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Examining the influence of mental health on dual contraceptive method use among college women in the United States
Sexual & Reproductive Healthcare 12 (2017) 24–29
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Examining the influence of mental health on dual contraceptive method use among college women in the United States Melanie Moore ⇑, Melissa Kwitowski, Sarah Javier Department of Psychology, Virginia Commonwealth University, USA
a r t i c l e
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Article history: Received 22 May 2016 Revised 17 January 2017 Accepted 25 January 2017
Keywords: Mental health Depression Contraception Dual method use Young women
a b s t r a c t Objectives: To examine mental health influences on dual contraceptive method use (i.e., the use of a hormonal contraceptive or intrauterine device with a condom barrier) among college women. Study design: Data from N = 307 sexually active women who completed the 2014 National College Health Assessment at a large mid-Atlantic university were analyzed. Following chi-square tests of associations, multivariate logistic regressions examined the relation between mental health and sociodemographic factors and dual contraceptive method use. Results: Among all women, 27% utilized a dual contraceptive method during last vaginal intercourse. A prior depressive disorder diagnosis was significantly associated with lower odds of dual method use compared to use of other contraceptive methods combined (aOR, 0.39; 95% CI: 0.19–0.79), use of no method (aOR, 0.12; 95% CI: 0.03–0.55), or use of hormonal contraceptives only (aOR, 0.39; 95% CI: 0.18–0.85). Conclusions: Mental health is an important contributor to contraceptive method use. Health care providers should consider the role of mental health when counseling women about contraceptive options during routine gynecological visits. Results suggest that mental health screenings may be helpful in identifying those most at risk for not using dual contraceptive methods. Ó 2017 Elsevier B.V. All rights reserved.
Introduction High incidence rates of sexually transmitted infections (STIs) and unintended pregnancy remain significant public health concerns among young women in the United States. Women aged 20–24 have the highest risk and incidence rates of STIs such as chlamydia, gonorrhea, and syphilis, compared to women of other age groups [1]. Undiagnosed/untreated STIs can have serious reproductive health consequences for women, such as the occurrence of pelvic inflammatory disease or ectopic pregnancy—both of which can reduce fertility [2]. Untreated STIs result in infertility for approximately 20,000 women each year [3]. In addition to high STI rates, young women aged 18–24 represent the majority of unintended pregnancies—pregnancies defined as being unwanted or mistimed—among women of all age groups [4]. From 2001– 2006, rates of unintended pregnancy increased among women aged 20–24 from 59% to 64% [4]. One strategic approach to simultaneously reducing high rates of STIs and unintended pregnancy among young women is the
⇑ Corresponding author at: Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA 23284, USA. E-mail address: [email protected] (M. Moore). http://dx.doi.org/10.1016/j.srhc.2017.01.004 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
promotion of dual contraceptive method use. Dual contraceptive method use involves the concurrent use of both a hormonal contraceptive (e.g., intrauterine device, oral contraceptive pills) and a condom barrier (male or female) during vaginal sex, and is the most effective method in preventing both STI transmission and unintended pregnancy [5]. Despite the known effectiveness of dual contraceptive methods, most sexually active young women use condoms or hormonal contraceptives alone [6] and little is known about factors that impact dual method use among young women. The purpose of this study was to explore the relation between mental health variables and dual contraceptive use among college women. While poor mental health has been linked to inconsistent contraception use and contraception non-use [7,8], the influence of mental health on dual contraceptive method use has been largely unexamined. It is estimated that psychiatric disorders impact upwards of 30% of women of reproductive age each year [9]. Previous work has indicated that mental health status can adequately predict contraception use in women aged 18–20 years [7,8]. Specifically, evidence suggests that psychological stress symptoms are linked to contraception non-use or use of less effective contraceptive methods [7,8]. Indeed, across populations and settings, it appears that women suffering from depression, anxiety, and related stress, have consistently higher levels of contraceptive non-use, misuse, and
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discontinuation when compared to women without these symptoms [10]. As such, research has begun to focus on the ways in which mental health status can impact decisions regarding reproductive health including contraception, pregnancy, infertility, and menopause [11]. A variety of explanations for this relationship have been proposed; some researchers posit that associated mental health deficits in risk assessment, planning, social learning, and motivation as well as excessive worry and decreased concern about susceptibility to pregnancy may explain suboptimal decision-making regarding contraceptive methods [10]. However, the ways in which mental health symptoms influence contraceptive method use remain unclear. Given the role of depression and mental health in preventive care decision-making, examining the influence of mental health on dual contraceptive method use and non-use is an important next step. Research urging providers to consider the role of psychological symptoms in contraception adherence as a way of optimizing the efficacy of their contraceptive counseling [12], further supports the need for this work. The purpose of the current study was to examine the relation between mental health and dual contraceptive method use among sexually active college women at risk for STI and unintended pregnancy. In 2010, The Healthy People 2020 initiative (US Department of Health and Human Services. Healthy People 2020, 2010) endorsed dual contraceptive method use as a needed area of focus among young adults [13]. In the recent years following this initiative, studies investigating the prevalence of dual contraceptive method and associated factors noted that dual method use among young women has increased [14–17]; however, many of these studies have focused exclusively on sociodemographic and sexual behavior associations of dual method use. Few studies have examined the role of mental health in dual method use in college-aged women [7,8]. This study aims to add to a limited body of knowledge by investigating the relations between mental health concerns and contraceptive use. Materials and methods Data The American College Health Association-National College Health Assessment II (ACHA-NCHA II) is a national research assessment administered throughout the United States [18]. Data from the 2014 ACHA-NCHA II were collected from a convenience sample online at a large mid-atlantic university by the student wellness center. A subset of items from this questionnaire relating to contraceptive use, sexual behavior, reproductive health, and sociodemographic information were included in secondary data analysis for the current study. Prior to data collection, the institutional review board (IRB) gave permission to collect study data. Students completed informed consent online and were informed prior to beginning study questionnaires that all responses were confidential and that questions causing discomfort could be skipped. Additional information about the ACHA-NCHA II is available at the organization’s website (http://www.acha-ncha.org).
