dealt with structural or institutional barriers to contraception (2-4) but have aisq shown the importance of perceptions of birth control itself (5). Although almo st 36% of the subjects of the origins1 clinic-based study initially presented when they already suspected that they were pregnant (l), there was no information on young women who never r.ttcn.ded a clinic. This study uses a school population to address two areas of interest which follow from the clinic-based report: 1) How do reasons for delay among young people who do and do not visit clinicsdiffer,

if they differ at all? Thus, are there reasons which are sufficiently powerful not only tr delay but to prevent sexually active young people from taking that precautionary step? 2) When a progtim successfully provides students with access to clinical facilities and increases both overall and prompt attendance at a reproductive health cente-, do reasons for delay change? What are the expressed reasons for delay among those Ivho, in the presence of proximate, free, and popular services stil fail to utilize professional facilities availtible to them? In addition to permitting us to answer these questions, __ the extensive data in the school surveys allow us to explore the extent to which reasons young people give for postponing attendance at a contraceptive

Medicine, 1991 Published by Bsevier Science Publishing Co., Inc., 6.5 Avenue of the Americas, New York, NY 10010

225

1054-139x/91/$3.50

226

ZABIN ET AL.

facility accord with information

about their sexual knowledge, attitudes, and behavior. They allow us to answer the question: To what extent do behaviors and other perceptions young people report give us insight .Wo their reasons for delaying clinic attend’ance? Do they support or contradict the messages their reasons give us about how clinic services might be better accessible to them?

Methods ‘a2 originalstudy of adolescents’ delay in clinic at-

tendance included first-time patients in 32 family clinics in eight cities in the United States (1). Respondents answered while awaiting care, before counseling took place. The 435 black sexually active young women 118 years of age who answered the relevant question are utilized in t.his study. Similar questions were asked of students in two inner city Baltimore schools in baseline data collected for the evaluation of a pregnancy prevention program and were repeated in several follow-up interviews (6,7). As we have reported elsewhere (7,8), the program offered medical and education/counseling services. A social worker and a pediatric nurse practitioner or a midwife were assigned to each program school and were available to the students during the school day; they delivered classroom lectures and conducted small group and individual counseling sessions to students who came to their Health Suite. The same staff was available to the students in the afternoon in a c&tic close to both schools. Contraception and reproductive health care were offered as well as individual and group counseling and education. Condoms were available and young men were counseled in their use; thus, clinic attendance was an important component for males as well as females. Compared to two control schools which completed surveys but received no special services, the program demonstrated a dramatic increase in the percentage of young people who had ever attended a clinic, a deCrease in the interval between onset of sexual intercourse and clinic attendance, and a decrease in both childbearing and abortion rates. Data collected before the inauguration of the 28month intervention are reported here (“baseline” in the tables that follow) and compared with data reported by those exposed to the program for 2 or more years. The junior and senior high schools in which the program was offered are included in this report; control schools are omitted. planning

JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 3

From the original 32-clinic sample, the data utilized he:,::, are restricted to the responses of black patients becB rse all of the comparison students were black. Similariy, data from 19-year-old girls are omitted in order 24 ,natch the sampIe as closely as possible to the school population. The school data reported here were based on all students completing the baseline questionnaire, approximately 98% of the students presqnt on the day of administration of the survey in the program schools. Among them, 388 sexually active girls responded to the relevant question. At follow-up, only the responses of those students who were exposed to the program for 2 years or more are included; that is, exposure implies presence in the school while the program was offered, not necessarily program utilization. (If schoollinked initiatives are designed to reach those who do not present for service, their effects must be evaluated in the entire student body, nd:$tmerely among the self-sekcted individuals who seek out their offerings.) Since data were collected in spring, 2 years of exposure includes eight and ninth graders in the 1 unior high school if they had attended from seventh grade on, but excludes seventh graders. Similarly, in the senior high school, only lOth, llth, and 12th graders in attendance for 2 or more years are included. Those who transferred into the school more recently and all ninth graders are excladed. Among those with 2 or more years exposure, 422 sexually active females responded to the question explored here. In each self-administered survey the students were asked whether or not they had ever attended a clinic for contraception. They were asked to check all the reasons which contributed to their difficulty in attending a clinic more promptly, and to identify their single most important reason. The questions on delay were phrased similarly in the two sites but a few options offered the respondents in each site were not offewcl in the other. Talcs, in the original clinic survey, .the phrase “Just didn’t get around to it” was high on the list of responses. Although procrastination is a typical adolescent behavior, that question was not considered specific enough to give the information we sought from the school population and was therefore omitted. “I never thought of it” was also omitted from the school questionnaires. Sir#larIy, in the schnsl survey the possibility that youngwomen might not have attended because they were not having sex ‘was explored; that choice had not been included in the original clinic questiormaire. Accordingly, in reporting distributions of the responBe;tts’ most important and contributing

