Exploring Knowledge and Attitudes about Emergency ...

Exploring Knowledge and Attitudes about Emergency Contraceptive Pills among University Students in Jamaica A Qualitative Approach A Sorhaindo, D Becker, H Fletcher, S Garda, S Mitchell

ABSTRACT Emergency contraceptive pills (ECPs) are an importan/ option jor university students ·who may be at high risk for unplanned pregnancies. In the Caribbean, little research has been carried out on university student's knowledge and opinions of this method. This study uses qualitative methodo/ogy to explore knowledge and opinions on ECPs among university students attending The University of the West Jndies (UW/) Mona campus_ We conducted eight focus groups (n = 71) with female and male university students al The University of the West /ndies, Kingston, Jamaica. in March 2000. The group discussions /asted approximately two hours. We tape-recorded discussions and then transcribed and ana~vzed them b,v coding responses according to themes. General knowledge of ECPs was high. but students lacked specific injormation about the method such as its time frame and its mechcmism of action. Most students supported the method, especial(J-' after learning corree/ informa/ion. However, severa/ students were concerned about its side e.ffects and the potential for abuse or irresponsible use by young adults. Although the university students in this study /acked detailed information about ECPs, their opinion toward the method was favourab/e. We suggest further research to investigare the prevalence of misinformation about the method among other groups ofJamaicans.

Explorando Conocimientos y Actitudes en Relación con las Pastillas Anticonceptivas de Emergencia entre los Estudiantes Universitarios en Jamaica Un Enfoque Cualitativo A Sorhaindo, D Becker, H Fletcher, S Garcia, S Mitchell

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RESUMEN

Las pastillas anticonceptivas de emergencia (PAE) constituyen una opcwn importante para los estudiantes universitarios que corren un alto riesgo de embarazos no planificados. En el Caribe apenas se han realizado investigaciones sobre el conocimiento y las opiniones que los estudiantes universitarios tienen de este método. El presente estudio utiliza una metodología cualitativa a fin de explorar los conocimientos y opiniones sobre PAE entre los estudiantes universitarios que asisten a la Universidad de West lndies (UWI). campus A1ona. Condujimos la investigación con ocho grupos focales (n = 71), es decir, con grupos orientados de estudiantes hembras y varones de la Universidad de lfest lndies. Kingston, Jamaica, en marzo del 2000. Las discusiones con los grupos duraron aproximadamente dos horas. Grabamos. transcribimos y finalmente analizamos las discusiones. cod~ficando las respuestas según los temas. El conocimiento general de las PAE fue alto, pero los estudiantes carecían de información especifica sobre el método, tal como los dntos sobre su marco de tiempo y su mecanismo de acción. La mayoría de los estudiantes eran partidarios del método. especialmente después de conocer la información correcta. Sin embargo, varios estudiantes mostraron preocupación por los efectos colaterales del PAE. así como por la posibilidad de que los adultos From: Population Council, Regional Office for Latín America and the Caribbean, Panzacola #62, Interior 102, Colonia Villa Coyoacan, Mexico and The University Hospital of the West lndies, Kingston, Jamaica, West lndies.

Correspondence: Ms SG Garcia, Population Council, Regional Office for Latin America and the Caribbean, Panzacola #62, Interior 102, Colonia Villa Coyoacan, Mexico, DF CP 04000. Fax: (52)555659-8541.

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Emergency Contraceptive Pills

jóvenes hicieran un uso abusivo o irresponsable del mismo. Aunque los estudiantes universitarios en este estudio mostraron falta de il?formación detallada sobre las PAE. su opinión sobre el método fue favorable. Sugerimos que se realicen más trabajos de esta índole encanúnados a investigar la prevalencia de la falta de i'?lormación sobre el método entre otros grupos de jamaicanos. West ludian Med J 200-t; 53 ( 1): 3-t

