An evaluation of knowledge and attitudes - SAGE Journals

Article

Emergency contraception education for health and human service professionals: An evaluation of knowledge and attitudes

hej Health Education Journal 69(2) 175–182 © The Author(s) 2010 Reprints and permission: sagepub. co.uk/journalsPermissions.nav DOI: 10.1177/0017896910364886 http://hej.sagepub.com

Lisa Colarossi, Marissa Billowitz and Vicki Breitbart Planned Parenthood of New York City, New York, NY, USA

Abstract Objective: To assess the knowledge and attitudes of health care providers, health educators, and social service providers before and after a training session on emergency contraceptive pills. Design: A survey study using pre–post training measurements. Setting: Two hundred and twenty-three medical, social service, and health education providers in receiving a 2.5-hour training session at their work site. Methods: Human subjects approval was obtained from an Internal Review Board. Anonymous surveys were administered a few weeks prior to the training session and at completion of the training session. The training programme was free and not conditional on survey completion. No incentives were offered for research participation. Results: A single training session was associated with increased knowledge about the timing, efficacy, and safety of emergency contraceptive pills as well as with more positive attitudes about use of emergency contraceptive pills. This was true for health care workers, health educators, and social service providers. Social service providers had the least amount of knowledge prior to the training session, but had the same amount of knowledge as the other two groups after the training session. Social service providers also had the least positive attitudes about emergency contraception before and after the training session, when compared with the other two groups; however, positive attitudes of social service workers did significantly increase after the training session, which resulted in smaller differences between the groups at post-test. Conclusion: Among other educational and motivational tools to increase use of emergency contraception, training of human service professionals can increase the knowledge and attitudes necessary for informing their numerous clients about how to access emergency contraceptive pills as well as their safety and efficacy.

Keywords emergency contraception, reproductive health, education, evaluation

Introduction Emergency contraception pills (ECPs) can prevent a pregnancy after sexual intercourse without prior contraceptive use or method failure. However, despite high rates of unintended pregnancy in Corresponding author: Dr Lisa Colarossi, Director of Research and Evaluation, Planned Parenthood of New York City, 26 Bleecker Street, New York, NY 10012, USA. E-mail: [email protected]

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the USA and the safety and availability of ECPs, inaccurate and non-use persists due to barriers to access, lack of information, and attitudes about ECPs1–3. ECPs are more effective when taken as soon as possible after unprotected intercourse; thus, it is critical for women to have knowledge about access to ECPs, preferably before they need to use them. Professionals such as health care providers, health educators, and social service workers interact with large numbers of women and are important and trusted sources of information. Their knowledge and attitudes about ECPs can enhance or impede women’s use of emergency contraception (EC)4–7, and few studies have evaluated training initiatives for different human service professionals. New York City (NYC) has higher rates of unintended pregnancies (64 per cent) than the national average (51 per cent), despite the availability of low cost or free public health care that is relatively accessible8. Human services professionals in NYC are in unique positions to inform women from different backgrounds, ages, and immigration status about EC. This article presents the results of a pre-test–post-test evaluation of the Emergency Contraception Education and Outreach Program training session conducted with staff from 10 different community organizations around NYC. We analyse the changes that took place and the differences between medical, health educator, and social service providers in their knowledge about what EC is, where to get it, and how EC works, as well as shifts in attitudes about informing clients about EC.

Background Many women of reproductive age continue to lack information about ECPs despite over 10 years of its availability by prescription, and several years behind the counter without a prescription9. Further, women who have more information about EC are more likely to use it; and those who do not know about EC are more likely to have an unintended pregnancy9,10. Nevertheless, surveys of health and social service providers have shown that they infrequently inform their clients and/or provide advanced prescriptions to their clients, and are even less likely to do so for adolescents4,11,12. Lack of knowledge regarding pill availability, timing of administration, and efficacy is associated with lower levels of counselling and prescribing6,7,13. Even when knowledge of ECPs is high, intention to educate clients may be limited by attitudes, beliefs, and professional expectations4,5,14–16. Only a few educational intervention programmes have been tested for their impact on provider knowledge, attitudes, and behaviours regarding ECPs12,17–20, and these have focused almost solely on medical providers. These studies have found increases in knowledge, positive attitudes, intentions to counsel and prescribe, and provider self-reported increases in prescribing and counselling. Changes were found for both brief and extended interventions. Nevertheless, in the general population, overall knowledge remains low and providers remain ambivalent about discussing EC with clients, necessitating ongoing training and evaluation of professionals5,15,16,20,21. Further research is needed with a variety of different providers, such as nurses, physicians, educators, and social service staff to determine differences in knowledge and attitudes across these roles.