May 1991

reasons, questions will be marked not available (na) in the surveys in which they were omitted.

Results Table 1 presents the original responses given in the cknic settings; the first percentages refer to the most important reasons and the second percentages to contributing reasons. The next four columns give these data for students at baseline, the first two for those who hnd attended a contraceptive facility at some time, and the next two for students who had never attended such a facility. The right-hand panel repeats this pattern for young women surveyed after they had been in a school with the pregnancy prevention program for 2 years Or more. (Many respondents who answered the checklist on contributing reasons did not note the singYe most important reason as requested. Therefore, N for the two columns within each survey group differ. Respondents to the “most important” reasons are a subset of those who answered the question on “contributing” reasons.) It is quite possible that the young people who have attended clinics are reporting problems which they have overcome. Although their recollections of the period before they attended may reflect what they currently find difficult, it is equally possible &at the obstacles to which they refer are no longer salient. On the other hand, responses of those who have never attended a clinic can be more easily interpreted: they are probably reporting reasons which are current and therefore stiQ powerful. Table 1 shows that the students report essentially the same primary reasons for delay as the original clinic attendees; furthermore, there are few differences in the ordering of responses between those who had and those who had not attended a clinic for contraception. In fact, in all1the surveys reported here, in clinics and schools, before and after program exposure, and among those who had and those who had not attended contraceptive facilities, the same top three reasons are cited as most important among the reasons which are available in every questionnaire. They include the belief that birth control is dangerous, postponement until a’ relationship is “closer,” and fear of parental discovery. The first reason-fear that birth control is dangerous-is cited by a very similar percentage of the sexually active black girls in the original clinic population (34.1%) and students in the school sample who had attended a clinic before the program was in Rlac? (35.4%). It is cited by an even larger per-

DELAY IN CONTRACEPTWE CLINIC UTILIZATION

227

centage of rhose who had never been to a cwc (44.7%). !k prevalent is fear of contraception that it is cited in the baseline data as a contributing reason by a higher percentage of the young students who never attended a clinic than any other reason among any of the distributions in Table 1. In the original clinic study, there were significant differences between the level of fear of contraception among Close with the longest delays t3 clinic attendance and those who came promptly (p = .0006). Furthermore, there were many more blacks who held this conviction than whites. The frequettcy with which the current black sample reports a perception of birth control as dangerous, and the significant differences in its frequency between those who have and those who have not attended a clinic at baseline (P = .003), echo those findings in these nonclinic samples and suggest the importance of this barrier to medical contraception among the minority popUlii‘iihl. The program did reduce the proportion who held this belie; a:nong all the respondents; the differences between proportions citing it before and after the program were significant at p = .03. I-lowever, although the program had significa$t effects on clinic attendance (7), it was apparently unable to eliminate the sense that birth control is dangerous. Whereas almost half the sexually active young women had not attended a clinic before the program, only 26.8% had failed to attend after exposure. [These percentages are based on those who responded to the question about reasons for delay. Therefore they differ slightly from our published reports based on the entire sample in which the proyortion of sexually active young women who never attanded a clinic dropped from 48.1% at baseline to 29.1% for those expoqd to the program 2 or more years (7).] Thus, although fear of contraception remained an important reason cited by 31.0% of those who failed to attend, its ability entirely to discourage attendance appeared to become less powerful. Another response that ranks high on all the lists is the postponement of attendance until the respondent has a closer relationship with her partner. That would be a 1ogicaIreason for delay if the respondents defined the onset of coitus as evidence of a closer relationship. Unfortunately, that was rarely the case. TF-,emean interval from first intercourse to first Clink attendance wals 15.7 months among the black patients in :he original clinic sample (1); among students who had attended a clinic at baseline that @,eer~alwas 15.9 months. Among the sexually active baseline schod sample who had not yet attendea