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INTRODUCTION Emergency contraceptive methods which prevent pregnancies foliO\ving unprotected sex are available worldwide ( 1-4 ). The three best known emergenc·y· contraceptive methods are hormonal emergency contraceptive pills (ECPs). copper-bearing intrauterine devices (IUDs), and mifepristone. Of these options, ECPs are the most accessible. They are casy to administcr and are frequemly available at pharmacies "vithout a prescription (5). Emcrgcncy contraccptive pills can play a critical role in limiting unintended pregnancies. reducing unsafe abortion and in lowering rates of maternal morbidity and rno11ality. Rates of unplanned pregnancy are high worldwide due to lack of knowledge about contraceptive methods, lack of access to rnethods, inability of women to negotiate contraceptive use, and coerced sex. Even when contraceptive methods are available and used correctly, women are still vulnerable to contraceptive failure. Although ECPs have been available for decades in many countries (3), public awareness of the method is generally low (6). In addition, many \VOmen hold misconceptions about thc method. and in particular, have incorrect beliets about the rnethod's side et1ects and its mechanism of action. This misinformation may lead them to choose not to use ECPs even \vhen they are available (7). Researchers and reproductive health advocates have documented knowledge and opinions of ECPs and have í.:Onducted activities to increase awareness and availability of the method in many regions (4, 8-9). \\'hile substantial work on emergency contraception (EC) has been carried out in Latín America and the Spanish-speaking Caribbean (10-13) comparatively little infonnation is available on EC in the English-speaking Caribbean ( 14 ). A study on the provision of EC among lnternational Planned Parenthood Federation affiliates in Latin Arnerica and the Caribbean found that Caribbean atliliates wcre less 1ikely to offer EC than Central and South American affiliates ( 15). Jamaica is an appropriate location for exploratory rcsearch on EC for a numbcr of reasons. 1t is the largest island in the English-speaking Caribbean, and Kingston, its capital. is thc largest English-speaking city in the region. Kingston residcnts are among the first to receive infonnation on and to adopt new contraceptive methods. Contraceptive methods that become popular in Kingston are likely to spread to other parts of Jamaica. In addition. EC is already included in the Jamaican family planning nom1s and a dedicated ECP

product is available to women by prescription ( 15). Regular oral contraceptives, which can be used as ECPs, if taken in a higher dosage, are available over-the-counter at pharmacies. The rate of unplanned pregnancy in Jamaica is high. particularly among young women (16). According to a nationally representati·ve survcy of Jamaican women aged 15 to 44 years, 61% of all current or most recent pregnancies were mistimed or unwanted. Among women 15 to 19 years old, the percentage was 83, and among women 20 to 24 years old, it was 67% ( 17). Young Jamaican women faced with unplanned pregnancies may tum to unsafe, illegal abortions, since abortion is illegal in most circumstances ( 18). Complications ffom unsafe abortions are a leading cause of maternal mortaJity in Jamaica ( 18). Emergency contraceptive pills could be an important option to help prevent unplanned pregnancies ifyoung v.romen knew about the rnethod. A study among Jarnaicans aged 15 to 24 years found that only 9 1Yó had ever heard of EC ( 19). University students are one group of young adults vulnerable to unplarmed pregnancies and with a need for EC. Students may also \vish to delay pregnancies until finishing their education or starting their careers. Emergency contraceptive pills are likely to be an acceptable option to university students, who in general, are better informed about and more supportive of contraceptive methods than the general population (7, 20). To better understand university students knmvledgc and opinions on ECPs. we carried out focus group discussions with students at the Mona campus ofThe University of the \Vest lndies (U\VI) in Kingston, Jamaica. The Mona campus ís the largest of the four U\VI campuses. \Vith a student population of approximately 11 000. the Mona Campus attracts many young adults from Jamaica and the surrounding islands. About 80% of the student body takes classes on-campus while the rest have cJasses at otT-campus sites. During the 1999-2000 year, 13% of the total student body lived in the on-campus donnitories.

SUBJECTS AND l\·lETHODS V../e held eight focus groups during one week in March 2000 with undergraduate students at UWI. Participating students were recruited by other students trom on-campus donnitories and various si tes off campus. In order not to bias the selection of participants, students were not told the topic of discussion in advancc. Three groups \-vere held with males and tive with females. Each group consisted of eight to ten students.