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course in the last 30 days). Sample restrictions resulted in a final analytic sample of N = 307 women for the present study. Outcome variables The primary outcome variable of interest was a two-part item on dual contraceptive method use during the last act of vaginal intercourse, and was measured on a categorical scale (0 = No; 1 = Yes). Women were first asked if they used a method of birth control during the last time they had sex; those who responded yes were asked about the type of birth control method they used. Methods of birth control were assessed by the following question: ‘‘Please indicate whether or not you or your partner used each of the following methods of birth control to prevent pregnancy the last time you had vaginal intercourse.” Students had the option of selecting from 15 items which included: (1) hormonal contraceptives (birth control pills, birth control shots, birth control implants, birth control patch, and vaginal ring); (2) intrauterine device (IUD); (3) condom barriers (male or female condom), and (4) additional methods (diaphragm or cervical cap, contraceptive sponge, spermicide, fertility awareness, withdrawal, sterilization, or other). Students could select more than one method if applicable. In the current study, a new dichotomous contraceptive use variable to reflect dual contraceptive use was created over two steps. In the first step, women were separated into the following groups: (1) condom barrier use (use of male or female condom in absence of a hormonal contraceptive or IUD); (2) hormonal contraceptive or IUD (in absence of a condom barrier method); (3) dual method (use of male or female condom barrier in addition to an IUD or hormonal contraceptive); (4) other method (in absence of a condom barrier and/or IUD or hormonal contraceptive); or (5) no method used. In the second step, women were further categorized into the following two groups for the purposes of analyzing our primary outcome: (0) single method, other method, and no method (1) used both a hormonal contraceptive and a condom barrier during last sex. Independent variables Lifetime history of depression Participants were asked the following question: Have you ever been diagnosed with depression? Response options were ‘‘no” (coded as 0) and ‘‘yes” (coded as 1). This single item measure has been used to assess lifetime history of depression in previous literature conducted among college women [18,19]. Stress Participants were asked the following question: ‘‘Within the last 12 months, how would you rate the overall level of stress you have experienced?” Response options were no stress, less than average stress, average stress, more than average stress, and tremendous stress. Response options were then dichotomized for analyses as follows: no stress, less than average stress, or average stress (coded as 0), and more than average stress and tremendous stress (coded as 1).
Analytic sample
Sociodemographic variables
The initial sample consisted of 686 total women. To meet the study’s aims, inclusion criteria in the current sample included females ages 18–25, who reported a single marital status. Marital status and age were included as inclusion criteria because unmarried young adult women have the highest rates of STIs and unintended pregnancies [1,4]. In addition, the sample was restricted to sexually active women (i.e., reporting having had vaginal inter-
Sociodemographic variables of interest were: age (18–25), race, and relationship status (e.g., not in a relationship or in a relationship). Age was categorized into two groups (18–19 and 20–25), to determine if there were differences in contraceptive use among teenagers compared to older young adults given previous research indicating differences in contraceptive use by age [20]. Based on previous literature suggesting that racial minority women were
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M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
less likely to use dual methods of contraception, race was dichotomized into White and racial minority [21]. Variables of interest related to sexual behavior and reproductive health included the following: number of sexual partners in the past 12 months, having a gynecological exam in the past 12 months, and being diagnosed or treated with an STI (chlamydia, genital herpes, genital warts/HPV, gonorrhea, and/or HIV) in the past 12 months. Analytic plan All analyses were conducted using IBM SPSS Version 22 [22]. Prior to analysis, data were screened for missing values and normality. All categorical variables were recoded so that they included zero. The current study utilized multivariate logistic regression models to access study outcomes. In subsequent multivariable models, multicollinearity, outliers, and mutually exclusiveness of categories were assessed. A multiple logistic regression model was used to estimate the relative contribution of the independent variables on odds of dual method use versus dual method non-use. Demographic (age, race, and relationship status) and sexual behaviors (number of sexual partners in the past 12 months, recent gynecological exam, and past year STI history) were included as covariates in the multivariate models based on previous research indicating relationships between similar variables and contraceptive method use [6]. In addition, stress and lifetime history of depression were included given previous research identifying mental health status as having an important role in preventative health [10]. Finally, a series of multivariable logistic regression models examined odds of dual contraceptive method use when compared to other contraceptive methods. We report adjusted odds ratios (aOR), and controlled for sociodemographic, sexual behavior, and reproductive health factors. Results Characteristics of the sample Table 1 presents the demographic makeup of the current sample. The majority of the sample was between the ages 20–25 (74.3%), identified as White (62.5%), and were in a committed relationship (80.5%). Of the sample, 61.6% reported having a gynecological exam in the past 12 months, and only 4.6% reported being diagnosed or treated with a STI. Nearly 31.9% reported having had multiple sexual partners within the past 12 months. Nearly 58% reported above average stress levels in the past 12 months, and almost 30% had a history of ever being diagnosed with depression. Dual contraceptive method use prevalence was 27% during last vaginal sexual intercourse. Approximately 41% used hormonal contraceptives in absence of a condom barrier, and 18.2% used condoms in absence of hormonal contraceptives. No contraceptive method was used among 9.1% of the sample, and approximately 1% used alternative methods of birth control, which did not include hormonal contraceptives, IUDs, or condom barriers. Multivariate analyses related to dual method use A hierarchical logistic regression examined the effect of demographic and mental health on the outcome of dual method use versus non-dual method use (all other methods combined). Results of this analysis are presented in Table 2. In the first step, age, race, and relationship status were entered as control variables. In the second step, having had gynecological exam, having been diagnosed or treated with an STI, and number of sexual partners in
Table 1 Characteristics of sexually active college women ages 18–25 at a large, Mid-Atlantic university (from the 2014 American College Health Association – National College Health Assessment). Total N = 307 N Demographic variables Race/ethnicity White Racial minoritya Age 18–19 20–25 Relationship status Not in a relationship In a relationship
307 192 115 307 79 228 306 59 247
Sexual risk variables Had a routine gynecological exam in the past 12 months? No Yes Diagnosed with an STI in the last 12 months?b No Yes Had multiple sexual partners in the last 12 months? No Yes
304 115 189 304 290 14 305 207 98
Contraceptive use at last vaginal intercourse Hormonal contraceptive Condom barrier Dual methodc Other method No method
127 56 83 4 28
Mental health variables Stress Average or below Above average Ever diagnosed with depression? No Yes
307 130 177 305 220 85
%
62.5 37.5 25.7 74.3 19.2 80.5
37.5 61.6 94.5 4.6 67.4 31.9 41.4 18.2 27.0 1.3 9.1
42.3 57.7 71.7 27.7
a Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. b STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category. c Dual method = Use of both a hormonal contraceptive and condom barrier during vaginal sex.
the past 12 months were entered. In the third step, stress and a lifetime history of depression were included. In the adjusted odds model, lifetime history of depression emerged as being significantly associated with dual method use (p = 0.01) compared to the use of other methods (all other method categories combined); women who had previously received a diagnosis of depression were less likely to use a dual method (aOR = 0.39). A second set of logistic regression models analyzed the influence of demographic and mental health variables on the outcomes of: (1) odds of dual method use versus use of no method, (2) dual method use versus condom barrier use, and (3) dual method versus hormonal contraceptive use. Results of this analysis are represented in Table 3. Lifetime history of depression was associated with lower odds (aOR = 0.12) of using a dual method compared to no method and lower odds of using a dual method compared to a hormonal contraceptive (aOR = 0.39). Having a gynecological exam in the past 12 months was significantly associated with greater odds of dual method use versus the use of no method (aOR = 9.2) and greater odds of using a dual method compared to condoms alone (aOR = 2.87). Being in a racial minority group was associated with increased odds of using a dual method compared to a hormonal contraceptive (aOR = 2.2).