228

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zAB~N ET AL.

of Sexklly Active Respondents by Reasons Cited as Most Important for Delaying Piit Clinic Visit, and percentage Citing F&h Reason as Contributing to Their Delay, by Survey Site, l%gram Exposure, and Clinic Attendance

‘f’;lblc 1. percentage Distribution

School population at baseline

Clinicpopulation

Ever to a clinic Most imporReacon

(n :l7)

School population at 2 or more years

Never to a clinic

Ever to a cfinic

Most Most Most ContribimporContribimporCaSttrib- imporContrib!&ing tant uting tam uting tant uting (II = 435) (n = 162) (a = 209) (I = 140) (n = 179) (3 = 175) (n = 309)

Never to a clinic Most important (n = 84)

Contrib uting (?I = 113)

13.6

34.1

13.0

35*4

19.3

4.7

13.1

23.0

10.7

31.tF’

9.1

25.9

13.6

34.4

10.0

27.4

23.4

30.4

10.7

34.5

8.5 na

28.0 na

11.1 12.3

26.8 19.6

20.7 17.1

34.6 24.6

17.1 12.6

23.J 12-d

20.2 23.8

2:;

6.9

22.5

6.2

22.5

5.0

20.1

4.6

16.2

4.8

23.0

5.7

23.0

1.9

15.8

1.4

11.7

5.1

12.6

2.4

14.2

5.7

19.6

7.4

17.2

4.3

14.5

4.6

8.7

2.4

15.Y

3.8

14.3

1.2

1.4

0.7

1.7

1.1

3.2

3.6

4.4

3.5

15.6

8.0

13.9

2.9

15.6

1.1

6.5’

1.2

13.J

3.5

10.3

4.9

7.7

4.3

12.3

1.7

2.9

1.2

7.1*

2.5

16.7

1.9

10.0

1.4

8.9

1.7

8.4

1.2

8.0

2.5 1.9

15.6 8.2

4.9 1.9

14.8 9.1

0.7 1.4

9.5 12.3

;I%

x.4 6.1

1.2 1.2

3.8 9.7

1.9

2.9

0.6

3.3

0.0

0.6

1.J

1,9

0.0

1.3

1.6

6.6

3.7

12.P

2.1

5.0

4.0

7.4

6.0

10.6*

where to get birth control Sex wit5

1.3

P.4

0.6

9.6

0.7

6.1

3.4

6.1

3.2

5.3

somwxe ia the fi+Zlki? Just didn’t get

0.0

1.1

0.6

1.9

0.7

1.1

0.0

1.3

0.0

0.0

13.9

37.3

8.8 5.4 100.0

17.5 6.6

DallgeKnla to use

Waitingfora &Ber d-P Afraidfamily would find out Not having sex Afraidtobe examined Did not have sex often enough to get pregnant Didnotexpact wzdtoget pregnant ‘fooyoungtoget pregnant Boyfriend did not wantbirth control Thought it cost too much Need to be older iogetbirth control WrOngtouSe

Forcedto have MeTOdusing good enou* DidlporknoW

md t+rit Never thought of at other

na

na

na

na

na

na

na

na

na

na

na na na _1.7 5.2 8.3 l”s9 loo.0 loo.0 100.0 100.0 ‘p s .Ol, ‘p s .OS, for the signiticance of differences between baseline and follow-up ‘k Ever c’rinicgluyups, and ’ in Never clinic groups‘p s 45, ‘p S .Ol for the dpitkance of diirences between Ever and Never clinic groups in same survey period. &

lY9

7.1

1:

May1991

any facility for contraception, the mean interval since first coitus was over a year and a half; while a few girls had only initiated coital activity the mon:h of the intervielv, half of the girls had been exposed for more than a year, a quarter for more than 2 years. Under these circumstances, the “closer relationship” they awaited was not the coital contact which exposed them to the risk of pregnancy. The pregnancy prevention program attempted to raise students consciousness of the importance of contraception with any coital exposure; nonetheIess, at follow-up young women still frequently responded that they were awaiting a “closer relationship.” In fact, that was the dominant reason for delay for as many as 23% of those who had attended a clinic. Among the subset whose Cast coitus occurred after the program was in place (this is the only group among whom a change could be observed if the program did create a n-ore realistic appreciation of risk), the mean interval from first coitus to first attendance was lowered to 6.4 months. For those whu had not attended a clinic, the mean exposure to intercourse at the time of the survey was 10.4 months. Thus, although there was a dramatic reduction in the duration of delay and an increase in the percentage who sought contraception, it remains critical to understand the nature of the relationship for which these young women were postponing attendance. Fear of discovery by parents is among the top reasons in all the distributions we report. The need for confidentiality appears particularly important to the subset of students who had never been to a clinic. In the original clinic sample, fear that parents would find out was more often cited by those who did not present until they suspected a pregnancy (35.5%) than by those whose behavior was preventive (22.4%), a difference significant a; p = .008. The same relationship is illustrated in the baseline school data where this reason is cited as most important by almost twice as many of the students who had not attended a clinic as those who had; although the difference bettveen the numbers who cite this reason among clinic and nonclinic groups does not reach si@ficance at ba&ne, it does among those exposed for 2 or more years (p = AM). Fear of parents is cited by over one third of the subset of sexually active students who, after exposure to the program, continue to be without professi.onaJ. contraceptive assistance. Thus, it remains a dominant reason for delay. In the original study, fear of parents was a much more powerful reason for delay among white than

DELAY IN CCNTRACEPTIVE CLINIC UTILIZATION

229

black 6; ds. Although the response ranks high on the list in the current minority sample, the frequency with which it is cited is similar to the black patients Jn the clinic population with one important exception: those in the school sample who have never been to a clinic have a higher likelihood of citing this reason than any blacks in the original clinic-based study, confirming its salience as a barrier to professional contraceptive services. AS many as 23% of the young women cite fear of the physical examination as a reason contributing to their delay. This fear does not decline apang those who have never attended the program clinic or any other facility after exposure to the program. Tables 2 and 3 compare the responses by age. The prime reasons fa,rdelay remain fairly constant. However, fear of the dangers of contraception is most prominent among girls 15 years and younger, especially those who have never attended a clinic. Over 55% cite this fear at baseline. Furthermore, the significant difference between those who have attended and those who have not is greatest among this age group. Not surprisingly, the notion that they are too young to get pregnant is also more frequently cited among the younger group. A third area of inquiry was the relationship hetween the explicit reasons for delay and =everal knowledge, attitude, and behavior variables that might impact upon the students’ responses. This relationship is typified by tt.e apparent contradiction reported above between the respondents’ explicit statements that they awaited a “closer relationship” and the coital behavior in which they were engaged. Although there are generally significant correlations between responses to the question on delay and the behaviors they report in many areas, a large minority of answers in each case are inconsistent. Thus, although more of those who thought they were “too young to get pregnant” were in the younger rather than the older age group (Tables 2 and 3), the vast majority of them knew pregnancy could occur right after the first menstrual period (83.3%), a benchmark which a!1 had reached. Just over 14% of the girls of all ages who did not seek services said they were having sex too infrequently to become pregnant (Table 1); they were, in fact, having sex less frequently than those who did not check that answer, but 93.3% of them knew that it was possible to conceive if a womzn “has sex only once.” Those who expressed fear of their parents’ discovery were less likely than those who did not check that answer to report that it was easy to talk about sexual behavior with Weir parents (40.4% vs. 63.6% at follow-up). They were

230

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ZABIN ET AL.

