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Changes in Young Women's Awareness, Attitudes, and Perceived Barriers to Using Emergency Contraception
J Pediatr Adolesc Gynecol (2005) 18:25–32
Original Studies Changes in Young Women’s Awareness, Attitudes, and Perceived Barriers to Using Emergency Contraception Allison M. Aiken, BS1,2, Melanie A. Gold, DO1,2, and Andrew M. Parker, PhD3 1
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; 2Children’s Hospital of Pittsburgh, Division of Adolescent Medicine, Pittsburgh, Pennsylvania, USA; 3Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
Abstract. Background: In a 1996 survey, most young women ages 13–20 years from an urban, hospital-based clinic and a drug treatment center had inadequate awareness of emergency contraception (EC), and perceived several barriers to its use. Since that time, the FDA has approved two products for EC, media coverage has increased, and physicians have provided more counseling about EC. Purpose: The purpose of this study is to compare the awareness, attitudes, and perceived barriers to using EC among a sample of young women from 1996 with a different sample of women from 2002. Methods: We recruited 139 young women (mean age 16.7 ⫾ 1.8 yrs) from the same adolescent clinic and drug treatment center as the 1996 sample. They had similar demographic characteristics, with the majority (63%) being African-American or multi-ethnic; 85% had ever been sexually active. They were interviewed using a questionnaire about their sexual and contraceptive history as well as their knowledge of and experience with EC. They then watched a 41/2 minute video and received a 5-minute didactic review of EC. Following the educational intervention, participants’ knowledge, attitudes, and perceived barriers to using EC were assessed. The questionnaire used to guide the interviews was nearly identical to that used in 1996. Results: Between 1996 and 2002, the percentage of participants reporting that they had ever heard of EC grew (44% vs. 73%, P ⬍ 0.001), as well as the percentage reporting that they had ever used EC (4% vs. 13%, P ⫽ 0.02). Of those participants who had ever heard of EC, fewer 1996 participants knew where to obtain it compared to 2002 participants (78% vs. 95%, P ⫽ 0.002) and fewer 1996 participants knew the correct time limits for use (20% vs. 51%, P ⬍ 0.001). The above data were collected prior to a didactic review session about EC. After receiving information about EC, the percentage of participants reporting a positive attitude toward EC grew between 1996 and 2002 (72% vs. 96%, P ⬍ 0.001). Young women also had fewer concerns about Address correspondence to: Melanie A. Gold, DO, Children’s Hospital of Pittsburgh, Division of Adolescent Medicine, 3705 5th Avenue, Pittsburgh, PA 15213; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
safety and side effects in 2002. The 1996 participants were more likely to report barriers to using EC compared to the 2002 participants. In 1996, EC side effects and impact on fertility were the most commonly perceived barriers to EC use. However, in 2002 the frequency of all reported barriers decreased and cost had become the number one perceived barrier. Conclusion: Since 1996, young women at an urban hospital-based adolescent clinic and drug treatment center increased their awareness, use, and positive attitudes towards EC, as well as decreased their perceived barriers to using EC. Educational interventions that focus on improving knowledge among younger adolescents, specifically about correct time limits and identifying ways to find affordable EC, will address the most common knowledge deficits and perceived barriers to EC use among adolescents.
Key Words. Emergency contraception—adolescents— contraception—postcoital contraception—knowledge— attitudes—perceived barriers
Introduction Although pregnancy and birth rates among U.S. adolescent women continue to decline, it is estimated that 822,000 pregnancies occurred among 15–19 year old women in 2000 resulting in 469,000 births and 235,000 abortions.1 U.S. teens became pregnant nearly twice as often as their counterparts in Great Britain or Canada and three to four times more often than teens in France or Sweden with little difference in rates of sexual activity.2 Emergency contraception (EC) is the only form of contraception that can reduce the risk of pregnancy after unprotected sex or when a planned contraceptive method fails. EC may be particularly useful for adolescent women whose first sexual intercourse or sporadic 1083-3188/05/$22.00 doi:10.1016/j.jpag.2004.11.002
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pattern of intercourse is frequently unplanned and therefore unprotected.3 In order to use EC correctly, adolescents must be well informed. They must know that EC exists, know the time limits within which it is effective, know where to obtain it, and be able and willing to access it. Fears and misconceptions about side effects, potential effects on future fertility, and confusion with mifepristone (RU486) used for abortion may hinder young women from accessing this backup method of contraception.4–11 A 1996 nationally representative study of over 4,000 Swiss teens showed most sexually active young women (89%) knew about EC and 20% reported ever using EC.12 In the United States, awareness of EC has lagged behind Europe and U.S. teenagers have historically had the lowest rates of awareness and knowledge. In a 1996 telephone survey of 1,510 U.S. teenagers, only 33% of 12–18 year old girls had heard of the “morning-after pill” or EC and only 9% knew the correct time limits for it use.13 A 1998 study found only 30% of inner city adolescents had ever heard of EC and 84% reported having no idea what steps could be taken after unprotected intercourse to reduce the likelihood of pregnancy.7 In 1997 the FDA recognized the use of certain combination and progestin-only oral contraceptives for EC14 and products designed specifically for EC were approved in 1998 (Preven쑓, Gynetics, Somerville, NJ) and 1999 (Plan B쑓, Women’s Capital Corporation). Following these FDA approvals, there has been increased public and health care provider education campaigns.15–17 As a result of these changes, awareness of EC is improving. Recent data collected between November 2001 and February 2002 showed 52% of 15–17-year-olds have heard of EC or morning after pills8 and data collected in 2003 showed 55% of California teens were aware that there is something a woman can do after sex to prevent pregnancy.18 Data collected from studies at various sites pre- and post-1998 imply an increase in adolescents’ awareness of EC. However, to date, no longitudinal studies (or studies assessing awareness and knowledge levels of adolescent women from the same site) have been conducted to confirm this trend. The purpose of this study is to assess changes in female adolescents’ awareness of, attitudes towards, and perceived barriers to using EC in 2002 compared to 1996, among a similar sample of adolescents from the same two sites. We hypothesized that the changes in public and provider awareness of EC would lead to increased awareness and knowledge of EC, more favorable attitudes toward using EC, and fewer perceived barriers to EC use among female adolescents.
