- Email: [email protected]
Emergency contraception knowledge after a community education campaign
Contraception 76 (2007) 366 – 371
Original research article
Emergency contraception knowledge after a community education campaign☆ Rebekah E. Gee a,b,c,d,⁎, Laurent C. Delli-Bovi b , Cynthia H. Chuang e a
University of Pennsylvania, Philadelphia, PA 19104, USA Brigham and Women's Hospital, Boston, MA 02115, USA c Robert Wood Johnson Foundation Clinical Scholars Program, Chapel Hill, NC 27599, USA d Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA e Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA, USA Received 22 May 2007; revised 12 July 2007; accepted 13 July 2007 b
Abstract Background: This study evaluates the effectiveness of a community education campaign in the Boston community of Jamaica Plain conducted by the Massachusetts Emergency Contraception (EC) Network aimed at improving public knowledge of EC. Study Design: Pre- and postintervention surveys of reproductive-age women were conducted to evaluate the effectiveness of the community education campaign. Knowledge of EC was compared before and after the intervention using surveys of community-based samples of women. Results: One hundred eighty-eight and 290 women participated in the preintervention and postintervention surveys, respectively. Following the intervention, women were significantly more likely to have heard of EC (91% vs. 82%, p=.007), know the mechanism of action of EC (49% vs. 39%, p=.04), have discussed EC with a health care provider (38% vs. 25%, p=.003) and have received an advance prescription for EC (22% vs. 12%, p=.004), as well as were more likely to use EC in the future if needed (79% vs. 63%, p=.0002). Conclusion: This grassroots-based community education campaign on EC was effective in improving EC knowledge in this Boston community. © 2007 Elsevier Inc. All rights reserved. Keywords: Emergency contraception; Community education; Knowledge disparities; Contraceptive education; Unintended pregnancy
1. Introduction Despite the fact that emergency contraception (EC) has enormous potential to reduce the number of unintended pregnancies and abortions, there have been few studies of community-based interventions to increase awareness of EC, and studies to date reveal that EC is often underutilized [1–5]. Multiple barriers have been identified for the appropriate use of EC and include lack of knowledge about EC, confusion about the mechanism of action of EC, ☆ This study was funded by an “Expanding the Boundaries” grant by the research fund of the Brigham and Women's Hospital Obstetrics and Gynecology Department. ⁎ Corresponding author. University of Pennsylvania, Philadelphia, PA 19104, USA. Tel.: +1 215 573 3979; fax: +1 215 573 2742. E-mail address: [email protected] (R.E. Gee).
0010-7824/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2007.07.007
social stigma about EC, inability to gain access to EC and pharmacist refusal to provide EC [6–13]. This study and the community educational campaign it describes were conducted prior to FDA approval of over-the-counter use of Plan B® (Barr Pharmaceuticals, Pomona, NY) EC for women 18 years and older. Although EC access is now likely to be improved, social, ideological, educational and financial barriers to access likely remain. It is therefore imperative that educational efforts target reproductive-age women, health care providers and pharmacists about EC and its appropriate use. This study describes a survey conducted after a community education campaign in the Boston neighborhood of Jamaica Plain. This campaign was launched by the Massachusetts EC Network, a coalition of community organizations, medical providers and government agencies that share a common goal of reducing unintended pregnancy
R.E. Gee et al. / Contraception 76 (2007) 366–371
by improving knowledge of and access to EC in Massachusetts. The campaign focused on increasing awareness about EC through outreach to the public, health care providers and pharmacists. Prior to initiation of the campaign, baseline knowledge about EC among reproductive-age women living in the community was assessed for the purpose of guiding the design and content of the educational intervention. The most significant finding of the initial survey was that knowledge of EC varied greatly based on race. The findings of that survey, conducted in 2003, have been previously published [14]. Based on the results of the initial survey, which revealed a significant disparity in knowledge by race/ ethnicity, the intervention included specific measures aimed at the Latino community. 2. Materials and methods The campaign evaluated by this study was an education campaign conducted by the Massachusetts EC Network with the primary aim of increasing knowledge regarding EC in the Boston community of Jamaica Plain. This community was chosen because of its socioeconomic and ethnic heterogeneity. Pre- and postintervention surveys were conducted on community-based samples of women who evaluated knowledge of EC, access to EC and willingness to use EC. The Institutional Review Boards of Brigham and Women's Hospital and the Boston Medical Center approved this study. 2.1. Study intervention The Massachusetts EC Network conducted the community education campaign from Fall 2003 until Spring 2005. The goal of the campaign was to improve EC knowledge among reproductive-age women living in Jamaica Plain. Therefore, the majority of the campaign was directed at public outreach. Outreach efforts for community residents included displaying educational signs in the community and distributing pamphlets to local businesses. In addition to the general public, health care providers and pharmacists were targeted for outreach. Educational packets on EC were provided to the community health centers and pharmacies located in Jamaica Plain. The packets included a sample health center/pharmacy policy on EC, fact sheets/brochures for providers/pharmacists/patients, prescribing protocol, and informational posters. Educational sessions in the form of lectures and one-on-one detailing were also offered to the health centers and pharmacies. Updated materials used for the intervention are available at the EC Network's website: www.massecnetwork.org. Volunteers with pharmacy training contacted pharmacists in the community and did outreach and education. Due to the findings of the initial survey in 2003, which demonstrated significant knowledge disparity in the Latino community of Jamaica Plain, the Massachusetts EC Network collaborated with Latino community leaders and community groups serving the community in an effort to
367