Table 2. Percentage of 11- to 15-year-old Sexually Active Respondents Citing Each Reason as Most ImprMant for hiaeg ~h,_ir First clinic Visit, and Percentage Citing Each Reason as Contnbuting to Delay, by Age, Program Exposure, and Cliiic Attendance Baseline 2 2 yr Never to clinic

Ever to clinic Most important

Ever to clinic

Never to clinic Most inipor- Conhibutant iing (n = 22) (n = 31)

(n = %)

Most important (n = 23)

Contrib uting (n = 40)

29.1

55.2

13.0

25.0

13.6

45.2

Mokt important (n = 79)

Contrib-

14.6

Contributing (n -- 59) 33.4

Waiting for a closer relationship with partner

a.3

28.6

10.1

26.0

21.7

30.0

13.6

32.3

Afraid family would find out if 1 came Not having sex Afraid to be examined

14.1 6.3 4.2

35.6 11.9 23.7

21.5 10.1 2.5

35.4 18.8 25.0

17.4 4.3 8.7

27.5 7.5; 12.5

18.2 22.7 0.0

32.3 32.3 32.3

0.0

Reason Dangerous to use

-

(n = 48)

rttillg

Did not have sex often enough to get pn%nant Did not expect sex Wantedto get pregnant Too you% to get pregnant

4.2 2.1 12.5

15.3 13.6 1.7 16.9

1.3 3.8 1.3 3.8

15.6 16.7 2.1 20.8

1.3 0.0 0.0 4.3

10.0 15.0 2.5 10.0

0.0 4.5 4.5 4.5

12.9 29.0 6.5 25.8

Boyfriend did not want biia control Thought it cost too much

10.4 2.1

13.6 3.4

6.3 0.0

11.7 10.4

4.3 0.0

7.5 2.5

0.0 0.0

16.1 9.7

Need to be older to get birth control

6.3

22.0 I.3 12.5 4.3 12.5 4.5 -_L_>*.., __ ‘p s .OSfor the significance of diffeferences between Eve? and Never clinic groups in the same survey period.

16.1

more likely to report that they did not want their parents to know they were sexually active (60.8%

vs. 32.2%). If a girl had never attended a clinic she was more likely to report that she did not want her parents to know. But in each of these comparisons, there remain a Gbstantial number whose replies were discrepant. Similarly, those who said they were “not having sex” report less frequent coitus than those who did not check that r~$y, whether reporting on the previous month or the month in which their sexual activity was greghtest. But in no case was their mean frequency zero. Their knowledge appeared to be adequate for them to know they were in need of contraceptive ptotection: 98.7% knew that one could get pregnant at a single exposure.

Discussion The main reasoris sexually active young black women give for postponing attendance at a contraceptive facility are surprisingly consistent when clinic patients in eight U.S. cities are compared to an inner city school sample. Furthermore, the three main reasons for delay given by those in the school sample who had never been to a clinic for birth con-

trol are the same asPhose cited by students who had, at soE*e time, sought contraceptive services. So robust are these three reasons that even after exposure to an intensive program, the few sexually active young women -Nho still havls not sough.t contraceptive assistance continue to give them as prime explanations for their delay. The proportions citing m3ny of the contributing reasons diminished among tirose who attended a clinic. This no doubt facilitated their attendance. However, as suggested above, their responses may refer to the period before they attended. On the other hand, among the subset who never attended at all, the proportions citing many of the barriers to clinic attendance remained high and the order in which the reasons were cited was not substantially changed. The importance of these major deterrents to clinic attendance is thus confirmed in the school population by the continuing-and at times exaggerated-importance of these deterrents to those who were unable to overcome them even after program exposure. The program sharply increased the numbers of girls who sought services (7); thus, for z~any it ap-

parently changed or weakened perceptions that had stood in the way. Whereas at baseline, 48% of the

DE%AY EN CONTR4CEFIlVE

May 1993

CLINIC UTILIZATBON

1131

‘kabte 3. Pe?wttage

of 16- to l&Year-Old Sexually Active Respondents Citing Each Reason as Most Important for Delaying First Clinic Visit, and Percentage Citing Each Reason as Contributing to Their &lay, by Age, Program