Materials and Methods Study Design Young women were recruited from the waiting area of a hospital-based adolescent clinic (HAC) and from a residential drug treatment center (DTC) in Pittsburgh, Pennsylvania, in the summer of 1996 and again in June 2002 through February 2003. After they provided written informed consent, participants were administered a 5–10 minute interview to assess demographic characteristics and sexual and contraceptive history including knowledge about EC. Participants reporting previous awareness of EC completed a 5-minute knowledge pre-test. All participants were then provided a 5–10 minute review of information about EC. In 1996, participants listened to an audiotape that read verbatim an educational pamphlet about EC that was created specifically for the study (available on request). In 2002, participants watched “Emergency Contraception: Patient Video”19 followed by a 5-minute didactic presentation to cover material which was not specifically addressed in the video and was commonly misunderstood by 1996 participants. Points emphasized during this discussion included: (1) EC is a back-up birth control method and not to be used as a regular method because it is less effective at preventing pregnancy and does not prevent sexually transmitted diseases, (2) times or situations that one may need to use EC, (3) side effect information, (4) EC is available without parental permission, and (5) lack of effect of EC on future fertility. Immediately following the review, participant’s knowledge was re-tested with a post-test identical to the pre-test. Then participants were asked additional open-ended questions and were read Likert scale statements to assess their attitudes and perceived barriers to EC use. This section lasted about 10–15 minutes, with the entire visit taking 30–45 minutes. The Human Rights Committee (Institutional Review Board) of the Children’s Hospital of Pittsburgh approved the study. Parental consent was waived and participants’ written informed consent was obtained prior to enrollment. Participants A total of 272 participants were interviewed, 133 in 1996 (95 from HAC and 38 from DTC) and 139 in 2002–2003 (100 from HAC and 39 from DTC). Participants were eligible to participate if they were female adolescents between the ages of 13 and 21 years. They could be sexually active, virginal, or abstinent. The HAC population was 73% African American or multi-ethnic and 21% Caucasian, with a mean age of 16.5 ⫾ 1.9 years. Most (80%) had been sexually active with a mean age at coitarche of 14.3 ⫾ 1.8 years. Among the sexually active group, 68% had ever had unprotected sex and 20% had ever been pregnant.
Aiken et al: Changes in Attitudes toward Emergency Contraception
While only assessed for the 2002 sample, over half of the participants (53%) were on medical assistance. DTC participants were 66% Caucasian and 21% African American or multi-ethnic, with a mean age of 16.2 ⫾ 1.1 years. The DTC population constitutes a high-risk population with 97% having been sexually active with a mean age of coitarche at 12.7 ⫾ 2.2 years. Among the sexually active group, 96% had ever had unprotected sex and 38% had ever been pregnant. In 2002, 28% reported being on medical assistance. Measures The questionnaire used to guide the interviews consisted of four sections. The first section contained 27 items on demographic information including age, race, sexual, contraceptive and obstetrical history and whether the participant ever heard of and used EC. This section was identical in the surveys used in 1996 and 2002, with one exception—the 2002 questionnaire had two additional demographic questions. The second section, the knowledge pre-test, contained 19 items (three open-ended, one multiple choice, and 15 true/ false) to assess knowledge level of EC for those participants who endorsed that they had ever heard about EC prior to the study. Three new true/false questions were added to the 2002 questionnaire. The post-test questions to assess knowledge were identical to the pre-test questions; they were completed by all participants after receiving the educational intervention. The last section of the survey (15 open-ended and 11 Likert scale items) assessed acceptability and perceived barriers to using EC. Seven new open-ended questions were added to the 2002 questionnaire to assess participant’s opinions about obtaining an advance prescription for EC, over-the-counter status of EC, and what EC should cost. Data Analysis Analyses were completed using Statistical Package for Social Sciences (SPSS).20 Comparisons of groups on categorical variables were performed using chi-square tests. Comparisons of groups on continuous variables were performed using two-tailed independent sample t-tests. Analyses were considered significant at α ⫽ 0.05. Logistic regressions were performed to look at predictors of awareness of, use of, and attitudes towards EC. Linear regression analyses were performed to look at predictors of perceived barriers. Relative to the HAC group, the DTC group had more Caucasians (P ⬍ 0.001), more sexually active individuals (P ⬍ 0.001), experienced coitarche at a younger age (P ⬍ 0.001), and had a higher past-pregnancy rate (P ⫽ 0.003). However, results regarding awareness of, attitudes towards, and perceived barriers to using EC, across years, did not differ substantially
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when the HAC and DTC sites were analyzed separately or combined together. Therefore the HAC and DTC data were combined and all subsequent results report analyses conducted on the combined sample for each time frame.
Results Demographics Table 1 summarizes the demographic characteristics. Between 1996 and 2002, the mean age of the two groups increased (from 16.1 to 16.7 years, P ⫽ 0.002) as did the reported mean age at first intercourse or coitarche (from 13.3 to 14.3 years, P ⫽ 0.001; Table 1). A smaller proportion of respondents were African American or multiethnic in 1996 than in 2002 (53% vs. 63%, P ⫽ 0.03). Among participants who had been sexually active, the percent reporting ever having unprotected intercourse decreased from 1996 to 2002 (83% vs. 72%, P ⫽ 0.04). The frequency of using a method of pregnancy prevention increased from 1996 to 2002 (mean 57% vs. 69%, P ⫽ 0.009). EC Awareness, Use, and Knowledge Between 1996 and 2002, awareness of EC increased (Table 2). The number reporting that they had ever heard of EC grew (44% vs. 73%, P ⬍ 0.001), as well as the number reporting that they had ever used EC (4% vs. 13%, P ⫽ 0.02; last row, Table 1). The first row of Table 3 displays a logistic regression model that predicts having heard of EC by year. When controlling for study site, age (as a continuous variable), race, religion, and sexual activity, awareness of EC increased from 1996 to 2002 (OR ⫽ 2.90, P ⬍ 0.001; Model χ2 ⫽ 54.6, df ⫽ 9, P ⬍ 0.001, Nagelkerke R2 ⫽ .25). Focusing on the sexually active adolescents, a second regression incorporated several sexual history variables, including age of coitarche, whether they have ever been pregnant, had unprotected sex, and birthcontrol method used at last sex (data not shown). This analysis revealed similar findings with awareness of EC increasing from 1996 to 2002. Those who had ever heard of EC completed the pre-intervention knowledge test. Among this group, the percent correctly stating where to get EC was significantly lower in 1996 than in 2002 (Table 4). Likewise, the percent correctly choosing 72 hours as the time limit for taking EC after unprotected intercourse was significantly lower in 1996 compared to 2002. However, there were no significant changes in knowledge that EC is not a type of abortion or that minors can get EC without parental permission.
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Table 1. Demographic Characteristics by Study Year Variables Mean Age in years ⫾ SD Race African American Caucasian Other Maternal Level of Education Not finish high school High school or GED Some college Religion None Non-Catholic Christian Catholic Other Religious beliefs affect day-to-day decisions* A lot A little Not at all Religious beliefs affect decisions about whether or not to have sex** Completely Quite a bit Somewhat Not at all Religious beliefs affect decisions about pregnancy prevention** Completely Quite a bit Somewhat Not at all Health Insurance** Medical Assistance Private/HMO Self pay Other Unsure Reproductive Health Ever been sexually active Ever been pregnant Ever had unprotected sex Mean Coitarche in years ⫾ SD Contraception used at last sex Male condom Birth control pills Mean Percent of Times Used Contraception ⫾ SD Ever used EC
1996 (n ⫽ 133) 16.1 % 53 34 13
⫾ 1.5 (n) (69) (45) (17)
2002 (n ⫽ 139) 16.7 % 63 32 4
⫾ 1.8 (n) (88) (45) (6)
p value 0.002 0.03
⬍0.001 31 (38) 45 (56) 24 (29)
14 (18) 39 (52) 47 (63)
32 42 15 11
17 55 17 10
(24) (76) (24) (14)
4 20 42 34
(4) (21) (44) (36)
18 14 19 49
(19) (15) (20) (52)
46 24 7 11 12
(64) (33) (10) (15) (17)
0.03 (43) (55) (20) (14)
21 (19) 40 (36) 38 (34)
84 29 83 13.3
(112) (32) (93) ⫾ 2.3
85 22 72 14.3
(118) (26) (84) ⫾ 1.6
0.88 0.25 0.04 0.001
65 (73) 21 (24) 57.1 ⫾ 34.4
71 (82) 23 (27) 69.1 ⫾ 33.1
0.37 0.79 0.009
4 (4)
13 (16)
0.02
*only collected in 1996. **only collected in 2002.