Sorhaindo, et al

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The study was approved by The University of ""''est Indies Section of Student Affairs. All participants signed infonned consent forms. We did not ask participants for their names or other unique identií)'ing information; however, all students completed a short anonymous questionnaire providing background demographic information. Participants were compensated $400 Jamaican dollars (approximately $1 O USD) for their time. The moderator's guide \Vas adapted from a guide used in a previous qualitative study on EC (20) (our version is available upon request). The same moderator led each focus group. The moderator began each discussion by asking pa~i­ cipants about their knowledge and opinions of contracepttve methods generally. After fifteen minutes, she described EC as "methods of contraception that women can use after sex to prevent pregnancy," and asked students to share what they knew about these methods. She then gave a detailed description of ECPs and asked students for their opinions. Discussions lasted about two hours. All group discussions were audio-recorded and transcribed. Two readers identified main themes in the data and summarized these across groups (21 ). The readers then shared notes, discussed any discrepancies, and carne to a consensus about the interpretation of the data.

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RESULTS Characteristics of study population A total of 71 students participated in the focus group discussions. The table summarizes the demographic characteristics of the participants. More than half (56%) were female. Over one-third were in their first year at the university. Students ranged in age from 17 to 38 years of age, with a mean of 21 years. Most were studying towards a degree in the social sciences. Seventy per cent repo~ed that they were sexually active. Among the sexually active, the mean age of tirst sexual intercourse was 16 years.

Knowledge and opinions on contraceptive methods Knowledge of contraceptive methods was high in all groups. Participants in each group named eight or more ways to prevent a pregnancy. The most frequently mentio~ed contraceptive methods were abstinence, mate condoms, pills, injections, diaphragms, withdrawal and tubal ligation. Many females and a few males had exaggerated perceptions of the side effects of contraceptive methods, in particular, "medicalized" forms of contraception that require physician supervision. Of the contraceptive methods discussed: the majority felt condoms and abstinence were the most rehable and safe. Across all groups, participants mentioned problems with the various options. Condoms could break, slip off, and cause allergic reactions in certain people. Oral contraceptives lead to weight gain and could purportedly cause the "womb to rot. ·-· The injection could affect future fertility. Sorne had

Table.

35 Demographíc characteristics of focus group participants (n =71Y

Characteristic Sex

Female Mal e

40 (56) 29 (41)

Year of study al university

First Second Third

Fourth Field of sUJdy Social sciences Pure and applied sciences Arts and education Medica! sciences Regularly practices religious activity Yes No Sexually active Yes No Ever been pregmmt or impregnated a partner; Yes No

25 (35) 20 (28) 19 (27) 5 (7) 26 24 14 7

(37) (34) (20) (10)

46 (65) 19 (27) 50 (70) 20 (28) 4 (8) 45 (90)

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The information in this table is bascd on participants' responses to the anonymous self-administered questiom1aire. . 2 Not all percentages total lo 100% due to missing data and roundmg. ' Among sexually active participants.

heard that IUDs cause infections. Finally, tubal ligations were not "foolproof " Knowledge ofpost-coital contraceptive methods

Participants mentioned the following traditiona] method~ of preventing pregnancies following unprotected sex: douchmg, inserting a spennicide, taking a wann shower, eating papaya seeds, and drinking beverages '-Vith aspirin-based analgesi~, and water with bleach. The majority did not take these tradttional post-coital contraceptive methods seriously. One individual strongly believed eating papaya seeds postcoitally prevented pregnancies. Students in seven of the eight groups spontaneously referred to ECPs, most often as the "morning afier pill" or as the "day after pill. ''In the one group where ECPs were not spontaneously mentioned, participants acknowledged that they had heard of the method after it was described. Participants had leamed about ECPs primarily from three sources: the media, friends and family, and healthcare providers. Men more commonly leamed about ECPs from informal sources such as friends, whereas females reported learning about ECPs through formal sources such as high school classes, magazines, newspapers, television programmes, or healthcare professionals. Although sorne participants in all groups had heard of ECPs, the levcl and accuracy of knowledge of the method varied. In the female group where ECPs were not spon-