M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29 Table 2 Multivariable odds of dual method use versus non-dual method use at last vaginal intercourse (from the 2014 American College Health Association – National College Health Assessment). Characteristic
Dual method use versus nonuse aORa
Step 1: Demographic variables Race/ethnicity White Racial minorityb Age 18–19 20–25 Relationship status Not in a relationship In a relationship Step 2: Sexual risk variables Had a routine gynecological exam in the past 12 months? No Yes Diagnosed with an STI in the last 12 months?c No Yes Had multiple sexual partners in the last 12 months? No Yes Step 3: Mental health variables Stress Average or below Above average Ever diagnosed with depression?* No Yes
95% CI
Sig. (p*) 0.28
Referent 1.37
0.77–2.44 0.51
Referent 1.24
0.66–2.35 0.93
Referent 1.04
0.48–2.23 0.17
Referent 1.51
0.84–2.70 0.73
Referent 1.25
0.35–4.42 0.34
Referent 1.38
0.71–2.67 0.58
Referent 0.86
0.49–1.49 0.01
Referent 0.39
0.19–0.79
Note: In the analysis, variables from Step 1 are entered into the model first. Then, variables from Step 2 are entered using Stepwise Logistic Regression (LR) and build on the model from Step 1. Finally, variables from Step 3 are entered using Stepwise LR and build on the model from Step 2. * p < 0.05. a aOR adjusts for other variables entered in the same step. b Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. c STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category.
Discussion This study highlights the influence of lifetime history of depression on dual method contraceptive use during sexual intercourse among young college women at risk for STIs and unintended pregnancy. Previous work in the field of reproductive health has noted the significant impact mental health concerns have on both reproductive and sexual health decisions [10]. A number of prior studies have previously demonstrated that women with mental health concerns exhibit higher patterns of contraception non-use, misuse and discontinuation [10]. Given the established relationship between women’s mental health and contraceptive use, the current study sought to understand how mental health concerns impact dual contraceptive method use. Findings revealed a significant relation between lifetime history of depression and dual contraceptive use. History of a prior depression diagnosis was associated with lower odds of dual method use when compared to use of no method, hormonal contraceptives, or all other methods combined. Stress was not significantly associated with dual contraceptive use. This outcome may be due to the associated comorbidity of stress and depression or the way in which stress was measured in the current study. These results indi-
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cate that it is critical for healthcare providers to consider not only physical but also emotional functioning of patients when counseling about contraceptive methods and sexual decision-making [7]. Across the sample the prevalence of dual contraceptive method during last vaginal sex was 27.9%, indicating that the majority of the sample were not using the most effective form of simultaneous STI and pregnancy prevention. The most frequently reported contraceptive method was hormonal contraceptives in absence of a condom barrier (43%), followed by dual contraceptives (27.9%), and finally use of condoms in absence of hormonal contraceptives (18.8%). No method was used among 9.4% of the current sample. Women reported that hormonal contraceptives were the most popular contraceptive method, which support previous literature that women prioritize pregnancy prevention over STI prevention in choosing a contraceptive method [23]. While hormonal contraceptives are the most effective method of pregnancy prevention when used correctly [24], they provide no protection against STI transmission. Condom barriers are an effective means of preventing pregnancy [25] and STIs [26] but, incorrect or inconsistent use can decrease effectiveness [26]. Condoms also have higher rates of failure as a birth control method—they result in 18 or more annual pregnancies per 100 women—compared to between 6 and 12 annual pregnancies among those using hormonal contraceptives [24]. Thus, given the limitations of hormonal contraceptives in STI prevention and limitations of condom barriers in pregnancy prevention, the promotion of either method alone does not provide optimal protection against both unintended pregnancy and STIs for women. Dual contraceptive method use provides the most effective method of protection [5]. In the current study, women who were racial minorities were more likely to report use of a dual method compared to hormonal contraceptive alone, a finding which conflicts with previous research indicating that racial/ethnic minority women are less likely to use dual methods of protection [21]. While this finding was significant, it should be interpreted in light of the fact that all racial minority women were grouped into one category during analyses. Women who had received a gynecological exam in the past 12 months were also more likely to report use of a dual method at last vaginal sex compared to the use of no method or condoms only. This reiterates the importance of healthcare providers in the contraceptive decision-making process. Indeed, previous literature supports the importance of routine gynecological exams in educating women about the best methods of protection against STIs and unintended pregnancy [25]. Implications Given the ways in which mental health symptoms impact contraceptive use, health care settings specializing in reproductive care represent ideal spaces for symptom detection, intervention, and prevention [9]. However, it must also be noted that symptoms associated with mental health concerns such as anxiety and depression can hinder patient-provider communication and rapport in critical ways that might go unnoticed by both parties [9]. As such, evidence suggests a strong need for standardized assessment of mental health symptoms and psychological well-being as an integral and routine part of routine reproductive health care. Given the hectic pace of clinical and health settings, standardized mental health assessment measures are an effective, efficient and practical technique for identifying issues in psychological wellbeing, and as a result, improving family planning and reproductive health care [9]. Additionally, healthcare workers should be mindful when working with individuals with mental health concerns to create feasible and tailored strategies regarding contraceptive method use [27]. For example, health care providers may also con-
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M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
Table 3 Multivariable odds of dual method use versus other contraceptive use at last vaginal intercourse (from the 2014 American College Health Association – National College Health Assessment). Characteristic
Step 1: Demographic variables Race/ethnicity* White Racial minorityb Age 18–19 20–25 Relationship status Not in a relationship In a relationship Step 2: Sexual risk variables Had a routine gynecological exam in the past 12 months?* No Yes Diagnosed with an STI in the last 12 months?c No Yes Had multiple sexual partners in the last 12 months? No Yes Step 3: Mental health variables Stress Average or below Above average Ever diagnosed with depression?* No Yes
Dual method use versus hormonal contraceptive use
Dual method use versus condom use
Dual method use versus no method
aORa
95% CI
aORa
95% CI
aORa
95% CI
Referent 2.21
1.14–4.30
Referent 0.70
0.32–1.51
Referent 0.50
0.16–1.50
Referent 1.43
0.69–2.95
Referent 1.04
0.43–2.55
Referent 0.54
0.15–1.95
Referent 0.45
0.18–1.17
Referent 1.96
0.70–5.48
Referent 3.69
1.03–13.27
Referent 0.86
0.44–1.71
Referent 2.87
1.32–6.23
Referent 9.20
2.60–32.52
Referent 1.15
0.28–4.78
Referent 1.28
0.20–8.34
Referent 2.31
0.10–51.34
Referent 1.41
0.68–2.94
Referent 1.42
0.56–3.58
Referent 1.10
0.31–3.89
Referent 0.93
0.50–1.75
Referent 0.83
0.38–1.81
Referent 0.81
0.27–2.43
Referent 0.39
0.18–0.85
Referent 0.48
0.18–1.30
Referent 0.12
0.03–0.55
*
p < 0.05. a aOR adjusts for other variables entered in the same step. b Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. c STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category.