reach this group of women. This collaboration resulted in working with outreach workers at health centers, training peer health educators, targeting a homeless shelter for Latino women and their families and distributing Spanish language information at cultural fairs. Volunteer members of the Massachusetts EC Network provided much of the assistance for the intervention, but some paid staff time was involved. The total budget for this intervention was approximately US$10,000, which primarily covered staff time and printing educational materials. Funding for the education campaign study was provided by NARAL ProChoice Massachusetts and the EC Network. 2.2. Survey methodology Participants were recruited to participate in the surveys through convenience sampling in the same location and time of year prior to the intervention in May 2003 and after the intervention in May 2005. The 2003 sample was compared to the most recent U.S. census in 2000 from Jamaica Plain, and no statistical difference was found in race/ethnicity distribution; however, age distribution differed significantly (p=.003), with the study population overrepresenting the youngest age group. No statistical difference was found between the 2003 and 2005 survey populations. Specific details regarding the participant recruitment and survey development have been published previously [14]. Participants were recruited at public locations frequented by local residents over a period of several weeks. Subjects were informed that the anonymous survey was for the purpose of medical research and that their participation was voluntary. After completing the survey, women were offered a small bag containing the contact information of the principal investigator, chocolates, condoms and a pamphlet with basic facts about EC. Sample size calculations performed prior to the preintervention survey were aimed at detecting a meaningful difference in EC knowledge postintervention. Because the preintervention survey results revealed a knowledge disparity by race/ ethnicity, we recruited a larger sample size for the postintervention survey in order to have sufficient power to show a significant change in knowledge among Latino women. For the follow-up study, sample size calculations were based on the ability to calculate a meaningful difference in knowledge in the Latino community (25%). The survey was a self-administered written questionnaire designed specifically for this study. Demographics on age, race/ethnicity and community residence were collected. Women who were not residents of Jamaica Plain and between the ages of 18 and 44 were excluded from the study. Questions about EC are shown in the Appendix. In addition, women were asked about where they heard of EC (i.e., community) in order to help measure where efforts were most effective. The survey was designed at a fifth-grade literacy level and was available in both English and Spanish. The 2003 survey was pilot tested in English and Spanish to a representative sample of women.
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The dependent variable was determined by the question, “Have you ever heard of EC (also called the ‘morning-after pill’)?” If a participant answered “no,” she was instructed by the survey instrument to stop the survey. If the participant answered “yes,” she continued answering the remaining questions about EC. We assumed that if a woman had not heard about EC, then she had no further detailed knowledge about it. 2.3. Statistical analysis Data analysis was performed using SAS for Windows Version 8.2 (SAS Institute, Cary, NC). Demographic characteristics and responses to EC knowledge questions were determined and compared between the preintervention and postintervention participants using chi-square statistics. For both the preintervention and the postintervention surveys, we employed multivariate logistic regression to model the likelihood of having “heard of EC,” controlling for age, race/ ethnicity, education and religion. All analyses were two tailed, using a p value of .05 as criterion for statistical significance. 3. Results Detailed results from the 2003 preintervention survey have been published elsewhere [14]. Results from that survey relevant to evaluating the effectiveness of the intervention are presented here along with the results of the 2005 postintervention survey. Of the 332 surveys collected, 42 women were ineligible because they were not between the ages of 18 and 44 years. The remaining 290 surveys were analyzed. In the 2003 preintervention survey, 188 questionnaires were eligible for analysis. Demographic characteristics from the preintervention and postintervention cohorts are shown in Table 1. The pre- and postintervention cohorts did not differ significantly by age or race/ethnicity. Religion and education variables were not assessed in the 2003 preintervention questionnaire. Responses to the EC questions in the pre- and postintervention surveys are shown in Table 1. Significant improvements in EC knowledge were observed after the intervention. Ninety-one percent of women had heard of EC in the 2005 postintervention survey, as compared to 82% of women prior to the intervention (p=.007). Additionally, a greater proportion of women correctly answered that the mechanism of action of EC is by preventing pregnancy (49% vs. 39%, p=.04). Women reported a significant change with their EC experience regarding their health care providers as well. After the intervention, more women had discussed EC with a health care provider (38% vs. 25%, p=.003) and had received an advance prescription for EC (22% vs. 12%, p=.004), as compared with before the intervention. In addition, women were more likely to use EC in the future if needed (79% vs. 63%, p=.0002). The principal finding from the 2003 preintervention survey was that EC knowledge differed significantly by
Table 1 Comparison of respondent characteristics and survey responses in the 2003 preintervention (n=188) and 2005 postintervention (n=290) samples Characteristic Age (years) 18–24 25–29 30–34 35–39 40–44 Race/Ethnicity White, not Hispanic Black, not Hispanic Hispanic Other Education High school graduate or less At least some college Religion Catholic Non-Catholic Has heard of EC Has heard of EC and knows that it works by preventing pregnancy Has heard of EC and knows of the 72-to 120-h time window Has heard of EC and has discussed it with a health care provider Has heard of EC and has received an advance prescription Has heard of EC and is very/somewhat likely to use it in the future
Preintervention, n (%)
Postintervention, n (%)
p value a .12
58 42 41 26 21
(31) (22) (22) (14) (11)
61 (21) 88 (30) 72 (25) 36 (12) 32 (11)
106 (57) 20 (11) 55 (29) 6 (3)
161 (56) 35 (12) 69 (24) 25 (9)
.09
–
–
54 (19)
–
236 (81)
– – 154 (82) 73 (39)
85 (30) 200 (70) 262 (91) 141 (49)
.007 .04
91 (48)
150 (52)
.48
47 (25)
111 (38)
.003
22 (12)
64 (22)
.004
119 (63)
229 (79)
.0002
–
a Chi-square tests were used to compare 2003 preintervention and 2005 postintervention data.