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Emergency Contraceptive Pills

taneously mentioned, participants knew little more than that the method is used post-coitally. In other groups, students correctly identified sorne side effects of ECPs including headaches, nausea, vomiting. irregular cycles. spotting and bloating. Many students believed the side effects were more severe than the si de effects of regular oral contraceptives. Few participants had accurate infonnation on how much ECPs reduce the risk of pregnancy. In t\vo of the three male groups, no participants knew by how much ECPs reduce the risk of pregnancy, although one student believed that the method is less effective if used repeatedly. In the final male group, consensus was that ECPs reduce the risk of pregnancy by 90% to 96%. Most females thought ECPs reduce the risk of pregnancy by about 90%. Among the females who held this belief, many were disappointed to learn that the Yuzpc regimen of ECPs (combined oestrogen and progestin pills) reduces the risk of pregnancy by approximately 75% (23). One woman commented: "To think that il is called an emergenC)-1 {method], and it's on~v 75% safe. When 1 see emergency. 1 think it's like 99. 999% sure ··. Participants in several groups expressed confusion about the time fiame in which ECPs should be used. In three groups. the name commonly used for ECPs, "the moming after pill," caused confusion about when the regimen should be taken. As one student commented: ''The morning ajier {pi//]. 1 guess. is for the morning after_ Poslinor [the ECP dedicated product] 1 know works three days after. lt can work up to 72 hours, 1 think. " Most students also expressed contusion about exactly how ECPs work. Many thought ECPs prevent pregnancy by forcing a woman to get her period earlier, for example, by '\vashing out" her uterus or by "speed[ing] up [her menstrual] cycle." Other students confused ECPs with medica) abortion. One female studcnt postulated: "{ECPs are] like an abortion but not that painful. 1 guess.•Heaning you don t have to go through the u·hole procedure. ·· Students with better kno\1\l}edge about the scientific process of a pregnancy differentiated ECPs from abortion. One student stated: ·· You wouldn r cal/ [ECPsj an abortion because abortion is when the fetus starts growing. lt 's {more] like washing out the sperms. " A few students, not representative of the majority, knew one of ECPs mechanisms of action is to prevent implantation of a fertilized egg into the uterine wall. Opinions of ECPs Thc overwhelming consensus by the end of all sessions was that ECPs were a useful contraceptive option that should be more widely available in Jamaica. Nevertheless, students had several conccms. Safcty was a worry in three groups. Students wondered whether frequent use of the method might later lead to problems with fertility or to other reproductive complications. Many were dissatisfied with the notion that ECPs are to be used in cases of "contraceptive emergencies.'' They

wanted a better definition of what situations constitute ''contraceptive emergencies," more specific guidelines on the number oftimes women can use ECPs, and more information about why ECPs are not recommended tor routine use. The following female student's comment expresses this dissatisfaction: "An emergency can hnppen evet)' time yo u have sex. Suppose a woman should have sex hvice a week or something like that, cou/d yo u use it twice in a week? 1 'm serious, because it is supposed Jo be a back-up plan, yes, bw you wonder hmt· often it shou/d be used. And ~lyou use ir more than the amount o,{ times. what are the side e.ffects? .. Although most students were convinced that ECPs do not lead to abortions after the moderator described the method's mechanism of action, sorne students (one on average in each group) remained firm in their belief that ECPs caused abortions. As one young man explained: "ft could be dejined as aborrion in the sense that the potential is there lo become pregnant. Providing that the male has ejaculated, [there is] potential that it has fertilized the egg. so it could be considered ajorm ofabortion ". In another group, a woman stated that her religion prohibited both contraception and abortion, and declared that she would not do anything to prevent or termínate a pregnancy even in the case of a rape, because whatever happened was "'in God's plan." While most students did not hold this view, it is important to note that the majority of students maintained, even after hearing the scientific definition of when a pregnancy begins, that the beginning of pregnancy is a matter of personal belief and not a question science can answer. A few students feared that greater availability of ECPs would encourage "'in-esponsible" behaviour, particularly among teenagers and young adults. Sorne believed adolescents would have unprotected sex more frequently if they knew they could just take a pill the next morning to prevent a pregnancy. Sorne also feared that young people would broaden the definition of contraceptive emergencies to inelude all times they chose not to use a condom. Others. however, telt such situations would be rare and that it is more important to offer ECPs as a back-up method than to worry about potential abuses. One male participant commented: "l'Ou could seo-• to abstain. but the reality is that a /ot o.fyoung peop/e are not going to abstain. So what do yo u do then? Do you 111ant them to become pregnanr and then hove the burden of having an l.tm1lanted child? The option not to have the child seems like a better decision ". Suggested strategies .for disseminating ECP injormation Students rccommended using television, radio, special educationa1 programmes. the intemet, altemative media and promotions at parties or other social gatherings, including church gatherings, as means to infonn other Jamaicans about ECPs. They suggested targeting adolescents in particular with information on ECPs and contraceptives in general.