Programme description This study evaluates the professional training component of the Emergency Contraception Education and Outreach Program of Planned Parenthood of New York City (PPNYC). The programme was funded by the New York City Department of Health and Mental Hygiene (NYC DOHMH) as part of a city-wide initiative to increase use of ECPs. The full PPNYC programme encompassed a three-pronged approach: advanced provision of ECPs, public education campaigns through media and educational materials, and training and capacity building with staff at community

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based health and social service organizations who work with women of reproductive age in targeted NYC immigrant communities. Partner organizations were recruited based on their work in neighbourhoods with high unintended pregnancy rates. These organizations served a number of women of reproductive age, many of whom were newly immigrated to the USA and have limited access to reproductive health care in traditional settings. The programme offered these organizations free EC training workshops for their staff as well as written materials in Spanish and English in exchange for providing organizational space for the training session as well as time and encouragement for all staff to attend. The goals of the staff training component were to increase knowledge as well as to enhance positive attitudes about facilitating education and access to ECPs for their clients. A 2.5-hour didactic and experiential training exercise, which included factual information presented through interactive activities, discussion, and case examples, was provided to groups of 15 participants, on average, at the health care or social service organization where they worked. The curriculum provided information on how to access ECPs, dosage and timing, safety, efficacy, and mechanisms of action. Discussions and exercises focused on attitudes about contraception, sexual behaviour, and ECPs for adolescents and adults to explore personal barriers to counselling clients about ECPs. Because organizations were selected for their work with new immigrant women, cultural beliefs, values, and attitudes were also explored. Training sessions were conducted on-site at trainees’ agencies to facilitate ease of attendance as well as directly associating the information with their workplace context and the support of agency administrators for providing EC information to clients after the training session.

Method Sample Participants were recruited from 15 EC workshops conducted at 10 different community organizations in Brooklyn, the Bronx, and Manhattan, NYC. Organizations agreed to host EC training workshops and invited their staff to attend. Introductory meetings at each organization were held by the EC educator with the administrators to select training participants. There were 369 people who participated in a training session and completed a pre- or post-training survey. However, the study sample includes 223 training participants who completed matched pre- and post-training surveys (60 per cent of those who were trained). Of these, 82 (37 per cent) participants were health educators, 43 (19 per cent) were health care providers, and 98 (44 per cent) were social service providers.

Design and procedures A one-group, pre-post survey evaluation was conducted to measure changes in knowledge and attitudes about EC after a 2.5-hour training programme about EC. The same trainer developed the curriculum and conducted all sessions with a co-facilitator, both of whom were experienced health educators. Pre-training surveys were administered to participants about 2 weeks prior to the training session during an introductory meeting at each organization. Post-training surveys were administered immediately after the training session. The trainer administered and collected all surveys within a 15-minute time frame. No surveys were completed or mailed back at a later time. Surveys were answered anonymously, and a unique identifier was used to match participants from pre- to post-survey. An institutional review board approved the use of human subjects, and no funding

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for the programme or this study was provided from any commercial companies or any directly competing company whose product(s) or services are referred to in the manuscript.