Exposure, a,>d Clinic Attendance -

_Baseline

-P

Ever to clinic Most irnportant

I_ 2 2 yr

Never to clinic

Ever to clinic

Contributing (n = 150)

Most important (n = 63)

Contributing (n = 83)

12.3

36.0

6.6

32.5

13.2

25.8 9.6 14.9 7.0

36.7 23.3 22.7 22.0

9.8 19.7 26.2 8.2

28.9 33.7 .?I.,? 14.5

get pregnant Did not expect ser Wanted to get pregnant Too young to get preg:ri:Tnt Boyfriend did not want birth

2.6 8,8 0.4 6.1

16.0 lB.7 1.3 12.7

1.6 4.9 0.0 I.6

control Thought it cost too much Need to be older to grt birth

2.6 1.8

5.3 12.7

4.4

12.0

Reason Dangerous to use Waiting for a closer relationship with partner AfmU family would find out Not having sex Afraid to be examined Die not have sex often enough to

contra!

{n =

114)

_.YSL”

Most imporCon tribtant (?I = 152) (z%9)

Never to cfirtic Most irnFgr-

co I!Przj,-

22.7

s.7

25.6”

23.7 17.1 13.8 3.9

30.5 22.7 13.6 16.7

9.7 22.6 24.2 6.5

35.4 34.1 31.P tn.5

7.2 12.0 1.2 9.6

5.3 5.3 1.3 0.7

13.0 7.8 3.3 5.9

3.2 1.6 3.2 0.0

14.6 11.P 3.7 85~

1.6 3.3

6.0 7.2

1..3 2.0

2.2 9.3

1.6 1.6

3.7 7.3

0.0

6.0

2,6

10.0

0.0

6.1

“p I .Ol, ‘p 5 .05 for the significance of differences b*.:~~cen keline and f~ilow-up in Ewr chic group ‘p 5 .O$ dp z .Ol for the sigmicance of dilkrencei b~v~een Ever and P&ver chnic gcou? in the same gurvep oeriod.

sexuaally active students had nearer attended a Gnic or physician’s office for contracep:ion, only 29% of those who were exposed to the pi b~gr.~)nfailed trh mail themselves of services, either a( the program facility or elsewhere. Although the pl.vsical proximity of the clinic and the ease with whi:-h it could be accessed made a major difference, thesedata suggest that physical barriers to attendance were less prevalent among these young, women before the program began than the barriers imposed by many of their attitudes and perceptions. Cost or ignorance of a source are rarely cited as barriers even at baseiine. As important as cost and physical bhrriers may be to some young people, it appears that many of their perceptions must be changed before institutional obstacles become germane. The role of confidential treatment is critical in both age groups among those who have and those who havs not overcome this fundamental reason for delay. That over one third of the girls who stayed away from the clinic continued to cite this as their reason is distressing in view of the fact that confielential care was w&-publicized in the school program. It suggests the n!eed to personalize the promises of the staff, 8 need which can probably be met only through individual contact and counseling.

The disct-ep- L&S VW report between abstract knuy&dge of the risk GEprpgnaracy and the percegEOXWwhich dr!ayed .atk)nJance suggest the importance of helping ad&scents learn to internalize the infor-mstion they receive. That postmenarcheal young wc,rll.en cite their youth as a reason for delay is troubli:ig. So is the fact that long after first coitus many still await cllc!ser relationships before they seek medical contraception. It has been shown that coitus

is an early form of sexual expression among many young black teens, earlier in the eequence of physical contacts than among young wnites (9). That may imply a separation between the 2csene~ idung women seek in their sexual relationships and the act of intercourse, which CWLin turni p!ay an important role in delaying protective behavior. Perhaps the rt+ sponses of these youn.g black women imply their need for relationships close enough to permit them to accept and acknowledge thei, sexual activity, to be sufficiently comfortable with their sexuality to seek contraception. Perhaps they :*:zre r?4+-?g to feel close enough to discuss birth control with their partners. Those who deal with adolescents should be aware of the association between subjective aspects of their clients’ sexual relationships and the use of contraception. Adolescents’ emotions and