sider counseling patients with a lifetime history of depression about the benefits of using long acting reversible contraceptives (LARCs) for pregnancy protection as opposed to other forms of contraceptives that require frequent use or manipulation. Indeed, prior work in adolescent females indicates that depressive symptoms influence adherence to weekly contraceptive routines [8]. Additionally, research suggests that women under moderate to severe psychological distress are less likely to use maximum effective contraceptive methods (i.e. dual contraception) or forgo the use of contraception entirely [8]. Limitations Although current findings revealed important factors influencing contraceptive method use, there are several limitations to note. First, the current study employed a cross-sectional design, and therefore study results should be interpreted in light of crosssectional design limitations. All data was collected via selfreports, and although women were informed that all study responses were anonymous, women may have reported socially desirable responses. Given the recruitment strategy of participants, it is possible that the responses were influenced by non-response bias or by the fact that all women were enrolled in college. Further, lifetime history depression was measured via self-report of a previous diagnosis as opposed to a more comprehensive assessment of current depressive symptoms. It is possible that some participants had previously experienced symptoms of depression at a sub-clinical level that has never resulted in a diagnosis. In addition, many women do not seek treatment for depressive symptoms due to barriers including stigma and access to mental health services.
As such, it is possible that there were more women with a lifetime history of depression in our sample than what we were able to account for. Last, the majority of the current sample (80.7%) reported currently being in a committed relationship which may have affected study results. Indeed, prior research suggests that contraception use is markedly influenced by the type of sexual relationship in which one is engaged [28]. Indeed, relationships of a longer duration and increased commitment level are associated with a decreased likelihood of use of dual contraception or any type of contraceptive method during intercourse [29]. However, a significant predictor of contraceptive use in romantic couples lies in perceived partner support of contraceptive methods, as such; endorsing a current romantic relationship is not the only factor in predicting contraceptive use [30]. Conclusion This study indicates that history of depression is an important factor in dual method use, and that provider recommendations for contraceptive use should consider mental health status and history. It is estimated that if condoms were used in conjunction with an effective hormonal contraceptive, there would be a 40% reduction in unintended pregnancy and abortion, resulting in a reduction of 393,000 unintended pregnancies and 76,000 abortions annually [5]. Although dual contraception is widely accepted as the best method for both pregnancy and STI prevention, our findings revealed that among the high-risk young adult female college population this is a frequently underutilized method. Our findings suggest that mental health screenings may be important to imple-
M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
ment during routine visits, however future work will need to further investigate the understudied relation between mental health and contraceptive use. Psychological symptoms and disorders, namely depression, can significantly affect a patient’s contraception adherence and management. Addressing existing psychological concerns during consultation prior to contraceptive prescription might allow providers to more readily tailor contraception counseling to prevent pregnancy and disease while increasing medication adherence and compliance. Future studies should also examine dual contraceptive method use in specific at risk subgroups, such as, ethnic minorities and women of lower socioeconomic status who are at increased risk for STIs and unwanted pregnancies. In addition, there are few evidencedbased interventions that specifically target the utilization of dual methods among young women [15]. Future research should develop interventions that consider the role of mental health on reproductive health decisions in college women. Other variables that may influence dual methods of both hormonal contraceptives and barriers methods should be identified and examined (e.g. relationship type and duration, sexual history and risk perceptions, substance use, access to reproductive health services, sociocultural influences). Further investigation of the influential correlates of dual contraceptive method use in the at-risk college-aged sample is imperative for intervention efforts aimed at decreasing the prevalence of STIs and unintended pregnancies. Author disclosure statement The authors declare they have no conflicts of interest to disclose. Acknowledgements We would like to thank the American College Health Association and all of the students who participated in this study, thereby making this research possible. Role of the funding source You are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s), if any, in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. If the funding source(s) had no such involvement then this should be stated. References [1] Centers for Disease Control and Prevention (CDC). (2015). STD in Adolescents. Retrieved from. [2] Women’s Health. Health Journey Fact Sheet; 2013. Retrieved from . [3] Centers for Disease Control and Prevention (CDC). Reported STDs in the United States; 2015. Retrieved from . [4] Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001–2008. Am J Public Health 2014;104:S43–8. [5] Pazol K, Kramer MR, Hogue CJ. Condoms for dual protection: patterns of use with highly effective contraceptive methods. Public Health Rep 2010;125:208. [6] Tyler CP, Whiteman MK, Kraft JM, Zapata LB, Hillis SD, Curtis KM, et al. Dual use of condoms with other contraceptive methods among adolescents and young women in the United States. J Adolesc Health 2014;54:169–75.
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[7] Hall KS, Moreau C, Trussell J, Barber J. Young women’s consistency of contraceptive use—does depression or stress matter? Contraception 2013;88:641–9. [8] Hall KS, Moreau C, Trussell J, Barber J. Role of young women’s depression and stress symptoms in their weekly use and nonuse of contraceptive methods. J Adolesc Health 2013;53:241–8. [9] Farr SL, Curtis KM, Robbins CL, Zapata LB, Dietz PM. Use of contraception among US women with frequent mental distress. Contraception 2011;83:127–33. [10] Hall KS, Steinberg JR, Cwiak CA, Allen RH, Marcus SM. Contraception and mental health: a commentary on the evidence and principles for practice. Am J Obstet Gynecol 2015;212:740–6. [11] Stanton AL, Lobel M, Sears S, DeLuca RS. Psychosocial aspects of selected issues in women’s reproductive health: current status and future directions. J Consult Clin Psychol 2002;70:751. [12] Francis J, Presser L, Malbon K, Braun-Courville D, Linares LO. An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception. Contraception 2015;91:336–43. [13] US Department of Health and Human Services. Healthy People 2020 topics and objectives. Washington, DC: US Department of Health and Human Services; 2010. Retrieved from. [14] Bradley H, Leichliter JS, Gift TL. Does discussing sexually transmissible infections or HIV with a parent increase condom use among young women using other contraceptive methods? Sexual Health 2013;10:82–90. [15] Lopez LM, Stockton LL, Chen M, Steiner MJ, Gallo MF. Programs for preventing pregnancy and disease through using two methods of contraception; 2014. Retrieved from . [16] Ong J, Temple-Smith M, Wong W, McNamee K, Fairley C. When two is better than one: differences in characteristics of women using condoms only compared to those using condoms combined with an effective contraceptive. J Women’s Health 2014;23:168–74. [17] Walsh JL, Fielder RL, Carey KB, Carey MP. Dual method use among a sample of first-year college women. Perspect Sexual Reprod Health 2014;46:73–81. [18] American College Health Association. American College Health AssociationNational College Health Assessment II: Undergraduate students reference group executive summary spring 2014. Hanover, MD: American College Health Association; 2014. [19] Hossain MB, Memiah P, Adeyinka A. Are female college students who are diagnosed with depression at greater risk of experiencing sexual violence on college campus? J Health Care Poor Underserved 2014;25:1341–59. [20] Centers for Disease Control and Prevention. Current Contraceptive Status among Women 15-44: United States, 2011–2013; 2014. Retrieved from . [21] Payne C, Fanarjian N. Seeking causes for race-related disparities in contraceptive use. The Virtual Mentor 2014;16:805. [22] IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. [23] Bharadwaj P, Akintomide H, Brima N, Copas A, D’Souza R. Determinants of long-acting reversible contraceptive (LARC) use by adolescent girls and young women. Eur J Contracept Reprod Health Care 2012;17:298–306. [24] Centers for Disease Control and Prevention (CDC). Effective Planning Methods; 2015. Retrieved from . [25] Centers for Disease Control and Prevention (CDC). Unintended Pregnancy Prevention; 2015. Retrieved from . [27] Garbers S, Correa N, Tobier N, Blust S, Chiasson MA. Association between symptoms of depression and contraceptive method choices among lowincome women at urban reproductive health centers. Matern Child Health J 2010;14:102–9. [28] Johnson AZ, Sieving RE, Pettingell SL, McRee AL. The roles of partner communication and relationship status in adolescent contraceptive use. J Pediat Health Care 2015;29:61–9. [29] Bailey JA, Fleming CB, Catalano RF, Haggerty KP, Manhart LE. Romantic relationship characteristics and alcohol use: longitudinal associations with dual method contraception use. J Adolesc Health 2012;50:450–5. [30] Kenyon DB, Sieving RE, Jerstad SJ, Pettingell SL, Skay CL. Individual, interpersonal, and relationship factors predicting hormonal and condom use consistency among adolescent girls. J Pediat Health Care 2010;24:241–9.