Measures Measures of EC knowledge included 10 questions, answered as true or false, about the timing of ECP administration and effectiveness for pregnancy preventing, the overall safety and non-teterogenic effects of ECPs, and how to obtain EC. Knowledge items were aggregated into a summary score of the number of questions answered correctly out of a total of 10. Measures of attitudes about EC included five questions, answered on five-point Likert scales, about provision of ECPs to adolescents and adults. Attitude items were aggregated into a mean score, with 5 indicating the most positive attitude about EC and 1 as the most negative. Items are analysed separately and scores aggregated. All items were developed by a team of educators and researchers as part of a joint initiative between four health organizations and the NYC DOHMH. Regular meetings were held to develop and test the items for use in training workshops about EC. Items were based on earlier EC research studies that identified the major knowledge and attitude barriers to recommendation of EC by providers6,7.

Results Knowledge Pre-training knowledge scores ranged from 0 to 10 with a mean of 7.08 (SD = 2.21). Post-training scores increased to an average score of 8.80 (SD = 1.42) (paired t = 11.34, p = 0.000). Analysis of co-variance (ANCOVA) was used to test mean differences in post-test knowledge scores between health care providers, health educators, and social service workers (after controlling for pre-test scores). While health care providers and educators had significantly higher pre-test scores (M = 8.72, SD = 1.57 and M = 7.59, SD = 1.82, respectively) than did social service workers (M = 6.23, SD = 2.28), after the training session all three types of staff significantly increased their knowledge score and there were no significant differences at post-test between the groups (F(2) = 0.24, p = 0.79). Thus, social service providers showed the largest increases in knowledge scores, which matched the other groups’ scores at post-test. Table 1 presents a disaggregated item analysis of the percentage of participants in each group who answered separate knowledge questions correctly before and after the training session. An item analysis indicates that more social services workers, than those in the other groups, continue to believe that EC is an abortifacient and that a gynaecological exam is required to get ECPs.

Attitudes Pre-training attitude scores averaged 4.13 (SD = 0.64) (a score of 5.0 is the most positive). Posttraining attitude scores significantly increased to a mean of 4.42 (SD = 0.53) (paired t = 7.88, p = 0.000). ANCOVA was used to test mean differences in post-test attitude scores between health care providers, health educators, and social service workers (after controlling for pre-test scores). Health care providers and educators had significantly more positive pre-training attitudes (both groups M = 4.39, SD = 0.52) than did social service workers (M = 3.81, SD = 0.64). After the training session, all three groups had significantly more positive attitudes about ECPs; however, social

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Colarossi et al. Table 1. Percent of participants in each group answering correctly at pre- and post-training Knowledge items Health educators Health provider n = 82 n = 43 EC works best if taken in the first three days after unprotected sex, but it can still prevent pregnancy if taken up to five days Pre-test* Post-test EC will protect you from most STIs Pre-test Post-test EC is 100 per cent effective in preventing pregnancy Pre-test Post-test EC will not end a pregnancy Pre-test* Post-test* EC will not harm a pregnancy Pre-test* Post-test* EC is safe for teens Pre-test* Post-test EC is safe for adults Pre-test Post-test A teen can get EC without parental permission Pre-test** Post-test A gynaecological exam is required to get EC Pre-test percentage* Post-test percentage* It is possible to get EC before you need it Pre-test* Post-test

Soc service worker n = 98

83 96

86 95

48 90

99 90

100 92

95 94

76 89

86 77

77 79

72 88

77 93

56 77

57 93

37 58

22 89

77 93

91 95

70 91

77 95

91 98

81 97

88 96

96 100

75 90

57 70

93 88

56 64

71 87

96 92

52 84

Chi square analyses were conducted for each item by group. *p ≤ 0.05.

service workers continued to have significantly less positive attitudes than the other two groups (F(2) = 3.24, p = 0.04), but the gap was smaller than at pre-test. At post-test, health providers’ attitude scores increased a small amount to M = 4.50 (SD = 0.50), health educators’ score increased to 4.63 (SD = 0.42), and social service providers to M = 4.20 (SD = 0.55). Table 2 presents pre- and post-training means for each item separately by group. Although significant, the smallest attitude changes from pre- to post-training were on items about