Attitudes toward EC after the Educational Intervention After learning about EC, the young women were asked the open-ended question “What do you think of it?” Their answers were categorized as “clearly liking it” (coded 1 for a “positive attitude” toward EC) versus “clearly disliking it” or “hard to tell” (each coded 0 for “not having a positive attitude” toward EC). Those categorized as having a positive attitude toward EC
gave qualitative responses such as “it’s a good way to prevent pregnancy,” “I would use it,” or “more people should know about it.” Those categorized as not having a positive attitude toward EC said “I think it’s wrong, because it’s like an abortion” or “it will mess with your body.” Three raters independently coded each participant’s response as 0 or 1, with majority rule determining the final code. The (Kappa) reliability between each judge’s codes and final codes were
Aiken et al: Changes in Attitudes toward Emergency Contraception Table 2. Awareness of EC, Positive Attitudes Toward EC, and Mean Number of Barriers to using EC by Study Year
Variables Awareness of EC Positive attitudes toward EC Mean Number of Barriers to Using EC ( ⫾ SD)
1996 (n ⫽ 133) % (n)
2002 (n ⫽ 139) % (n)
44 (59) 72 (96)
73 (101) 96 (133)
5.0 ⫾ 2.4
3.9 ⫾ 2.3
Table 4. Pre-intervention Knowledge of EC by Study Year
Pre-intervention Knowledge
p value ⬍0.001 ⬍0.001 0.001
.82, .86, and .90. The analyses used only the final codes. There was a significant increase in positive attitudes towards EC over time at both sites. The percentage of participants who gave positive responses following the educational intervention grew from 1996 to 2002 (72% vs. 96%, P ⬍ 0.001; Table 2). Table 3 presents a logistic regression model of positive attitudes toward EC. Using the entire sample, positive attitudes towards EC increased from 1996 to 2002, controlling for the same variables described above (OR ⫽ 15.65, P ⬍ 0.001; Model χ2 ⫽ 45.5, df ⫽ 9, P ⬍ 0.001, Nagelkerke R2 ⫽ .28). Focusing on sexually active respondents, EC was once again viewed more positively in 2002 compared to in 1996 (data not shown). Based on the latter regression analysis, those who reported using birth control pills at last intercourse were also more likely to view EC positively (odds ratio ⫽ 5.11, CI:1.33–19.54, P ⫽ 0.02). It should be noted that the educational intervention was not the same in the two study years. In 2002 there was a change to video media with an additional didactic segment. To assess the potential effect of this change on positive attitudes toward EC, we compared the differences in positive attitudes between those who had heard of EC and those who had not, assuming an educational intervention would have a bigger effect on those who had not heard of EC. Using both chisquare tests and logistic regression, the relationship between attitude toward EC and awareness of EC did not change across the two years, providing evidence
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Know where to get EC Know time limits to use EC Know EC is not a type of abortion Know can get EC without parents permission
1996 (n ⫽ 59) % 78 20 63
(n) (47) (12) (37)
63 (37)
2002 (n ⫽ 101) % 95 52 55
(n) (96) (52) (56)
74 (75)
p-value 0.002 ⬍0.001 0.37 0.12
that the educational interventions worked similarly in both years. (Analysis not shown). The survey also assessed participants’ willingness to use EC; 50% said that they could “think of a time in the past” when they could have used it. Over half (58%) perceived a potential need to use EC in the future. Of these, 95% said that they would use EC if it was needed. Additional questions in 2002 assessed participants’ attitudes towards wanting an advance prescription for EC, whether EC should be available over the counter, and how much it should cost. Most (85%) participants reported they would want an advance prescription for EC so that it was available at home when needed. Fifty percent of participants believed that EC should be available over the counter. When asked how much EC should cost, responses ranged from $0 to $200, with a median of $20. $10 and $40 were the 25th and 75th percentiles, respectively. In 2002, all participants were asked whether they thought knowing about and having EC available (by advance prescription and over the counter) would change the likelihood of their having unprotected sex. Few participants (10%) felt that knowing about EC would increase their likelihood of having unprotected sex. Twenty-five percent of participants felt that having EC in advance would increase their likelihood of having unprotected sex and 16% felt that having EC available over the counter would increase their likelihood of having unprotected intercourse.
Table 3. Regressions of Awareness of EC, Positive Attitudes Toward EC, and Number of Barriers to Using EC by Year
Logistic Regressions a Awareness of EC (n ⫽ 269) Study year b Positive Attitudes Toward EC (n ⫽ 267) Study year b Linear Regression a Number of Barriers to Using EC (n ⫽ 253) Study year a
b
Mean
Odds ratio
.51 .52 Mean .54
2.90 15.65 Regression Coefficient ⫺.79
Regressions also included age, race, religion, and ever had sex as control variables. 1996 used as the reference category.