race/ethnicity. In that cohort, White women were significantly more likely to have heard of EC than both Latino women and Black women (99% vs. 75% vs. 51%, respectively, pb.05). In the 2005 post-intervention survey Latino women (79%) and Black women (88%) were still significantly less likely to have heard of EC than White women (79%; p=.0001 and .04 respectively) (Table 2). A limitation from the 2003 preintervention findings was the inability to control for additional socioeconomic characteristics. It was therefore uncertain whether the EC knowledge disparities observed were in fact due to race/ethnicity independently or other characteristics for which they were not controlled for. Education and religion variables were added to the 2005 postintervention survey. After controlling for those variables, race/ethnicity knowledge disparities remained significant. Age, education and religion were not significant predictors in the model (Table 2). The community education campaign specifically targeted the Latino population. Findings by race/ethnicity before and after the campaign are shown in Table 3. After the
R.E. Gee et al. / Contraception 76 (2007) 366–371 Table 2 Likelihood of not having heard of EC in the 2005 postintervention survey Characteristic
Race/Ethnicity White, not Hispanic Black, not Hispanic Hispanic Other Education High school or less Associate/Technical College Postgraduate Religion Catholic Non-Catholic
Postintervention Heard of EC (%)
AOR (95% CI) a
97 88 79 88
Referent 4.9 (1.2, 21.1) 8.5 (2.2, 32.5) 3.9 (0.8, 18.4)
83 91 96 90
1.9 (0.5, 6.8) 0.6 (0.1, 3.9) Referent 3.0 (0.8, 10.4)
85 94
1.5 (0.5, 4.4) Referent
a
Logistic regression was used to model the likelihood of not having heard of EC in the postintervention survey, controlling for age, race/ ethnicity, education and religion.
intervention, Latino women were significantly more likely to have heard of EC (79% vs. 51%, p=.001. Additional results further suggest that Latino women were effectively targeted by the community education campaign. Following the intervention, 51% of Latino women reported that they had discussed EC with a health care provider, as compared with 36% of White women (p=.04) and 39% of Black women (p=.29). Additionally, Latino women were more likely to report that they had received an advance prescription for EC in the postintervention survey than White women (32% vs. 18%, p=.03). Having less than a college education was also independently associated with having received an advance prescription for EC (p=.002). 4. Discussion The purpose of this study was to evaluate a community education campaign on EC in the Boston community of Jamaica Plain. After the campaign, we found that significantly more women had knowledge about EC, had discussed EC with their health care providers and had received advance prescriptions for EC. Although there was likely increasing awareness of EC nationwide due to media coverage and controversy over FDA approval for over-the-counter status, the Barr Pharmaceutical company that manufactures Plan B® has not had a marketing campaign in Spanish, and materials in English and Spanish for providers' offices had been available since 1999 when the product first gained FDA approval. Although this is an observational study, the significant increase in knowledge, particularly in the Latino community, may reflect the success of the educational efforts of the Massachusetts EC Network. The Massachusetts EC Network collaborated with Latino-based community organizations during the community campaign due to preintervention survey findings of
369
significant EC knowledge disparities by race/ethnicity. This study suggests that educational efforts targeted at ethnic groups can be effective in decreasing knowledge disparity. Cultural competency awareness and respect for community concerns, as demonstrated by the community campaign, have been shown to be effective at reducing health-related knowledge disparities [15–17]. In addition to the Latino community, the education campaign focused on health care providers and community programs, and our study found a significant increase in women hearing about EC through health care providers and community programs and organizations. Despite the significant increase in knowledge among Latino women, a significant disparity remains, and further efforts need to be targeted at these populations. In 2006, the FDA approved Plan B®, a dedicated EC product, for overthe-counter access for women 18 years and older. Now that Plan B® is available without prescription in the United States for women 18 years and older, the barrier of obtaining a prescription for these women has been removed. This was definitely a victory for improving EC access in this country; however, many issues remain unanswered. Providers will still need to educate women about EC, although they do not need to write a prescription for women 18 years and older. Although over-the-counter access should streamline the process of obtaining Plan B® for many women, the cost of the over-the-counter drug, estimated at US$50 per dose, may be prohibitive for many women. Additionally, it is still unknown how universal pharmacy stocking of the over-the-counter product will be. Finally, it is not known whether racial/ethnic minorities will be well informed of the