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Table 2. Pre- and post-training attitude means and standard deviations for each group Items EC use by adolescents will encourage sex without condoms or birth control (reverse scored) Pre-test mean (SD) Post-test mean (SD) EC should be made available to all who need it Pre-test mean (SD) Post-test mean (SD) All teens should be given information about EC Pre-test mean (SD) Post-test mean (SD) Providing EC is an important option for preventing unintended pregnancy Pre-test mean (SD) Post-test mean (SD) I feel comfortable informing others about EC Pre-test mean (SD) Post-test mean (SD)

Health educators n = 82

Health provider n = 43

Soc service worker n = 98

3.90 (1.07) 4.14 (1.03)*

3.60 (1.21) 3.56 (1.35)

3.11 (1.26) 3.45 (1.23)*

4.41 (1.07) 4.74 (0.70)*

4.40 (0.90) 4.77 (0.43)*

3.62 (1.19) 4.33 (0.82)*

4.76 (0.58) 4.89 (0.32)*

4.77 (0.43) 4.83 (0.38)

4.44 (0.73) 4.56 (0.58)

4.48 (0.77) 4.76 (0.46)*

4.77 (0.43) 4.84 (0.37)

4.07 (0.84) 4.47 (0.69)*

4.73 (0.47) 4.61 (0.95)

4.67 (0.61) 4.65 (0.61)

4.18 (0.80) 4.31 (1.04)*

Analysis of variance was used to test group differences for each item. Social service workers scored lower on every item than educators and providers (p < 0.05). *p < 0.05 between pre- and post-training scores on t-tests.

adolescents’ use of ECPs, with the most negative attitudes among social service providers. Comfort levels for informing others about EC were significantly higher among health educators than the other two groups.

Discussion We found that a single 2.5-hour training session was associated with increased knowledge about the timing, efficacy, and safety of ECPs as well as with more positive attitudes about providing ECPs. This was true for health care workers, health educators, and social service providers. Social service providers had the least amount of knowledge prior to the training session, but had the same amount of knowledge as the other two groups after the training session. Social service providers also had the least positive attitudes about EC before and after the training session, when compared with the other two groups. However, positive attitudes of social service workers did significantly increase after the training session, which resulted in smaller differences between the groups at post-test. An item analysis further showed that knowledge about access to ECPs without a gynaecological exam is more frequently misunderstood than other facts, followed by whether EC is 100 per cent effective and whether it will end a pregnancy. Although there were errors among all the groups on these items, more social service workers answered these questions wrongly. An analysis of the

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separate attitude items revealed that participants had the most negative attitudes about providing ECPs to adolescents, especially among social service workers. The study design cannot show that the training curriculum caused the changes in knowledge and attitudes, without a randomized control group, but these findings in conjunction with other studies suggest that a brief training programme is a plausible way to impact service providers from multiple professional roles. However, social service providers may be an important new group of professionals for education on EC, as they work with large numbers of at risk women, especially adolescents and immigrant women. The training programme presented here was targeted to professionals working in immigrant communities as studies have shown that immigrant women who lack sufficient information or face barriers to accessing contraception may resort to risky self-induced abortions when faced with an unintended pregnancy22. Moreover, due to their less frequent use of the health care system, social service providers may be a critical link to these women. ECPs are now available behind the counter without a prescription for adults, and to adolescents with a prescription, but awareness and utilization remain low2. Education and media directed to the public is one way to increase use of ECPs, but it is costly. Increasing knowledge and attitudes among providers working with clients who may need ECPs or are at high risk for unintended pregnancy is a more cost effective way to increase public use23,24. A comprehensive training programme, even if brief, is a good way to increase both knowledge and positive attitudes. It is important to target training to a variety of human service professionals. Health care providers have been the primary target of such interventions. However, this evaluation highlights the importance of targeting social service providers and other educators in non-medical settings who have contact with many youth and adults at high risk for unintended pregnancy. Acknowledgements This research was made possible by a grant from the NYC DOHMH to Planned Parenthood of New York City for the Emergency Contraception Education and Outreach Program. The authors thank Nyanda Labor from NYC DOHMH; and Haydee Morales, Michele Bayley, and Veronica Momjian from Planned Parenthood of New York City. The opinions expressed in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc.

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