b
95% Confidence interval
p value
1.66 5.08 95% Confidence ⫺1.38
⬍.001 ⬍.001 p value .009
5.08 48.20 interval ⫺.20
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Aiken et al: Changes in Attitudes toward Emergency Contraception
Perceived Barriers Participants were read a list of reasons why girls might not get EC and were asked to state if this was “not a reason,” “might be a reason,” or was “definitely a reason” for them to not get EC (even if they had unprotected intercourse). Responses of “might be a reason” or “definitely a reason” were combined together and considered as perceived barriers to using EC. In 1996, the top two perceived barriers to using EC were fears that it would “make me very sick” and fears that it would “make it hard to for me to get pregnant in the future.” These two barriers both decreased significantly between 1996 and 2002 (Table 5). In 2002, cost was the number one perceived barrier with 38% citing that cost of the medication might be or definitely would be a reason to not get EC and 37% citing cost of the visit. There were no significant changes in other perceived barriers, although the general trend was to decrease across time. An independent-samples t-test of the total number of barriers selected (from the list of eleven barriers from Table 5) showed the mean number of barriers decreased from five to fewer than four barriers from 1996 to 2002 (P ⫽ 0.001; Table 2). Table 3 presents a linear regression of the total number of barriers selected by respondents and demonstrates that perceived barriers dropped significantly from 1996 to 2002 (β ⫽ ⫺.79, P ⫽ 0.009; Model F ⫽ 3.3, df ⫽ 9, 243, P ⫽ 0.001, R2 ⫽ .11). Logistic regressions showed that being older or having ever been pregnant reduced the number of perceived barriers (data not shown). Discussion From 1996 to 2002 awareness of, use of, and positive attitudes toward EC increased among female adolescents at an urban hospital-based adolescent medicine Table 5. Comparison of Perceived Barriers to Using EC by Study Year
Perceived Barriers Will make me very sick Will make it hard for me to get pregnant in future Cost of the medicine Cost of visit Don’t know where to call for an appt Parents will find out Against religious or ethical beliefs Want to be pregnant Pelvic exam Can’t get pregnant Embarrassment
1996 (n ⫽ 130)
2002 (n ⫽ 139)
p-value
% (n) 67 (87) 66 (86)
% (n) 30 (42) 23 (32)
⬍0.001 ⬍0.001
42 (55) 33 (43) 39 (50)
38 (52) 37 (52) 29 (40)
0.44 0.46 0.09
35 (46) 27 (35)
32 (45) 23 (32)
0.60 0.46
27 27 23 14
31 21 16 14
0.53 0.24 0.14 0.82
(32) (34) (27) (20)
(43) (29) (22) (20)
clinic and a residential drug treatment center in Pittsburgh. In 1996, side effects and impact of EC on fertility were the most commonly perceived barriers to EC use. However, in 2002 the frequency of all reported barriers decreased and cost was the most frequently stated perceived barrier. Young women in our study reported that they would be more likely to have unprotected sex if emergency contraception was available in advance compared with simply being aware of the method (25% vs. 10%). Although this outcome has been raised as a concern in the debate about providing EC over-the-counter and in advance, other studies have shown that women do not have increased rates of unprotected sex when they are provided EC in advance.21–26 It appears that the expectations of young women in this study differ from the actual behavior of young women participating in prospective, randomized clinical trials. Our study has several limitations. Our sample sizes at each site were small and the participants were a convenience sample of young women from one urban hospital-based adolescent medicine clinic and one residential drug treatment center in Pittsburgh, PA. The adolescent clinic may provide more comprehensive or consistent counseling about EC. The drug rehabilitation center may represent a higher risk population so our combined results may not be generalizable to or representative of young women from other settings. Also, this study only surveyed female adolescents and thus cannot comment on awareness of EC among male adolescents. Although our sample may not be comparable to the general population, our data agrees with other survey studies conducted between 1995 and 2003 that show generally increasing awareness of EC among adolescent women. Another limitation is the reliance on self-reported EC use without confirmatory support from medical records or pharmaceutical records. In addition, interviews were conducted face-toface with participants who may have felt an expectation to report certain attitudes or behaviors related to EC. The implications of this study are that health care providers should continue to educate young women about EC, particularly younger adolescents who have lower awareness levels. Although both awareness and knowledge has improved over the past 6 years, the focus of educational interventions should be directed at three areas. First, knowledge about time limits to using EC should be emphasized at all health visits. In 2002, only about half of the girls who had heard of EC knew that EC could be used up to 72 hours after unprotected intercourse. Newer data now supports the use of EC for up to 120 hours or 5 days after unprotected sex.27–30 However, conveying that EC can be used up to 120 hours after unprotected sex should be accomplished without losing the message “the sooner, the better.”28 Second, in educating adolescents
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about EC it is important to clarify EC’s mechanism of action* (that EC is not an abortifacient -see footnote below) and that EC can be obtained without parental permission because there were no significant changes in knowledge in these areas over the last 6 years. Finally, it is critical to focus on teaching young women how to find locations where they can get affordable EC since cost was perceived as the greatest barrier to EC use. Acknowledgments: We would like to thank the Laurel Foundation and the University of Pittsburgh’s Medical Student Summer Research Program for providing financial support. We wish to acknowledge Naa Sackey, Kym A. Smith, Marianne Turkal, Rita L. Labbett, and Nicole A. Boback for their assistance on the study as well as Drs. Gina S. Sucato and Pamela J. Murray for their reviews of the manuscript. We also wish to thank the staff of the adolescent clinic at the Children’s Hospital of Pittsburgh and all the young women who generously shared their time and ideas.
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7. Cohall AT, Dickerson D, Vaughan R, et al: Inner-city adolescents’ awareness of emergency contraception. JAMWA 1998; 53:258 8. Kaiser Family Foundation, Hoff T, Greene L, et al: National Survey of Adolescent and Young Adults: Sexual Health Knowledge, Attitudes, and Experiences. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2003. 9. Langer A, Harper C, Garcia-Barrios C, et al: Emergency contraception in Mexico City: what do health care providers and potential users know and think about it? Contraception 1999; 60:233 10. Free C, Lee RM, Ogden J: Young women’s accounts of factors influencing their use and non-use of emergency contraception: in-depth interview study. BMJ 2002; 325: 1393 11. Zeiband S, Maxwell K: ‘It’s a mega dose of hormones, isn’t it?’ Why women may be reluctant to use emergency contraception. Br J Fam Plann 1996; 22:84 12. Ottessen S, Narring F, Renteria SC, et al: Emergency contraception among teenagers in Switzerland: a cross-sectional survey on the sexuality of 16- to 20-year-olds. J Adolesc Health 2002; 31:101 13. Delbanco SF, et al: Missed opportunities: teenagers and emergency contraception. Arch Pediatr Adolesc Med 1998; 152:727 14. Food and Drug Administration. Prescription Drug Products : Certain combined oral contraceptives for use as postcoital emergency contraception. Federal Register 1997; 62: 8610 15. Trussell J, Bull J, Koenig J, et al: Call 1-888-NOT-2-LATE: promoting emergency contraception in the United States. J Am Med Womens Assoc 1998; 53:247 16. Delbanco SF, Stewart FH, Koenig JD, et al: Are we making progress with emergency contraception? Recent findings on American adults and health professionals. J Am Med Womens Assoc 1998; 53:242 17. Trussell J, Koenig J, Vaughan B, et al: Evaluation of a media campaign to increase knowledge about emergency contraception. Contraception 2001; 63:81 18. Salganicoff A, Wentworth B, Ranji U: Emergency Contraception in California. The Henry J. Kaiser Family Foundation. Feb 2004. 19. “Emergency Contraception: Patient Video.” ETR Associates, Santa Cruz, CA. www.etr.org. 쑖1999. 20. Statistical Package for Social Sciences, Database version 11.5, SPSS Inc. Headquarters, 233 S. Wacker Drive, Chicago, IL 60606. 21. Glasier A, Baird D: The effects of self-administering emergency contraception. NEJM 1998; 339:1 22. Lovvorn A, Nerquaye-Tetteh J, Glover EK, et al: Provision of emergency contraceptive pills to spermicide users in Ghana. Contraception 2000; 61:287 23. Raine T, Harper C, Leon K, et al: Emergency contraception: Advance provision in a young, high-risk clinic population. Obstet Gynecol 2000; 96:1 24. Ellertson C, Ambardekar S, Hedley A, et al: Emergency contraception: Randomized comparison of advance provision and information only. Obstet Gynecol 2001; 98:570 25. Jackson RA, Schwartz EB, Freedman L, et al: Advance supply of emergency contraception: effect on use and usual