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perceptions may be more powerful cues to protective behavior thaa the onset of coitus. It is easy to speculate that teenagers’ response to quc&timmairesof this sort might be somewhat casual ay:d to interpret contradictions as evidence of carelesstkeas. There is, however, considerable evidence that they took the surveys quite seriously (10). We prefer to interpret the contradictions we find between their perceptions and their knowledge as evidence of their inability to internalize all they know; we see contradictions between their perceptions and their behaviors as evidence of their inability to act upon what they believe (11). The perceptions that bl0ckt.d their utilization of services appeilr often to be just that: they are perceptions, not supported by either their behavior or their abstract knowledge. One of tire most difficult barriers to c’iinic attendance tr, overcome may be fear of pel-Gc examination. With this in mind, the National Academy of Sciences’ panel on adolescent pregnancy suggested experimentation with less “medical” models of family planning service (12). Because these data suggest that fear of examination, while very widespread, is rarely the single dominant reason for delay, there is no guarantee that a change in clinic *,rocedures or education relative to those procedures .Nould change the level of attendance; however, th:. ::e is clear evidence that it remains a serious obstacle to preventive intervention. In light of the prevalence of sexually transmitted disease among adolescents, there has been some reluctance among providers to forego pelvic examination. However, rather than scaring young women away from professional sources of care, the possibility that examination be delayed until a follow-up visit, after confideme and trust are established, is an option to explore. It is a matter of serious concern that young women perceive contraception as dangerous in view of the safety of approved methods and the higher relative risk of pregnancy. But it is understandable that teenagers echo this fear; such attitudes are prevalent among adult women in the United States, A telephone survey of adults revealed that negative attitudes toward contraceptive methods were much more pervasive than problems of access or institut&al barriers to use (3% vs. 9%) (5). .fiere is every

JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 3

indication m our samples that the perception of risk is strong enqugh effectively to prevent attendance; while a powerful program increased the proportion of those who overcame their fear, this variable distiminates quite dramatically between those who do and those who do not avail themselves of professional services. Young people, indeed women of all ages, need accurate estimates of the effectiveness, side effects, risks, and benefits of all available contraceptive methods if they are to make rational choices for their own protection. Thfs widespread &ar of available and safe birth control methods must be addressed.

References 1. Zabin LS, Clark SD. Why they de!ay: A study of teenage family planning clinic patients. Fam Plann Perspect 1981; 13:205-17. 2. Chamie M, Eisman S, Forrest JD, et al. Factors affecting adoiescents’ use of family planning clinics. Fam Plann Perspect 1982;14:126-39. 3. &bin LS, Clark SD. Institutional factors affecting teenagers’ choice and reasons for delay in attending a fam:ly planning clinic. Fam Plann Perspect 1883;15:25-9. 4. Severy LJ, McKillop K. Low income women’s perceptions of family planning service alternatives. Fam Mann Perspect 1990;22%0-7. 5. Silverman J, Torres A, Forrest JD. Barriers to contraceptive services. Fam Plann Perspect 1987;19:94-102. 6. Zabin Ls, Hirsch MB, Smith EA, et al. Adolescent pregnancyprevent.2 n program: A model for research and evaluation. Adolesc Health Care 1986;7:Tl-87. 7. Zabin LS, Hirsch MB, Smith EA, et al. Evaluari~~n of a pregnancy prevention program for urban teenagers. Fam Plann Perspect 1986;183119-25. 8. Zabin LS, Hirsch MB, Streett R, et al. The Baltimore pregnancy prevention program for urban teenagers: How did it work? Fam PIann Perspect 1988;20:182-7. 9. Smith EA, Udry JR. Coital and non-coital sexual behaviors of white and black adolescents. Am J Public Health 198.5; 75:12#-3. 10. Zabin LS, Hirsch MB. Evaluation of pregnancy prevention programs in the school context. Lexington, MA, Lexington Books, 1987. 11. &bin LS, Hirsch MB, Smith EA, et al. Adolescent sexual attitudes and behavior: Are they consistent? Fam Plann Perspect 1984;16:181-5. id. Hayes CD. Risking the future: Adolescent sexuality, pregnancy, and childbearing. Washington, DC, National Academy Press, 1987.