availability of the product without prescription. At the time of our study, EC was only available by prescription. However, these uncertainties underscore the importance of research efforts that aim to measure community awareness. Physicians still need to play an active role in the education of their patients about EC. In this study, Black and Latino women and women with less than a college education were more likely to have received an advance prescription for EC. This finding may be due to the efforts of the EC network to educate these communities about EC. However, the increase in prescriptions to less-educated minority women may be a symptom of a general lack of access to health care or Table 3 Comparison of likelihood of having heard of EC in the 2003 preintervention and 2005 postintervention surveys Race/Ethnicity
White, not Hispanic Black, not Hispanic Hispanic Other
p value a
Heard of EC (%) Preintervention
Postintervention
99 75 51 100
97 88 79 88
.24 .32 .001 .37
a Chi-square statistics were used to compare the proportion of women not having heard of EC in the preintervention and postintervention surveys.
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inability to afford contraception among this population and, thus, a lack of access to routine contraceptive methods. In order to effectively decrease unintended pregnancy rates, continued effort needs to be made to decrease the growing uninsured population in the United States, decrease disparities in health care access and break down cultural barriers to appropriate contraception use. The convenience sampling method used in this study is a potential limitation. Sampling street pedestrians may underrepresent women with physical limitations or women from this neighborhood who do not frequent the venues sampled for other reasons. Additionally, there was no control population in our study. Although we assume that the community education campaign is the cause of the observed change in EC knowledge, other factors such as time trends and increasing media coverage unrelated to the intervention may be involved. However, we do believe that the improved EC knowledge was largely due to the campaign because responses indicated that women had heard of EC in venues targeted by the campaign. Additionally, the largest improvements in EC knowledge occurred among Latino women. Since this group was specifically targeted by the campaign, it further suggests that the changes documented were due to the intervention. The grassroots efforts launched by the Massachusetts EC Network resulted in great improvements in EC knowledge in this Boston community. This communitybased effort was inexpensive but proved to be effective in this community. Even with EC being available over the counter, timely and unburdened access to EC will require reproductive-age women to have adequate knowledge in order to desire and seek this product correctly. Through educational efforts like these, women can be empowered to increase their armamentarium of contraceptives and avoid unintended pregnancy. Acknowledgment The authors wish to thank the members of the Massachusetts EC Network including Stacie Garnett, Sylvia Lambrechts, Meredith Manze and Davida Eisenberg for their assistance with this research.
Appendix A. EC survey questions Have you ever heard of EC (also called the “morning-after pill”)? □ Yes □ No (If you answer NO, you have finished the survey) True or false: EC prevents a pregnancy from starting. □ True □ False □ I don't know Where have you heard of EC before? □ Choices: TV/radio, magazines/newspapers, health care provider (doctor, nurse, pharmacist), stores/restaurants/hair salons, community programs and organizations, family/friends, school
When should a woman take EC for it to work? □ 1 day before unprotected sex □ Up to 1 day after unprotected sex □ Up to 72 h (3 days) after unprotected sex □ Up to 120 h (5 days) after unprotected sex □ Up to 1 week (7 days) after unprotected sex □ I don't know How can a woman get EC in Massachusetts? □ It is not available at all □ It is available only with a prescription □ It is available at the drugstore without a prescription (over the counter) □ I don't know Has a doctor, nurse or pharmacist ever talked with you about EC? □ Yes □ No □ I'm not sure Has a doctor or nurse ever given you a prescription for EC to have in case you needed it in the future? □ Yes □ No □ I'm not sure Have you ever had a problem getting EC at a pharmacy when you went with a prescription? □ Yes □ No □ I'm not sure If you had unprotected sex and did not want to be pregnant, how likely would you be to use EC? □ Very likely □ Somewhat likely □ Somewhat unlikely □ Very unlikely
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R.E. Gee et al. / Contraception 76 (2007) 366–371 sexuality, and constructing zygotic bodies. Med Anthropol Q 2006;20: 297–320. [12] Sherman CA. Emergency contraception: the politics of post-coital contraception. J Soc Issues 2005;61:139–57. [13] Oritz ME, Ortiz RE, Fuentes MA, Parraguez VH, Croxatto HB. Postcoital administration of levonorgestrel does not interfere with postfertilization events in the New-World monkey Cebus apella. Hum Reprod 2004;19:1352–6. [14] Chuang CH, Freund KM. Emergency contraception knowledge among women in a Boston community. Contraception 2005;71:157–60.