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Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
Examining the influence of mental health on dual contraceptive method use among college women in the United States Melanie Moore ⇑, Melissa Kwitowski, Sarah Javier Department of Psychology, Virginia Commonwealth University, USA
a r t i c l e
i n f o
Article history: Received 22 May 2016 Revised 17 January 2017 Accepted 25 January 2017
Keywords: Mental health Depression Contraception Dual method use Young women
a b s t r a c t Objectives: To examine mental health influences on dual contraceptive method use (i.e., the use of a hormonal contraceptive or intrauterine device with a condom barrier) among college women. Study design: Data from N = 307 sexually active women who completed the 2014 National College Health Assessment at a large mid-Atlantic university were analyzed. Following chi-square tests of associations, multivariate logistic regressions examined the relation between mental health and sociodemographic factors and dual contraceptive method use. Results: Among all women, 27% utilized a dual contraceptive method during last vaginal intercourse. A prior depressive disorder diagnosis was significantly associated with lower odds of dual method use compared to use of other contraceptive methods combined (aOR, 0.39; 95% CI: 0.19–0.79), use of no method (aOR, 0.12; 95% CI: 0.03–0.55), or use of hormonal contraceptives only (aOR, 0.39; 95% CI: 0.18–0.85). Conclusions: Mental health is an important contributor to contraceptive method use. Health care providers should consider the role of mental health when counseling women about contraceptive options during routine gynecological visits. Results suggest that mental health screenings may be helpful in identifying those most at risk for not using dual contraceptive methods. Ó 2017 Elsevier B.V. All rights reserved.
Introduction High incidence rates of sexually transmitted infections (STIs) and unintended pregnancy remain significant public health concerns among young women in the United States. Women aged 20–24 have the highest risk and incidence rates of STIs such as chlamydia, gonorrhea, and syphilis, compared to women of other age groups [1]. Undiagnosed/untreated STIs can have serious reproductive health consequences for women, such as the occurrence of pelvic inflammatory disease or ectopic pregnancy—both of which can reduce fertility [2]. Untreated STIs result in infertility for approximately 20,000 women each year [3]. In addition to high STI rates, young women aged 18–24 represent the majority of unintended pregnancies—pregnancies defined as being unwanted or mistimed—among women of all age groups [4]. From 2001– 2006, rates of unintended pregnancy increased among women aged 20–24 from 59% to 64% [4]. One strategic approach to simultaneously reducing high rates of STIs and unintended pregnancy among young women is the
⇑ Corresponding author at: Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA 23284, USA. E-mail address: [email protected] (M. Moore). http://dx.doi.org/10.1016/j.srhc.2017.01.004 1877-5756/Ó 2017 Elsevier B.V. All rights reserved.
promotion of dual contraceptive method use. Dual contraceptive method use involves the concurrent use of both a hormonal contraceptive (e.g., intrauterine device, oral contraceptive pills) and a condom barrier (male or female) during vaginal sex, and is the most effective method in preventing both STI transmission and unintended pregnancy [5]. Despite the known effectiveness of dual contraceptive methods, most sexually active young women use condoms or hormonal contraceptives alone [6] and little is known about factors that impact dual method use among young women. The purpose of this study was to explore the relation between mental health variables and dual contraceptive use among college women. While poor mental health has been linked to inconsistent contraception use and contraception non-use [7,8], the influence of mental health on dual contraceptive method use has been largely unexamined. It is estimated that psychiatric disorders impact upwards of 30% of women of reproductive age each year [9]. Previous work has indicated that mental health status can adequately predict contraception use in women aged 18–20 years [7,8]. Specifically, evidence suggests that psychological stress symptoms are linked to contraception non-use or use of less effective contraceptive methods [7,8]. Indeed, across populations and settings, it appears that women suffering from depression, anxiety, and related stress, have consistently higher levels of contraceptive non-use, misuse, and
M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
discontinuation when compared to women without these symptoms [10]. As such, research has begun to focus on the ways in which mental health status can impact decisions regarding reproductive health including contraception, pregnancy, infertility, and menopause [11]. A variety of explanations for this relationship have been proposed; some researchers posit that associated mental health deficits in risk assessment, planning, social learning, and motivation as well as excessive worry and decreased concern about susceptibility to pregnancy may explain suboptimal decision-making regarding contraceptive methods [10]. However, the ways in which mental health symptoms influence contraceptive method use remain unclear. Given the role of depression and mental health in preventive care decision-making, examining the influence of mental health on dual contraceptive method use and non-use is an important next step. Research urging providers to consider the role of psychological symptoms in contraception adherence as a way of optimizing the efficacy of their contraceptive counseling [12], further supports the need for this work. The purpose of the current study was to examine the relation between mental health and dual contraceptive method use among sexually active college women at risk for STI and unintended pregnancy. In 2010, The Healthy People 2020 initiative (US Department of Health and Human Services. Healthy People 2020, 2010) endorsed dual contraceptive method use as a needed area of focus among young adults [13]. In the recent years following this initiative, studies investigating the prevalence of dual contraceptive method and associated factors noted that dual method use among young women has increased [14–17]; however, many of these studies have focused exclusively on sociodemographic and sexual behavior associations of dual method use. Few studies have examined the role of mental health in dual method use in college-aged women [7,8]. This study aims to add to a limited body of knowledge by investigating the relations between mental health concerns and contraceptive use. Materials and methods Data The American College Health Association-National College Health Assessment II (ACHA-NCHA II) is a national research assessment administered throughout the United States [18]. Data from the 2014 ACHA-NCHA II were collected from a convenience sample online at a large mid-atlantic university by the student wellness center. A subset of items from this questionnaire relating to contraceptive use, sexual behavior, reproductive health, and sociodemographic information were included in secondary data analysis for the current study. Prior to data collection, the institutional review board (IRB) gave permission to collect study data. Students completed informed consent online and were informed prior to beginning study questionnaires that all responses were confidential and that questions causing discomfort could be skipped. Additional information about the ACHA-NCHA II is available at the organization’s website (http://www.acha-ncha.org).