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Aiken et al: Changes in Attitudes toward Emergency Contraception contraception-a randomized trial. Obstet Gynecol 2003; 102:8 Gold MA, Wolford JE, Smith KA, et al: The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004; 17:87 Rodrigues I, Grou F, Joly J: Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected sexual intercourse. Am J Obstet Gynecol 2001; 184: 531 Piaggio G, von Hertzen H, Grimes DA, et al: Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet 1999; 353:721 Ellertson C, Evans M, Ferden S, et al: Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Obstet Gynecol 2003; 101:1168 von Hertzen H, Piaggio G, Ding J, et al: WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002; 360:1803
31. Croxatto HB, Devoto L, Durand M, et al: Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature. Contraception 2001; 63:111 32. Ling WY, Robichaud A, Zayid I, et al: Mode of action of DL-norgestrel and ethinylestradiol combination in postcoital contraception. Fertil Steril 1979; 32:297 33. Ling WY, Wrixon W, Acorn T, et al: Mode of action of dl-norgestrel and ethinylestradiol combination in postcoital contraception. III. Effect of preovulatory administration following the luteinizing hormone surge on ovarian steroidogenesis. Fertil Steril 1983; 40:631 34. Glasier A: Emergency postcoital contraception. N Engl J Med 1997; 337:1058 35. Swahn ML, Westlund P, Johannisson E, et al: Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle. Acta Obstet Gynecol Scand 1996; 75:738 36. Trussell J, Ellertson C, Dorflinger L: Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action. Contraception 2003; 67:161 37. Marions L, Cekan SZ, Bygdeman M, et al: Effect of emergency contraception with levonorgestrel or mifepristone on ovarian function. Contraception 2004; 69:373
Original Studies Changes in Young Women’s Awareness, Attitudes, and Perceived Barriers to Using Emergency Contraception Allison M. Aiken, BS1,2, Melanie A. Gold, DO1,2, and Andrew M. Parker, PhD3 1
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; 2Children’s Hospital of Pittsburgh, Division of Adolescent Medicine, Pittsburgh, Pennsylvania, USA; 3Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
Abstract. Background: In a 1996 survey, most young women ages 13–20 years from an urban, hospital-based clinic and a drug treatment center had inadequate awareness of emergency contraception (EC), and perceived several barriers to its use. Since that time, the FDA has approved two products for EC, media coverage has increased, and physicians have provided more counseling about EC. Purpose: The purpose of this study is to compare the awareness, attitudes, and perceived barriers to using EC among a sample of young women from 1996 with a different sample of women from 2002. Methods: We recruited 139 young women (mean age 16.7 ⫾ 1.8 yrs) from the same adolescent clinic and drug treatment center as the 1996 sample. They had similar demographic characteristics, with the majority (63%) being African-American or multi-ethnic; 85% had ever been sexually active. They were interviewed using a questionnaire about their sexual and contraceptive history as well as their knowledge of and experience with EC. They then watched a 41/2 minute video and received a 5-minute didactic review of EC. Following the educational intervention, participants’ knowledge, attitudes, and perceived barriers to using EC were assessed. The questionnaire used to guide the interviews was nearly identical to that used in 1996. Results: Between 1996 and 2002, the percentage of participants reporting that they had ever heard of EC grew (44% vs. 73%, P ⬍ 0.001), as well as the percentage reporting that they had ever used EC (4% vs. 13%, P ⫽ 0.02). Of those participants who had ever heard of EC, fewer 1996 participants knew where to obtain it compared to 2002 participants (78% vs. 95%, P ⫽ 0.002) and fewer 1996 participants knew the correct time limits for use (20% vs. 51%, P ⬍ 0.001). The above data were collected prior to a didactic review session about EC. After receiving information about EC, the percentage of participants reporting a positive attitude toward EC grew between 1996 and 2002 (72% vs. 96%, P ⬍ 0.001). Young women also had fewer concerns about Address correspondence to: Melanie A. Gold, DO, Children’s Hospital of Pittsburgh, Division of Adolescent Medicine, 3705 5th Avenue, Pittsburgh, PA 15213; E-mail: [email protected]
쑖 2005 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
safety and side effects in 2002. The 1996 participants were more likely to report barriers to using EC compared to the 2002 participants. In 1996, EC side effects and impact on fertility were the most commonly perceived barriers to EC use. However, in 2002 the frequency of all reported barriers decreased and cost had become the number one perceived barrier. Conclusion: Since 1996, young women at an urban hospital-based adolescent clinic and drug treatment center increased their awareness, use, and positive attitudes towards EC, as well as decreased their perceived barriers to using EC. Educational interventions that focus on improving knowledge among younger adolescents, specifically about correct time limits and identifying ways to find affordable EC, will address the most common knowledge deficits and perceived barriers to EC use among adolescents.
Key Words. Emergency contraception—adolescents— contraception—postcoital contraception—knowledge— attitudes—perceived barriers
Introduction Although pregnancy and birth rates among U.S. adolescent women continue to decline, it is estimated that 822,000 pregnancies occurred among 15–19 year old women in 2000 resulting in 469,000 births and 235,000 abortions.1 U.S. teens became pregnant nearly twice as often as their counterparts in Great Britain or Canada and three to four times more often than teens in France or Sweden with little difference in rates of sexual activity.2 Emergency contraception (EC) is the only form of contraception that can reduce the risk of pregnancy after unprotected sex or when a planned contraceptive method fails. EC may be particularly useful for adolescent women whose first sexual intercourse or sporadic 1083-3188/05/$22.00 doi:10.1016/j.jpag.2004.11.002
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Aiken et al: Changes in Attitudes toward Emergency Contraception
pattern of intercourse is frequently unplanned and therefore unprotected.3 In order to use EC correctly, adolescents must be well informed. They must know that EC exists, know the time limits within which it is effective, know where to obtain it, and be able and willing to access it. Fears and misconceptions about side effects, potential effects on future fertility, and confusion with mifepristone (RU486) used for abortion may hinder young women from accessing this backup method of contraception.4–11 A 1996 nationally representative study of over 4,000 Swiss teens showed most sexually active young women (89%) knew about EC and 20% reported ever using EC.12 In the United States, awareness of EC has lagged behind Europe and U.S. teenagers have historically had the lowest rates of awareness and knowledge. In a 1996 telephone survey of 1,510 U.S. teenagers, only 33% of 12–18 year old girls had heard of the “morning-after pill” or EC and only 9% knew the correct time limits for it use.13 A 1998 study found only 30% of inner city adolescents had ever heard of EC and 84% reported having no idea what steps could be taken after unprotected intercourse to reduce the likelihood of pregnancy.7 In 1997 the FDA recognized the use of certain combination and progestin-only oral contraceptives for EC14 and products designed specifically for EC were approved in 1998 (Preven쑓, Gynetics, Somerville, NJ) and 1999 (Plan B쑓, Women’s Capital Corporation). Following these FDA approvals, there has been increased public and health care provider education campaigns.15–17 As a result of these changes, awareness of EC is improving. Recent data collected between November 2001 and February 2002 showed 52% of 15–17-year-olds have heard of EC or morning after pills8 and data collected in 2003 showed 55% of California teens were aware that there is something a woman can do after sex to prevent pregnancy.18 Data collected from studies at various sites pre- and post-1998 imply an increase in adolescents’ awareness of EC. However, to date, no longitudinal studies (or studies assessing awareness and knowledge levels of adolescent women from the same site) have been conducted to confirm this trend. The purpose of this study is to assess changes in female adolescents’ awareness of, attitudes towards, and perceived barriers to using EC in 2002 compared to 1996, among a similar sample of adolescents from the same two sites. We hypothesized that the changes in public and provider awareness of EC would lead to increased awareness and knowledge of EC, more favorable attitudes toward using EC, and fewer perceived barriers to EC use among female adolescents.