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[15] Griffin Jr JP, Floyd A. How to promote effective African American partnerships for community-based HIV/AIDS planning: lessons learned from the Atlanta Regional Minority Health Network. J Health Care Poor Underserved 2006;17:44–52. [16] Baquet CR, Mack KM, Mishra SI, et al. Maryland's Special Populations Network. A model for cancer disparities research, education, and training. Cancer 2006;107:2061–70. [17] Kim S, Flaskerud JH, Koniak-Griffin D, Dixon EL. Using communitypartnered participatory research to address health disparities in a Latino community. J Prof Nurs 2005;21:199–209.
Original research article
Emergency contraception knowledge after a community education campaign☆ Rebekah E. Gee a,b,c,d,⁎, Laurent C. Delli-Bovi b , Cynthia H. Chuang e a
University of Pennsylvania, Philadelphia, PA 19104, USA Brigham and Women's Hospital, Boston, MA 02115, USA c Robert Wood Johnson Foundation Clinical Scholars Program, Chapel Hill, NC 27599, USA d Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA e Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA, USA Received 22 May 2007; revised 12 July 2007; accepted 13 July 2007 b
Abstract Background: This study evaluates the effectiveness of a community education campaign in the Boston community of Jamaica Plain conducted by the Massachusetts Emergency Contraception (EC) Network aimed at improving public knowledge of EC. Study Design: Pre- and postintervention surveys of reproductive-age women were conducted to evaluate the effectiveness of the community education campaign. Knowledge of EC was compared before and after the intervention using surveys of community-based samples of women. Results: One hundred eighty-eight and 290 women participated in the preintervention and postintervention surveys, respectively. Following the intervention, women were significantly more likely to have heard of EC (91% vs. 82%, p=.007), know the mechanism of action of EC (49% vs. 39%, p=.04), have discussed EC with a health care provider (38% vs. 25%, p=.003) and have received an advance prescription for EC (22% vs. 12%, p=.004), as well as were more likely to use EC in the future if needed (79% vs. 63%, p=.0002). Conclusion: This grassroots-based community education campaign on EC was effective in improving EC knowledge in this Boston community. © 2007 Elsevier Inc. All rights reserved. Keywords: Emergency contraception; Community education; Knowledge disparities; Contraceptive education; Unintended pregnancy
1. Introduction Despite the fact that emergency contraception (EC) has enormous potential to reduce the number of unintended pregnancies and abortions, there have been few studies of community-based interventions to increase awareness of EC, and studies to date reveal that EC is often underutilized [1–5]. Multiple barriers have been identified for the appropriate use of EC and include lack of knowledge about EC, confusion about the mechanism of action of EC, ☆ This study was funded by an “Expanding the Boundaries” grant by the research fund of the Brigham and Women's Hospital Obstetrics and Gynecology Department. ⁎ Corresponding author. University of Pennsylvania, Philadelphia, PA 19104, USA. Tel.: +1 215 573 3979; fax: +1 215 573 2742. E-mail address: [email protected] (R.E. Gee).
0010-7824/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2007.07.007
social stigma about EC, inability to gain access to EC and pharmacist refusal to provide EC [6–13]. This study and the community educational campaign it describes were conducted prior to FDA approval of over-the-counter use of Plan B® (Barr Pharmaceuticals, Pomona, NY) EC for women 18 years and older. Although EC access is now likely to be improved, social, ideological, educational and financial barriers to access likely remain. It is therefore imperative that educational efforts target reproductive-age women, health care providers and pharmacists about EC and its appropriate use. This study describes a survey conducted after a community education campaign in the Boston neighborhood of Jamaica Plain. This campaign was launched by the Massachusetts EC Network, a coalition of community organizations, medical providers and government agencies that share a common goal of reducing unintended pregnancy
R.E. Gee et al. / Contraception 76 (2007) 366–371
by improving knowledge of and access to EC in Massachusetts. The campaign focused on increasing awareness about EC through outreach to the public, health care providers and pharmacists. Prior to initiation of the campaign, baseline knowledge about EC among reproductive-age women living in the community was assessed for the purpose of guiding the design and content of the educational intervention. The most significant finding of the initial survey was that knowledge of EC varied greatly based on race. The findings of that survey, conducted in 2003, have been previously published [14]. Based on the results of the initial survey, which revealed a significant disparity in knowledge by race/ ethnicity, the intervention included specific measures aimed at the Latino community. 