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course in the last 30 days). Sample restrictions resulted in a final analytic sample of N = 307 women for the present study. Outcome variables The primary outcome variable of interest was a two-part item on dual contraceptive method use during the last act of vaginal intercourse, and was measured on a categorical scale (0 = No; 1 = Yes). Women were first asked if they used a method of birth control during the last time they had sex; those who responded yes were asked about the type of birth control method they used. Methods of birth control were assessed by the following question: ‘‘Please indicate whether or not you or your partner used each of the following methods of birth control to prevent pregnancy the last time you had vaginal intercourse.” Students had the option of selecting from 15 items which included: (1) hormonal contraceptives (birth control pills, birth control shots, birth control implants, birth control patch, and vaginal ring); (2) intrauterine device (IUD); (3) condom barriers (male or female condom), and (4) additional methods (diaphragm or cervical cap, contraceptive sponge, spermicide, fertility awareness, withdrawal, sterilization, or other). Students could select more than one method if applicable. In the current study, a new dichotomous contraceptive use variable to reflect dual contraceptive use was created over two steps. In the first step, women were separated into the following groups: (1) condom barrier use (use of male or female condom in absence of a hormonal contraceptive or IUD); (2) hormonal contraceptive or IUD (in absence of a condom barrier method); (3) dual method (use of male or female condom barrier in addition to an IUD or hormonal contraceptive); (4) other method (in absence of a condom barrier and/or IUD or hormonal contraceptive); or (5) no method used. In the second step, women were further categorized into the following two groups for the purposes of analyzing our primary outcome: (0) single method, other method, and no method (1) used both a hormonal contraceptive and a condom barrier during last sex. Independent variables Lifetime history of depression Participants were asked the following question: Have you ever been diagnosed with depression? Response options were ‘‘no” (coded as 0) and ‘‘yes” (coded as 1). This single item measure has been used to assess lifetime history of depression in previous literature conducted among college women [18,19]. Stress Participants were asked the following question: ‘‘Within the last 12 months, how would you rate the overall level of stress you have experienced?” Response options were no stress, less than average stress, average stress, more than average stress, and tremendous stress. Response options were then dichotomized for analyses as follows: no stress, less than average stress, or average stress (coded as 0), and more than average stress and tremendous stress (coded as 1).
Analytic sample
Sociodemographic variables
The initial sample consisted of 686 total women. To meet the study’s aims, inclusion criteria in the current sample included females ages 18–25, who reported a single marital status. Marital status and age were included as inclusion criteria because unmarried young adult women have the highest rates of STIs and unintended pregnancies [1,4]. In addition, the sample was restricted to sexually active women (i.e., reporting having had vaginal inter-
Sociodemographic variables of interest were: age (18–25), race, and relationship status (e.g., not in a relationship or in a relationship). Age was categorized into two groups (18–19 and 20–25), to determine if there were differences in contraceptive use among teenagers compared to older young adults given previous research indicating differences in contraceptive use by age [20]. Based on previous literature suggesting that racial minority women were
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M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
less likely to use dual methods of contraception, race was dichotomized into White and racial minority [21]. Variables of interest related to sexual behavior and reproductive health included the following: number of sexual partners in the past 12 months, having a gynecological exam in the past 12 months, and being diagnosed or treated with an STI (chlamydia, genital herpes, genital warts/HPV, gonorrhea, and/or HIV) in the past 12 months. Analytic plan All analyses were conducted using IBM SPSS Version 22 [22]. Prior to analysis, data were screened for missing values and normality. All categorical variables were recoded so that they included zero. The current study utilized multivariate logistic regression models to access study outcomes. In subsequent multivariable models, multicollinearity, outliers, and mutually exclusiveness of categories were assessed. A multiple logistic regression model was used to estimate the relative contribution of the independent variables on odds of dual method use versus dual method non-use. Demographic (age, race, and relationship status) and sexual behaviors (number of sexual partners in the past 12 months, recent gynecological exam, and past year STI history) were included as covariates in the multivariate models based on previous research indicating relationships between similar variables and contraceptive method use [6]. In addition, stress and lifetime history of depression were included given previous research identifying mental health status as having an important role in preventative health [10]. Finally, a series of multivariable logistic regression models examined odds of dual contraceptive method use when compared to other contraceptive methods. We report adjusted odds ratios (aOR), and controlled for sociodemographic, sexual behavior, and reproductive health factors. Results Characteristics of the sample Table 1 presents the demographic makeup of the current sample. The majority of the sample was between the ages 20–25 (74.3%), identified as White (62.5%), and were in a committed relationship (80.5%). Of the sample, 61.6% reported having a gynecological exam in the past 12 months, and only 4.6% reported being diagnosed or treated with a STI. Nearly 31.9% reported having had multiple sexual partners within the past 12 months. Nearly 58% reported above average stress levels in the past 12 months, and almost 30% had a history of ever being diagnosed with depression. Dual contraceptive method use prevalence was 27% during last vaginal sexual intercourse. Approximately 41% used hormonal contraceptives in absence of a condom barrier, and 18.2% used condoms in absence of hormonal contraceptives. No contraceptive method was used among 9.1% of the sample, and approximately 1% used alternative methods of birth control, which did not include hormonal contraceptives, IUDs, or condom barriers. Multivariate analyses related to dual method use A hierarchical logistic regression examined the effect of demographic and mental health on the outcome of dual method use versus non-dual method use (all other methods combined). Results of this analysis are presented in Table 2. In the first step, age, race, and relationship status were entered as control variables. In the second step, having had gynecological exam, having been diagnosed or treated with an STI, and number of sexual partners in
Table 1 Characteristics of sexually active college women ages 18–25 at a large, Mid-Atlantic university (from the 2014 American College Health Association – National College Health Assessment). Total N = 307 N Demographic variables Race/ethnicity White Racial minoritya Age 18–19 20–25 Relationship status Not in a relationship In a relationship
307 192 115 307 79 228 306 59 247
Sexual risk variables Had a routine gynecological exam in the past 12 months? No Yes Diagnosed with an STI in the last 12 months?b No Yes Had multiple sexual partners in the last 12 months? No Yes
304 115 189 304 290 14 305 207 98
Contraceptive use at last vaginal intercourse Hormonal contraceptive Condom barrier Dual methodc Other method No method
127 56 83 4 28
Mental health variables Stress Average or below Above average Ever diagnosed with depression? No Yes
307 130 177 305 220 85
%
62.5 37.5 25.7 74.3 19.2 80.5
37.5 61.6 94.5 4.6 67.4 31.9 41.4 18.2 27.0 1.3 9.1
42.3 57.7 71.7 27.7
a Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. b STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category. c Dual method = Use of both a hormonal contraceptive and condom barrier during vaginal sex.