Materials and Methods Study Design Young women were recruited from the waiting area of a hospital-based adolescent clinic (HAC) and from a residential drug treatment center (DTC) in Pittsburgh, Pennsylvania, in the summer of 1996 and again in June 2002 through February 2003. After they provided written informed consent, participants were administered a 5–10 minute interview to assess demographic characteristics and sexual and contraceptive history including knowledge about EC. Participants reporting previous awareness of EC completed a 5-minute knowledge pre-test. All participants were then provided a 5–10 minute review of information about EC. In 1996, participants listened to an audiotape that read verbatim an educational pamphlet about EC that was created specifically for the study (available on request). In 2002, participants watched “Emergency Contraception: Patient Video”19 followed by a 5-minute didactic presentation to cover material which was not specifically addressed in the video and was commonly misunderstood by 1996 participants. Points emphasized during this discussion included: (1) EC is a back-up birth control method and not to be used as a regular method because it is less effective at preventing pregnancy and does not prevent sexually transmitted diseases, (2) times or situations that one may need to use EC, (3) side effect information, (4) EC is available without parental permission, and (5) lack of effect of EC on future fertility. Immediately following the review, participant’s knowledge was re-tested with a post-test identical to the pre-test. Then participants were asked additional open-ended questions and were read Likert scale statements to assess their attitudes and perceived barriers to EC use. This section lasted about 10–15 minutes, with the entire visit taking 30–45 minutes. The Human Rights Committee (Institutional Review Board) of the Children’s Hospital of Pittsburgh approved the study. Parental consent was waived and participants’ written informed consent was obtained prior to enrollment. Participants A total of 272 participants were interviewed, 133 in 1996 (95 from HAC and 38 from DTC) and 139 in 2002–2003 (100 from HAC and 39 from DTC). Participants were eligible to participate if they were female adolescents between the ages of 13 and 21 years. They could be sexually active, virginal, or abstinent. The HAC population was 73% African American or multi-ethnic and 21% Caucasian, with a mean age of 16.5 ⫾ 1.9 years. Most (80%) had been sexually active with a mean age at coitarche of 14.3 ⫾ 1.8 years. Among the sexually active group, 68% had ever had unprotected sex and 20% had ever been pregnant.
Aiken et al: Changes in Attitudes toward Emergency Contraception
While only assessed for the 2002 sample, over half of the participants (53%) were on medical assistance. DTC participants were 66% Caucasian and 21% African American or multi-ethnic, with a mean age of 16.2 ⫾ 1.1 years. The DTC population constitutes a high-risk population with 97% having been sexually active with a mean age of coitarche at 12.7 ⫾ 2.2 years. Among the sexually active group, 96% had ever had unprotected sex and 38% had ever been pregnant. In 2002, 28% reported being on medical assistance. Measures The questionnaire used to guide the interviews consisted of four sections. The first section contained 27 items on demographic information including age, race, sexual, contraceptive and obstetrical history and whether the participant ever heard of and used EC. This section was identical in the surveys used in 1996 and 2002, with one exception—the 2002 questionnaire had two additional demographic questions. The second section, the knowledge pre-test, contained 19 items (three open-ended, one multiple choice, and 15 true/ false) to assess knowledge level of EC for those participants who endorsed that they had ever heard about EC prior to the study. Three new true/false questions were added to the 2002 questionnaire. The post-test questions to assess knowledge were identical to the pre-test questions; they were completed by all participants after receiving the educational intervention. The last section of the survey (15 open-ended and 11 Likert scale items) assessed acceptability and perceived barriers to using EC. Seven new open-ended questions were added to the 2002 questionnaire to assess participant’s opinions about obtaining an advance prescription for EC, over-the-counter status of EC, and what EC should cost. Data Analysis Analyses were completed using Statistical Package for Social Sciences (SPSS).20 Comparisons of groups on categorical variables were performed using chi-square tests. Comparisons of groups on continuous variables were performed using two-tailed independent sample t-tests. Analyses were considered significant at α ⫽ 0.05. Logistic regressions were performed to look at predictors of awareness of, use of, and attitudes towards EC. Linear regression analyses were performed to look at predictors of perceived barriers. Relative to the HAC group, the DTC group had more Caucasians (P ⬍ 0.001), more sexually active individuals (P ⬍ 0.001), experienced coitarche at a younger age (P ⬍ 0.001), and had a higher past-pregnancy rate (P ⫽ 0.003). However, results regarding awareness of, attitudes towards, and perceived barriers to using EC, across years, did not differ substantially
27
when the HAC and DTC sites were analyzed separately or combined together. Therefore the HAC and DTC data were combined and all subsequent results report analyses conducted on the combined sample for each time frame.
Results Demographics Table 1 summarizes the demographic characteristics. Between 1996 and 2002, the mean age of the two groups increased (from 16.1 to 16.7 years, P ⫽ 0.002) as did the reported mean age at first intercourse or coitarche (from 13.3 to 14.3 years, P ⫽ 0.001; Table 1). A smaller proportion of respondents were African American or multiethnic in 1996 than in 2002 (53% vs. 63%, P ⫽ 0.03). Among participants who had been sexually active, the percent reporting ever having unprotected intercourse decreased from 1996 to 2002 (83% vs. 72%, P ⫽ 0.04). The frequency of using a method of pregnancy prevention increased from 1996 to 2002 (mean 57% vs. 69%, P ⫽ 0.009). EC Awareness, Use, and Knowledge Between 1996 and 2002, awareness of EC increased (Table 2). The number reporting that they had ever heard of EC grew (44% vs. 73%, P ⬍ 0.001), as well as the number reporting that they had ever used EC (4% vs. 13%, P ⫽ 0.02; last row, Table 1). The first row of Table 3 displays a logistic regression model that predicts having heard of EC by year. When controlling for study site, age (as a continuous variable), race, religion, and sexual activity, awareness of EC increased from 1996 to 2002 (OR ⫽ 2.90, P ⬍ 0.001; Model χ2 ⫽ 54.6, df ⫽ 9, P ⬍ 0.001, Nagelkerke R2 ⫽ .25). Focusing on the sexually active adolescents, a second regression incorporated several sexual history variables, including age of coitarche, whether they have ever been pregnant, had unprotected sex, and birthcontrol method used at last sex (data not shown). This analysis revealed similar findings with awareness of EC increasing from 1996 to 2002. Those who had ever heard of EC completed the pre-intervention knowledge test. Among this group, the percent correctly stating where to get EC was significantly lower in 1996 than in 2002 (Table 4). Likewise, the percent correctly choosing 72 hours as the time limit for taking EC after unprotected intercourse was significantly lower in 1996 compared to 2002. However, there were no significant changes in knowledge that EC is not a type of abortion or that minors can get EC without parental permission.