2. Materials and methods The campaign evaluated by this study was an education campaign conducted by the Massachusetts EC Network with the primary aim of increasing knowledge regarding EC in the Boston community of Jamaica Plain. This community was chosen because of its socioeconomic and ethnic heterogeneity. Pre- and postintervention surveys were conducted on community-based samples of women who evaluated knowledge of EC, access to EC and willingness to use EC. The Institutional Review Boards of Brigham and Women's Hospital and the Boston Medical Center approved this study. 2.1. Study intervention The Massachusetts EC Network conducted the community education campaign from Fall 2003 until Spring 2005. The goal of the campaign was to improve EC knowledge among reproductive-age women living in Jamaica Plain. Therefore, the majority of the campaign was directed at public outreach. Outreach efforts for community residents included displaying educational signs in the community and distributing pamphlets to local businesses. In addition to the general public, health care providers and pharmacists were targeted for outreach. Educational packets on EC were provided to the community health centers and pharmacies located in Jamaica Plain. The packets included a sample health center/pharmacy policy on EC, fact sheets/brochures for providers/pharmacists/patients, prescribing protocol, and informational posters. Educational sessions in the form of lectures and one-on-one detailing were also offered to the health centers and pharmacies. Updated materials used for the intervention are available at the EC Network's website: www.massecnetwork.org. Volunteers with pharmacy training contacted pharmacists in the community and did outreach and education. Due to the findings of the initial survey in 2003, which demonstrated significant knowledge disparity in the Latino community of Jamaica Plain, the Massachusetts EC Network collaborated with Latino community leaders and community groups serving the community in an effort to
367
reach this group of women. This collaboration resulted in working with outreach workers at health centers, training peer health educators, targeting a homeless shelter for Latino women and their families and distributing Spanish language information at cultural fairs. Volunteer members of the Massachusetts EC Network provided much of the assistance for the intervention, but some paid staff time was involved. The total budget for this intervention was approximately US$10,000, which primarily covered staff time and printing educational materials. Funding for the education campaign study was provided by NARAL ProChoice Massachusetts and the EC Network. 2.2. Survey methodology Participants were recruited to participate in the surveys through convenience sampling in the same location and time of year prior to the intervention in May 2003 and after the intervention in May 2005. The 2003 sample was compared to the most recent U.S. census in 2000 from Jamaica Plain, and no statistical difference was found in race/ethnicity distribution; however, age distribution differed significantly (p=.003), with the study population overrepresenting the youngest age group. No statistical difference was found between the 2003 and 2005 survey populations. Specific details regarding the participant recruitment and survey development have been published previously [14]. Participants were recruited at public locations frequented by local residents over a period of several weeks. Subjects were informed that the anonymous survey was for the purpose of medical research and that their participation was voluntary. After completing the survey, women were offered a small bag containing the contact information of the principal investigator, chocolates, condoms and a pamphlet with basic facts about EC. Sample size calculations performed prior to the preintervention survey were aimed at detecting a meaningful difference in EC knowledge postintervention. Because the preintervention survey results revealed a knowledge disparity by race/ ethnicity, we recruited a larger sample size for the postintervention survey in order to have sufficient power to show a significant change in knowledge among Latino women. For the follow-up study, sample size calculations were based on the ability to calculate a meaningful difference in knowledge in the Latino community (25%). The survey was a self-administered written questionnaire designed specifically for this study. Demographics on age, race/ethnicity and community residence were collected. Women who were not residents of Jamaica Plain and between the ages of 18 and 44 were excluded from the study. Questions about EC are shown in the Appendix. In addition, women were asked about where they heard of EC (i.e., community) in order to help measure where efforts were most effective. The survey was designed at a fifth-grade literacy level and was available in both English and Spanish. The 2003 survey was pilot tested in English and Spanish to a representative sample of women.