the past 12 months were entered. In the third step, stress and a lifetime history of depression were included. In the adjusted odds model, lifetime history of depression emerged as being significantly associated with dual method use (p = 0.01) compared to the use of other methods (all other method categories combined); women who had previously received a diagnosis of depression were less likely to use a dual method (aOR = 0.39). A second set of logistic regression models analyzed the influence of demographic and mental health variables on the outcomes of: (1) odds of dual method use versus use of no method, (2) dual method use versus condom barrier use, and (3) dual method versus hormonal contraceptive use. Results of this analysis are represented in Table 3. Lifetime history of depression was associated with lower odds (aOR = 0.12) of using a dual method compared to no method and lower odds of using a dual method compared to a hormonal contraceptive (aOR = 0.39). Having a gynecological exam in the past 12 months was significantly associated with greater odds of dual method use versus the use of no method (aOR = 9.2) and greater odds of using a dual method compared to condoms alone (aOR = 2.87). Being in a racial minority group was associated with increased odds of using a dual method compared to a hormonal contraceptive (aOR = 2.2).
M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29 Table 2 Multivariable odds of dual method use versus non-dual method use at last vaginal intercourse (from the 2014 American College Health Association – National College Health Assessment). Characteristic
Dual method use versus nonuse aORa
Step 1: Demographic variables Race/ethnicity White Racial minorityb Age 18–19 20–25 Relationship status Not in a relationship In a relationship Step 2: Sexual risk variables Had a routine gynecological exam in the past 12 months? No Yes Diagnosed with an STI in the last 12 months?c No Yes Had multiple sexual partners in the last 12 months? No Yes Step 3: Mental health variables Stress Average or below Above average Ever diagnosed with depression?* No Yes
95% CI
Sig. (p*) 0.28
Referent 1.37
0.77–2.44 0.51
Referent 1.24
0.66–2.35 0.93
Referent 1.04
0.48–2.23 0.17
Referent 1.51
0.84–2.70 0.73
Referent 1.25
0.35–4.42 0.34
Referent 1.38
0.71–2.67 0.58
Referent 0.86
0.49–1.49 0.01
Referent 0.39
0.19–0.79
Note: In the analysis, variables from Step 1 are entered into the model first. Then, variables from Step 2 are entered using Stepwise Logistic Regression (LR) and build on the model from Step 1. Finally, variables from Step 3 are entered using Stepwise LR and build on the model from Step 2. * p < 0.05. a aOR adjusts for other variables entered in the same step. b Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. c STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category.
Discussion This study highlights the influence of lifetime history of depression on dual method contraceptive use during sexual intercourse among young college women at risk for STIs and unintended pregnancy. Previous work in the field of reproductive health has noted the significant impact mental health concerns have on both reproductive and sexual health decisions [10]. A number of prior studies have previously demonstrated that women with mental health concerns exhibit higher patterns of contraception non-use, misuse and discontinuation [10]. Given the established relationship between women’s mental health and contraceptive use, the current study sought to understand how mental health concerns impact dual contraceptive method use. Findings revealed a significant relation between lifetime history of depression and dual contraceptive use. History of a prior depression diagnosis was associated with lower odds of dual method use when compared to use of no method, hormonal contraceptives, or all other methods combined. Stress was not significantly associated with dual contraceptive use. This outcome may be due to the associated comorbidity of stress and depression or the way in which stress was measured in the current study. These results indi-
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cate that it is critical for healthcare providers to consider not only physical but also emotional functioning of patients when counseling about contraceptive methods and sexual decision-making [7]. Across the sample the prevalence of dual contraceptive method during last vaginal sex was 27.9%, indicating that the majority of the sample were not using the most effective form of simultaneous STI and pregnancy prevention. The most frequently reported contraceptive method was hormonal contraceptives in absence of a condom barrier (43%), followed by dual contraceptives (27.9%), and finally use of condoms in absence of hormonal contraceptives (18.8%). No method was used among 9.4% of the current sample. Women reported that hormonal contraceptives were the most popular contraceptive method, which support previous literature that women prioritize pregnancy prevention over STI prevention in choosing a contraceptive method [23]. While hormonal contraceptives are the most effective method of pregnancy prevention when used correctly [24], they provide no protection against STI transmission. Condom barriers are an effective means of preventing pregnancy [25] and STIs [26] but, incorrect or inconsistent use can decrease effectiveness [26]. Condoms also have higher rates of failure as a birth control method—they result in 18 or more annual pregnancies per 100 women—compared to between 6 and 12 annual pregnancies among those using hormonal contraceptives [24]. Thus, given the limitations of hormonal contraceptives in STI prevention and limitations of condom barriers in pregnancy prevention, the promotion of either method alone does not provide optimal protection against both unintended pregnancy and STIs for women. Dual contraceptive method use provides the most effective method of protection [5]. In the current study, women who were racial minorities were more likely to report use of a dual method compared to hormonal contraceptive alone, a finding which conflicts with previous research indicating that racial/ethnic minority women are less likely to use dual methods of protection [21]. While this finding was significant, it should be interpreted in light of the fact that all racial minority women were grouped into one category during analyses. Women who had received a gynecological exam in the past 12 months were also more likely to report use of a dual method at last vaginal sex compared to the use of no method or condoms only. This reiterates the importance of healthcare providers in the contraceptive decision-making process. Indeed, previous literature supports the importance of routine gynecological exams in educating women about the best methods of protection against STIs and unintended pregnancy [25]. Implications Given the ways in which mental health symptoms impact contraceptive use, health care settings specializing in reproductive care represent ideal spaces for symptom detection, intervention, and prevention [9]. However, it must also be noted that symptoms associated with mental health concerns such as anxiety and depression can hinder patient-provider communication and rapport in critical ways that might go unnoticed by both parties [9]. As such, evidence suggests a strong need for standardized assessment of mental health symptoms and psychological well-being as an integral and routine part of routine reproductive health care. Given the hectic pace of clinical and health settings, standardized mental health assessment measures are an effective, efficient and practical technique for identifying issues in psychological wellbeing, and as a result, improving family planning and reproductive health care [9]. Additionally, healthcare workers should be mindful when working with individuals with mental health concerns to create feasible and tailored strategies regarding contraceptive method use [27]. For example, health care providers may also con-
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M. Moore et al. / Sexual & Reproductive Healthcare 12 (2017) 24–29
Table 3 Multivariable odds of dual method use versus other contraceptive use at last vaginal intercourse (from the 2014 American College Health Association – National College Health Assessment). Characteristic
Step 1: Demographic variables Race/ethnicity* White Racial minorityb Age 18–19 20–25 Relationship status Not in a relationship In a relationship Step 2: Sexual risk variables Had a routine gynecological exam in the past 12 months?* No Yes Diagnosed with an STI in the last 12 months?c No Yes Had multiple sexual partners in the last 12 months? No Yes Step 3: Mental health variables Stress Average or below Above average Ever diagnosed with depression?* No Yes
Dual method use versus hormonal contraceptive use
Dual method use versus condom use
Dual method use versus no method
aORa
95% CI
aORa
95% CI
aORa
95% CI
Referent 2.21
1.14–4.30
Referent 0.70
0.32–1.51
Referent 0.50
0.16–1.50
Referent 1.43
0.69–2.95
Referent 1.04
0.43–2.55
Referent 0.54
0.15–1.95
Referent 0.45
0.18–1.17
Referent 1.96
0.70–5.48
Referent 3.69
1.03–13.27
Referent 0.86
0.44–1.71
Referent 2.87
1.32–6.23
Referent 9.20
2.60–32.52
Referent 1.15
0.28–4.78
Referent 1.28
0.20–8.34
Referent 2.31
0.10–51.34
Referent 1.41
0.68–2.94
Referent 1.42
0.56–3.58
Referent 1.10
0.31–3.89
Referent 0.93
0.50–1.75
Referent 0.83
0.38–1.81
Referent 0.81
0.27–2.43
Referent 0.39
0.18–0.85
Referent 0.48
0.18–1.30
Referent 0.12
0.03–0.55
*
p < 0.05. a aOR adjusts for other variables entered in the same step. b Racial minority categories included in the ACHA-NCHA II include Black or African American, Hispanic or Latino/a, Asian or Pacific Islander, American Indian, Alaskan Native, or Native Hawaiian Biracial or Multiracial, or Other. c STI = Sexually transmitted infection; ACHA-NCHA II survey includes chlamydia, genital herpes, genital warts/HPV, gonorrhea, and HIV under this category.