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Table 1. Demographic Characteristics by Study Year Variables Mean Age in years ⫾ SD Race African American Caucasian Other Maternal Level of Education Not finish high school High school or GED Some college Religion None Non-Catholic Christian Catholic Other Religious beliefs affect day-to-day decisions* A lot A little Not at all Religious beliefs affect decisions about whether or not to have sex** Completely Quite a bit Somewhat Not at all Religious beliefs affect decisions about pregnancy prevention** Completely Quite a bit Somewhat Not at all Health Insurance** Medical Assistance Private/HMO Self pay Other Unsure Reproductive Health Ever been sexually active Ever been pregnant Ever had unprotected sex Mean Coitarche in years ⫾ SD Contraception used at last sex Male condom Birth control pills Mean Percent of Times Used Contraception ⫾ SD Ever used EC
1996 (n ⫽ 133) 16.1 % 53 34 13
⫾ 1.5 (n) (69) (45) (17)
2002 (n ⫽ 139) 16.7 % 63 32 4
⫾ 1.8 (n) (88) (45) (6)
p value 0.002 0.03
⬍0.001 31 (38) 45 (56) 24 (29)
14 (18) 39 (52) 47 (63)
32 42 15 11
17 55 17 10
(24) (76) (24) (14)
4 20 42 34
(4) (21) (44) (36)
18 14 19 49
(19) (15) (20) (52)
46 24 7 11 12
(64) (33) (10) (15) (17)
0.03 (43) (55) (20) (14)
21 (19) 40 (36) 38 (34)
84 29 83 13.3
(112) (32) (93) ⫾ 2.3
85 22 72 14.3
(118) (26) (84) ⫾ 1.6
0.88 0.25 0.04 0.001
65 (73) 21 (24) 57.1 ⫾ 34.4
71 (82) 23 (27) 69.1 ⫾ 33.1
0.37 0.79 0.009
4 (4)
13 (16)
0.02
*only collected in 1996. **only collected in 2002.
Attitudes toward EC after the Educational Intervention After learning about EC, the young women were asked the open-ended question “What do you think of it?” Their answers were categorized as “clearly liking it” (coded 1 for a “positive attitude” toward EC) versus “clearly disliking it” or “hard to tell” (each coded 0 for “not having a positive attitude” toward EC). Those categorized as having a positive attitude toward EC
gave qualitative responses such as “it’s a good way to prevent pregnancy,” “I would use it,” or “more people should know about it.” Those categorized as not having a positive attitude toward EC said “I think it’s wrong, because it’s like an abortion” or “it will mess with your body.” Three raters independently coded each participant’s response as 0 or 1, with majority rule determining the final code. The (Kappa) reliability between each judge’s codes and final codes were
Aiken et al: Changes in Attitudes toward Emergency Contraception Table 2. Awareness of EC, Positive Attitudes Toward EC, and Mean Number of Barriers to using EC by Study Year
Variables Awareness of EC Positive attitudes toward EC Mean Number of Barriers to Using EC ( ⫾ SD)
1996 (n ⫽ 133) % (n)
2002 (n ⫽ 139) % (n)
44 (59) 72 (96)
73 (101) 96 (133)
5.0 ⫾ 2.4
3.9 ⫾ 2.3
Table 4. Pre-intervention Knowledge of EC by Study Year
Pre-intervention Knowledge
p value ⬍0.001 ⬍0.001 0.001
.82, .86, and .90. The analyses used only the final codes. There was a significant increase in positive attitudes towards EC over time at both sites. The percentage of participants who gave positive responses following the educational intervention grew from 1996 to 2002 (72% vs. 96%, P ⬍ 0.001; Table 2). Table 3 presents a logistic regression model of positive attitudes toward EC. Using the entire sample, positive attitudes towards EC increased from 1996 to 2002, controlling for the same variables described above (OR ⫽ 15.65, P ⬍ 0.001; Model χ2 ⫽ 45.5, df ⫽ 9, P ⬍ 0.001, Nagelkerke R2 ⫽ .28). Focusing on sexually active respondents, EC was once again viewed more positively in 2002 compared to in 1996 (data not shown). Based on the latter regression analysis, those who reported using birth control pills at last intercourse were also more likely to view EC positively (odds ratio ⫽ 5.11, CI:1.33–19.54, P ⫽ 0.02). It should be noted that the educational intervention was not the same in the two study years. In 2002 there was a change to video media with an additional didactic segment. To assess the potential effect of this change on positive attitudes toward EC, we compared the differences in positive attitudes between those who had heard of EC and those who had not, assuming an educational intervention would have a bigger effect on those who had not heard of EC. Using both chisquare tests and logistic regression, the relationship between attitude toward EC and awareness of EC did not change across the two years, providing evidence
29
Know where to get EC Know time limits to use EC Know EC is not a type of abortion Know can get EC without parents permission
1996 (n ⫽ 59) % 78 20 63
(n) (47) (12) (37)
63 (37)
2002 (n ⫽ 101) % 95 52 55
(n) (96) (52) (56)
74 (75)
p-value 0.002 ⬍0.001 0.37 0.12
that the educational interventions worked similarly in both years. (Analysis not shown). The survey also assessed participants’ willingness to use EC; 50% said that they could “think of a time in the past” when they could have used it. Over half (58%) perceived a potential need to use EC in the future. Of these, 95% said that they would use EC if it was needed. Additional questions in 2002 assessed participants’ attitudes towards wanting an advance prescription for EC, whether EC should be available over the counter, and how much it should cost. Most (85%) participants reported they would want an advance prescription for EC so that it was available at home when needed. Fifty percent of participants believed that EC should be available over the counter. When asked how much EC should cost, responses ranged from $0 to $200, with a median of $20. $10 and $40 were the 25th and 75th percentiles, respectively. In 2002, all participants were asked whether they thought knowing about and having EC available (by advance prescription and over the counter) would change the likelihood of their having unprotected sex. Few participants (10%) felt that knowing about EC would increase their likelihood of having unprotected sex. Twenty-five percent of participants felt that having EC in advance would increase their likelihood of having unprotected sex and 16% felt that having EC available over the counter would increase their likelihood of having unprotected intercourse.
Table 3. Regressions of Awareness of EC, Positive Attitudes Toward EC, and Number of Barriers to Using EC by Year
Logistic Regressions a Awareness of EC (n ⫽ 269) Study year b Positive Attitudes Toward EC (n ⫽ 267) Study year b Linear Regression a Number of Barriers to Using EC (n ⫽ 253) Study year a
b
Mean
Odds ratio
.51 .52 Mean .54
2.90 15.65 Regression Coefficient ⫺.79
Regressions also included age, race, religion, and ever had sex as control variables. 1996 used as the reference category.