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The dependent variable was determined by the question, “Have you ever heard of EC (also called the ‘morning-after pill’)?” If a participant answered “no,” she was instructed by the survey instrument to stop the survey. If the participant answered “yes,” she continued answering the remaining questions about EC. We assumed that if a woman had not heard about EC, then she had no further detailed knowledge about it. 2.3. Statistical analysis Data analysis was performed using SAS for Windows Version 8.2 (SAS Institute, Cary, NC). Demographic characteristics and responses to EC knowledge questions were determined and compared between the preintervention and postintervention participants using chi-square statistics. For both the preintervention and the postintervention surveys, we employed multivariate logistic regression to model the likelihood of having “heard of EC,” controlling for age, race/ ethnicity, education and religion. All analyses were two tailed, using a p value of .05 as criterion for statistical significance. 3. Results Detailed results from the 2003 preintervention survey have been published elsewhere [14]. Results from that survey relevant to evaluating the effectiveness of the intervention are presented here along with the results of the 2005 postintervention survey. Of the 332 surveys collected, 42 women were ineligible because they were not between the ages of 18 and 44 years. The remaining 290 surveys were analyzed. In the 2003 preintervention survey, 188 questionnaires were eligible for analysis. Demographic characteristics from the preintervention and postintervention cohorts are shown in Table 1. The pre- and postintervention cohorts did not differ significantly by age or race/ethnicity. Religion and education variables were not assessed in the 2003 preintervention questionnaire. Responses to the EC questions in the pre- and postintervention surveys are shown in Table 1. Significant improvements in EC knowledge were observed after the intervention. Ninety-one percent of women had heard of EC in the 2005 postintervention survey, as compared to 82% of women prior to the intervention (p=.007). Additionally, a greater proportion of women correctly answered that the mechanism of action of EC is by preventing pregnancy (49% vs. 39%, p=.04). Women reported a significant change with their EC experience regarding their health care providers as well. After the intervention, more women had discussed EC with a health care provider (38% vs. 25%, p=.003) and had received an advance prescription for EC (22% vs. 12%, p=.004), as compared with before the intervention. In addition, women were more likely to use EC in the future if needed (79% vs. 63%, p=.0002). The principal finding from the 2003 preintervention survey was that EC knowledge differed significantly by
Table 1 Comparison of respondent characteristics and survey responses in the 2003 preintervention (n=188) and 2005 postintervention (n=290) samples Characteristic Age (years) 18–24 25–29 30–34 35–39 40–44 Race/Ethnicity White, not Hispanic Black, not Hispanic Hispanic Other Education High school graduate or less At least some college Religion Catholic Non-Catholic Has heard of EC Has heard of EC and knows that it works by preventing pregnancy Has heard of EC and knows of the 72-to 120-h time window Has heard of EC and has discussed it with a health care provider Has heard of EC and has received an advance prescription Has heard of EC and is very/somewhat likely to use it in the future
Preintervention, n (%)
Postintervention, n (%)
p value a .12
58 42 41 26 21
(31) (22) (22) (14) (11)
61 (21) 88 (30) 72 (25) 36 (12) 32 (11)
106 (57) 20 (11) 55 (29) 6 (3)
161 (56) 35 (12) 69 (24) 25 (9)
.09
–
–
54 (19)
–
236 (81)
– – 154 (82) 73 (39)
85 (30) 200 (70) 262 (91) 141 (49)
.007 .04
91 (48)
150 (52)
.48
47 (25)
111 (38)
.003
22 (12)
64 (22)
.004
119 (63)
229 (79)
.0002
–
a Chi-square tests were used to compare 2003 preintervention and 2005 postintervention data.
race/ethnicity. In that cohort, White women were significantly more likely to have heard of EC than both Latino women and Black women (99% vs. 75% vs. 51%, respectively, pb.05). In the 2005 post-intervention survey Latino women (79%) and Black women (88%) were still significantly less likely to have heard of EC than White women (79%; p=.0001 and .04 respectively) (Table 2). A limitation from the 2003 preintervention findings was the inability to control for additional socioeconomic characteristics. It was therefore uncertain whether the EC knowledge disparities observed were in fact due to race/ethnicity independently or other characteristics for which they were not controlled for. Education and religion variables were added to the 2005 postintervention survey. After controlling for those variables, race/ethnicity knowledge disparities remained significant. Age, education and religion were not significant predictors in the model (Table 2). The community education campaign specifically targeted the Latino population. Findings by race/ethnicity before and after the campaign are shown in Table 3. After the
R.E. Gee et al. / Contraception 76 (2007) 366–371 Table 2 Likelihood of not having heard of EC in the 2005 postintervention survey Characteristic
Race/Ethnicity White, not Hispanic Black, not Hispanic Hispanic Other Education High school or less Associate/Technical College Postgraduate Religion Catholic Non-Catholic
Postintervention Heard of EC (%)
AOR (95% CI) a
97 88 79 88
Referent 4.9 (1.2, 21.1) 8.5 (2.2, 32.5) 3.9 (0.8, 18.4)
83 91 96 90
1.9 (0.5, 6.8) 0.6 (0.1, 3.9) Referent 3.0 (0.8, 10.4)
85 94
1.5 (0.5, 4.4) Referent
a
Logistic regression was used to model the likelihood of not having heard of EC in the postintervention survey, controlling for age, race/ ethnicity, education and religion.