sider counseling patients with a lifetime history of depression about the benefits of using long acting reversible contraceptives (LARCs) for pregnancy protection as opposed to other forms of contraceptives that require frequent use or manipulation. Indeed, prior work in adolescent females indicates that depressive symptoms influence adherence to weekly contraceptive routines [8]. Additionally, research suggests that women under moderate to severe psychological distress are less likely to use maximum effective contraceptive methods (i.e. dual contraception) or forgo the use of contraception entirely [8]. Limitations Although current findings revealed important factors influencing contraceptive method use, there are several limitations to note. First, the current study employed a cross-sectional design, and therefore study results should be interpreted in light of crosssectional design limitations. All data was collected via selfreports, and although women were informed that all study responses were anonymous, women may have reported socially desirable responses. Given the recruitment strategy of participants, it is possible that the responses were influenced by non-response bias or by the fact that all women were enrolled in college. Further, lifetime history depression was measured via self-report of a previous diagnosis as opposed to a more comprehensive assessment of current depressive symptoms. It is possible that some participants had previously experienced symptoms of depression at a sub-clinical level that has never resulted in a diagnosis. In addition, many women do not seek treatment for depressive symptoms due to barriers including stigma and access to mental health services.
As such, it is possible that there were more women with a lifetime history of depression in our sample than what we were able to account for. Last, the majority of the current sample (80.7%) reported currently being in a committed relationship which may have affected study results. Indeed, prior research suggests that contraception use is markedly influenced by the type of sexual relationship in which one is engaged [28]. Indeed, relationships of a longer duration and increased commitment level are associated with a decreased likelihood of use of dual contraception or any type of contraceptive method during intercourse [29]. However, a significant predictor of contraceptive use in romantic couples lies in perceived partner support of contraceptive methods, as such; endorsing a current romantic relationship is not the only factor in predicting contraceptive use [30]. Conclusion This study indicates that history of depression is an important factor in dual method use, and that provider recommendations for contraceptive use should consider mental health status and history. It is estimated that if condoms were used in conjunction with an effective hormonal contraceptive, there would be a 40% reduction in unintended pregnancy and abortion, resulting in a reduction of 393,000 unintended pregnancies and 76,000 abortions annually [5]. Although dual contraception is widely accepted as the best method for both pregnancy and STI prevention, our findings revealed that among the high-risk young adult female college population this is a frequently underutilized method. Our findings suggest that mental health screenings may be important to imple-
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ment during routine visits, however future work will need to further investigate the understudied relation between mental health and contraceptive use. Psychological symptoms and disorders, namely depression, can significantly affect a patient’s contraception adherence and management. Addressing existing psychological concerns during consultation prior to contraceptive prescription might allow providers to more readily tailor contraception counseling to prevent pregnancy and disease while increasing medication adherence and compliance. Future studies should also examine dual contraceptive method use in specific at risk subgroups, such as, ethnic minorities and women of lower socioeconomic status who are at increased risk for STIs and unwanted pregnancies. In addition, there are few evidencedbased interventions that specifically target the utilization of dual methods among young women [15]. Future research should develop interventions that consider the role of mental health on reproductive health decisions in college women. Other variables that may influence dual methods of both hormonal contraceptives and barriers methods should be identified and examined (e.g. relationship type and duration, sexual history and risk perceptions, substance use, access to reproductive health services, sociocultural influences). Further investigation of the influential correlates of dual contraceptive method use in the at-risk college-aged sample is imperative for intervention efforts aimed at decreasing the prevalence of STIs and unintended pregnancies. Author disclosure statement The authors declare they have no conflicts of interest to disclose. Acknowledgements We would like to thank the American College Health Association and all of the students who participated in this study, thereby making this research possible. Role of the funding source You are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s), if any, in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. If the funding source(s) had no such involvement then this should be stated. References [1] Centers for Disease Control and Prevention (CDC). (2015). STD in Adolescents. Retrieved from
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[7] Hall KS, Moreau C, Trussell J, Barber J. Young women’s consistency of contraceptive use—does depression or stress matter? Contraception 2013;88:641–9. [8] Hall KS, Moreau C, Trussell J, Barber J. Role of young women’s depression and stress symptoms in their weekly use and nonuse of contraceptive methods. J Adolesc Health 2013;53:241–8. [9] Farr SL, Curtis KM, Robbins CL, Zapata LB, Dietz PM. Use of contraception among US women with frequent mental distress. Contraception 2011;83:127–33. [10] Hall KS, Steinberg JR, Cwiak CA, Allen RH, Marcus SM. Contraception and mental health: a commentary on the evidence and principles for practice. Am J Obstet Gynecol 2015;212:740–6. [11] Stanton AL, Lobel M, Sears S, DeLuca RS. Psychosocial aspects of selected issues in women’s reproductive health: current status and future directions. J Consult Clin Psychol 2002;70:751. [12] Francis J, Presser L, Malbon K, Braun-Courville D, Linares LO. An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception. Contraception 2015;91:336–43. [13] US Department of Health and Human Services. Healthy People 2020 topics and objectives. Washington, DC: US Department of Health and Human Services; 2010. Retrieved from