b
95% Confidence interval
p value
1.66 5.08 95% Confidence ⫺1.38
⬍.001 ⬍.001 p value .009
5.08 48.20 interval ⫺.20
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Aiken et al: Changes in Attitudes toward Emergency Contraception
Perceived Barriers Participants were read a list of reasons why girls might not get EC and were asked to state if this was “not a reason,” “might be a reason,” or was “definitely a reason” for them to not get EC (even if they had unprotected intercourse). Responses of “might be a reason” or “definitely a reason” were combined together and considered as perceived barriers to using EC. In 1996, the top two perceived barriers to using EC were fears that it would “make me very sick” and fears that it would “make it hard to for me to get pregnant in the future.” These two barriers both decreased significantly between 1996 and 2002 (Table 5). In 2002, cost was the number one perceived barrier with 38% citing that cost of the medication might be or definitely would be a reason to not get EC and 37% citing cost of the visit. There were no significant changes in other perceived barriers, although the general trend was to decrease across time. An independent-samples t-test of the total number of barriers selected (from the list of eleven barriers from Table 5) showed the mean number of barriers decreased from five to fewer than four barriers from 1996 to 2002 (P ⫽ 0.001; Table 2). Table 3 presents a linear regression of the total number of barriers selected by respondents and demonstrates that perceived barriers dropped significantly from 1996 to 2002 (β ⫽ ⫺.79, P ⫽ 0.009; Model F ⫽ 3.3, df ⫽ 9, 243, P ⫽ 0.001, R2 ⫽ .11). Logistic regressions showed that being older or having ever been pregnant reduced the number of perceived barriers (data not shown). Discussion From 1996 to 2002 awareness of, use of, and positive attitudes toward EC increased among female adolescents at an urban hospital-based adolescent medicine Table 5. Comparison of Perceived Barriers to Using EC by Study Year
Perceived Barriers Will make me very sick Will make it hard for me to get pregnant in future Cost of the medicine Cost of visit Don’t know where to call for an appt Parents will find out Against religious or ethical beliefs Want to be pregnant Pelvic exam Can’t get pregnant Embarrassment
1996 (n ⫽ 130)
2002 (n ⫽ 139)
p-value
% (n) 67 (87) 66 (86)
% (n) 30 (42) 23 (32)
⬍0.001 ⬍0.001
42 (55) 33 (43) 39 (50)
38 (52) 37 (52) 29 (40)
0.44 0.46 0.09
35 (46) 27 (35)
32 (45) 23 (32)
0.60 0.46
27 27 23 14
31 21 16 14
0.53 0.24 0.14 0.82
(32) (34) (27) (20)
(43) (29) (22) (20)
clinic and a residential drug treatment center in Pittsburgh. In 1996, side effects and impact of EC on fertility were the most commonly perceived barriers to EC use. However, in 2002 the frequency of all reported barriers decreased and cost was the most frequently stated perceived barrier. Young women in our study reported that they would be more likely to have unprotected sex if emergency contraception was available in advance compared with simply being aware of the method (25% vs. 10%). Although this outcome has been raised as a concern in the debate about providing EC over-the-counter and in advance, other studies have shown that women do not have increased rates of unprotected sex when they are provided EC in advance.21–26 It appears that the expectations of young women in this study differ from the actual behavior of young women participating in prospective, randomized clinical trials. Our study has several limitations. Our sample sizes at each site were small and the participants were a convenience sample of young women from one urban hospital-based adolescent medicine clinic and one residential drug treatment center in Pittsburgh, PA. The adolescent clinic may provide more comprehensive or consistent counseling about EC. The drug rehabilitation center may represent a higher risk population so our combined results may not be generalizable to or representative of young women from other settings. Also, this study only surveyed female adolescents and thus cannot comment on awareness of EC among male adolescents. Although our sample may not be comparable to the general population, our data agrees with other survey studies conducted between 1995 and 2003 that show generally increasing awareness of EC among adolescent women. Another limitation is the reliance on self-reported EC use without confirmatory support from medical records or pharmaceutical records. In addition, interviews were conducted face-toface with participants who may have felt an expectation to report certain attitudes or behaviors related to EC. The implications of this study are that health care providers should continue to educate young women about EC, particularly younger adolescents who have lower awareness levels. Although both awareness and knowledge has improved over the past 6 years, the focus of educational interventions should be directed at three areas. First, knowledge about time limits to using EC should be emphasized at all health visits. In 2002, only about half of the girls who had heard of EC knew that EC could be used up to 72 hours after unprotected intercourse. Newer data now supports the use of EC for up to 120 hours or 5 days after unprotected sex.27–30 However, conveying that EC can be used up to 120 hours after unprotected sex should be accomplished without losing the message “the sooner, the better.”28 Second, in educating adolescents
Aiken et al: Changes in Attitudes toward Emergency Contraception
about EC it is important to clarify EC’s mechanism of action* (that EC is not an abortifacient -see footnote below) and that EC can be obtained without parental permission because there were no significant changes in knowledge in these areas over the last 6 years. Finally, it is critical to focus on teaching young women how to find locations where they can get affordable EC since cost was perceived as the greatest barrier to EC use. Acknowledgments: We would like to thank the Laurel Foundation and the University of Pittsburgh’s Medical Student Summer Research Program for providing financial support. We wish to acknowledge Naa Sackey, Kym A. Smith, Marianne Turkal, Rita L. Labbett, and Nicole A. Boback for their assistance on the study as well as Drs. Gina S. Sucato and Pamela J. Murray for their reviews of the manuscript. We also wish to thank the staff of the adolescent clinic at the Children’s Hospital of Pittsburgh and all the young women who generously shared their time and ideas.
References 1. U.S. Teenage Pregnancy Statistics Overall Trends, Trends by Race and Ethnicity, and State-by-State Information. New York, The Alan Guttmacher Institute, 2004 2. Darroch JE, Singh S, Frost JJ: Differences in teenage pregnancy rates among five developed countries: The Roles of sexual activity and contraceptive use. Family Planning Perspectives 2001; 33:244 3. Sex and America’s Teenagers. New York, The Alan Guttmacher Institute (AGI), 1994, pp. 24–25 4. Gold MA, Miller R: Adolescent and young women’s knowledge about, attitudes towards, and perceived barriers to using emergency contraception [abstract]. J Adolesc Health 1997; 20:144 5. Jackson R, Bimla Schwarz E, Freedman L, et al: Knowledge and willingness to use emergency contraception among low-income post-partum women. Contraception 2000; 61:351 6. Harper CC, Ellertson CE: The emergency contraceptive pill: a survey of knowledge and attitudes among students at Princeton University. Am J Obstet Gynecol 1995; 173:1438 *A single mechanism of action for emergency contraception has not been identified.31 Older studies reported histologic or biochemical changes in the endometrium that were thought to result in impairment of implantation32–33 or suggested interference in tubal transport of sperm, egg, or embryo.34 Others reported inhibition or delay in ovulation and insufficient corpus luteum function.35 A recent secondary analysis of five data sets using a new algorithm for conception probabilities supports the hypothesis that the primary mechanism of action of EC is delaying or inhibiting ovulation rather than inhibiting the implantation of a fertilized egg.36 A 2004 study assessed the mechanism of action of levonorgestrel and mifepristone used for emergency contraception: the luteinizing hormone peak was suppressed or delayed, follicle rupture was inhibited, and ovulation was disrupted.37
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31. Croxatto HB, Devoto L, Durand M, et al: Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature. Contraception 2001; 63:111 32. Ling WY, Robichaud A, Zayid I, et al: Mode of action of DL-norgestrel and ethinylestradiol combination in postcoital contraception. Fertil Steril 1979; 32:297 33. Ling WY, Wrixon W, Acorn T, et al: Mode of action of dl-norgestrel and ethinylestradiol combination in postcoital contraception. III. Effect of preovulatory administration following the luteinizing hormone surge on ovarian steroidogenesis. Fertil Steril 1983; 40:631 34. Glasier A: Emergency postcoital contraception. N Engl J Med 1997; 337:1058 35. Swahn ML, Westlund P, Johannisson E, et al: Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle. Acta Obstet Gynecol Scand 1996; 75:738 36. Trussell J, Ellertson C, Dorflinger L: Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action. Contraception 2003; 67:161 37. Marions L, Cekan SZ, Bygdeman M, et al: Effect of emergency contraception with levonorgestrel or mifepristone on ovarian function. Contraception 2004; 69:373