intervention, Latino women were significantly more likely to have heard of EC (79% vs. 51%, p=.001. Additional results further suggest that Latino women were effectively targeted by the community education campaign. Following the intervention, 51% of Latino women reported that they had discussed EC with a health care provider, as compared with 36% of White women (p=.04) and 39% of Black women (p=.29). Additionally, Latino women were more likely to report that they had received an advance prescription for EC in the postintervention survey than White women (32% vs. 18%, p=.03). Having less than a college education was also independently associated with having received an advance prescription for EC (p=.002). 4. Discussion The purpose of this study was to evaluate a community education campaign on EC in the Boston community of Jamaica Plain. After the campaign, we found that significantly more women had knowledge about EC, had discussed EC with their health care providers and had received advance prescriptions for EC. Although there was likely increasing awareness of EC nationwide due to media coverage and controversy over FDA approval for over-the-counter status, the Barr Pharmaceutical company that manufactures Plan B® has not had a marketing campaign in Spanish, and materials in English and Spanish for providers' offices had been available since 1999 when the product first gained FDA approval. Although this is an observational study, the significant increase in knowledge, particularly in the Latino community, may reflect the success of the educational efforts of the Massachusetts EC Network. The Massachusetts EC Network collaborated with Latino-based community organizations during the community campaign due to preintervention survey findings of
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significant EC knowledge disparities by race/ethnicity. This study suggests that educational efforts targeted at ethnic groups can be effective in decreasing knowledge disparity. Cultural competency awareness and respect for community concerns, as demonstrated by the community campaign, have been shown to be effective at reducing health-related knowledge disparities [15–17]. In addition to the Latino community, the education campaign focused on health care providers and community programs, and our study found a significant increase in women hearing about EC through health care providers and community programs and organizations. Despite the significant increase in knowledge among Latino women, a significant disparity remains, and further efforts need to be targeted at these populations. In 2006, the FDA approved Plan B®, a dedicated EC product, for overthe-counter access for women 18 years and older. Now that Plan B® is available without prescription in the United States for women 18 years and older, the barrier of obtaining a prescription for these women has been removed. This was definitely a victory for improving EC access in this country; however, many issues remain unanswered. Providers will still need to educate women about EC, although they do not need to write a prescription for women 18 years and older. Although over-the-counter access should streamline the process of obtaining Plan B® for many women, the cost of the over-the-counter drug, estimated at US$50 per dose, may be prohibitive for many women. Additionally, it is still unknown how universal pharmacy stocking of the over-the-counter product will be. Finally, it is not known whether racial/ethnic minorities will be well informed of the availability of the product without prescription. At the time of our study, EC was only available by prescription. However, these uncertainties underscore the importance of research efforts that aim to measure community awareness. Physicians still need to play an active role in the education of their patients about EC. In this study, Black and Latino women and women with less than a college education were more likely to have received an advance prescription for EC. This finding may be due to the efforts of the EC network to educate these communities about EC. However, the increase in prescriptions to less-educated minority women may be a symptom of a general lack of access to health care or Table 3 Comparison of likelihood of having heard of EC in the 2003 preintervention and 2005 postintervention surveys Race/Ethnicity
White, not Hispanic Black, not Hispanic Hispanic Other
p value a
Heard of EC (%) Preintervention
Postintervention
99 75 51 100
97 88 79 88
.24 .32 .001 .37
a Chi-square statistics were used to compare the proportion of women not having heard of EC in the preintervention and postintervention surveys.
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inability to afford contraception among this population and, thus, a lack of access to routine contraceptive methods. In order to effectively decrease unintended pregnancy rates, continued effort needs to be made to decrease the growing uninsured population in the United States, decrease disparities in health care access and break down cultural barriers to appropriate contraception use. The convenience sampling method used in this study is a potential limitation. Sampling street pedestrians may underrepresent women with physical limitations or women from this neighborhood who do not frequent the venues sampled for other reasons. Additionally, there was no control population in our study. Although we assume that the community education campaign is the cause of the observed change in EC knowledge, other factors such as time trends and increasing media coverage unrelated to the intervention may be involved. However, we do believe that the improved EC knowledge was largely due to the campaign because responses indicated that women had heard of EC in venues targeted by the campaign. Additionally, the largest improvements in EC knowledge occurred among Latino women. Since this group was specifically targeted by the campaign, it further suggests that the changes documented were due to the intervention. The grassroots efforts launched by the Massachusetts EC Network resulted in great improvements in EC knowledge in this Boston community. This communitybased effort was inexpensive but proved to be effective in this community. Even with EC being available over the counter, timely and unburdened access to EC will require reproductive-age women to have adequate knowledge in order to desire and seek this product correctly. Through educational efforts like these, women can be empowered to increase their armamentarium of contraceptives and avoid unintended pregnancy. Acknowledgment The authors wish to thank the members of the Massachusetts EC Network including Stacie Garnett, Sylvia Lambrechts, Meredith Manze and Davida Eisenberg for their assistance with this research.
Appendix A. EC survey questions Have you ever heard of EC (also called the “morning-after pill”)? □ Yes □ No (If you answer NO, you have finished the survey) True or false: EC prevents a pregnancy from starting. □ True □ False □ I don't know Where have you heard of EC before? □ Choices: TV/radio, magazines/newspapers, health care provider (doctor, nurse, pharmacist), stores/restaurants/hair salons, community programs and organizations, family/friends, school
When should a woman take EC for it to work? □ 1 day before unprotected sex □ Up to 1 day after unprotected sex □ Up to 72 h (3 days) after unprotected sex □ Up to 120 h (5 days) after unprotected sex □ Up to 1 week (7 days) after unprotected sex □ I don't know How can a woman get EC in Massachusetts? □ It is not available at all □ It is available only with a prescription □ It is available at the drugstore without a prescription (over the counter) □ I don't know Has a doctor, nurse or pharmacist ever talked with you about EC? □ Yes □ No □ I'm not sure Has a doctor or nurse ever given you a prescription for EC to have in case you needed it in the future? □ Yes □ No □ I'm not sure Have you ever had a problem getting EC at a pharmacy when you went with a prescription? □ Yes □ No □ I'm not sure If you had unprotected sex and did not want to be pregnant, how likely would you be to use EC? □ Very likely □ Somewhat likely □ Somewhat unlikely □ Very unlikely
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