Sorhaindo, et al especially those in high school. Adolescents were perceived as being vulnerable to unwanted pregnancies, poorly infonned about how to prevent pregnancies, and confronted with barriers in access to contraceptive methods and infonnation. Sex education in high schools was viewed as inadcquate and subject to the biases of teachers or administrators. Participants felt educational campaigns should stress that ECPs are not totally effective in preventing pregnancies, that they do not protect against sexually transmitted infections and HIV, and that they are not intended tor routine use.

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Strategies to increase access to ECPs In all focus groups, students noted that women faced difficulties in accessing ECPs, in particular, the dedicated ECP product, which currently requires a physician's prescription. Students debated whether the dedicated ECP product should be provided at phannacies without a prescription, however, there was no consensus. Sorne believed over-thecounter access would lead to abuse of the method, while others considered this unlikely and thought the change would enable more women to prevent unplanned pregnancies.

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DISCUSSION Learning more about university students' knowledge and opinions on ECPs is important for the design of future educational carnpaigns to spread information about the method and to increase its acceptability. In this study, students had general information about ECPs, but lacked sorne important details. This finding is similar to what has been found in studies of knowledge and opinions of ECPs among university students in other settings (4, 7), as well as in another study with university students in Jamaica (14). In the latter study, 84% ofstudents surveyed had heard ofECPs before, but only 61% knew how muc.h ECPs reduce the risk of pregnancy and only 28% knew the time frame in which the method should be initiated (14). Among the details on ECPs that students, in this study, lacked were accurate information about the method's time frame, its side effects, its mechanism of action and by how much it reduces the risk of pregnancy. Knowledge about these details is cntcial because without accurate information students may use the method incorrectly. In addition, misinformation can lead to fears of the method and lack of support for it. As in other studies, students in this study believed that they had less time to use ECPs than the 72-hour time limit (14). Sources of confusion about the method's time frame were the names commonly used for the method such as the "moming after pill" and the '"day after pill." These names convey the message that the method can only be used within 24 hours of unprotected intercourse, when in tact, the time limit is 72 hours. The terrninology ''emergency contraceptive pill," which does not convey the erroneous message that the

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method can only be used the day after unprotected intercourse, should be used in future educational campaigns. The si de effects of ECPs were another area of incorrcct information. In general, the students had cxaggerated perceptions of the side effects of ECPs and a few thought that these alone provided a compelling reason not to use the method. While the short-term side effects are typically more severe than those associated \vith regular oral contraceptives, they are temporary and usually disappear within a few hours (24). Students should be informed ofthe short-terrn nature of the side effects, so they can better weigh the risks and benefits of the method and make an informed decision about using it. A third area of confusion wa'i ECP's mechanism of action. A number of students believed that ECPs cause abortions. This belief has been reported in studies in other settings as well (25). The presentation of scientific information about how ECPs Vlork convinced the majority of students that ECPs do not lead to abortions, however, a minority continued to consider ECPs abortive, even after scientific evidence was presented. In addition, the scientific definition of the beginning of pregnancy did not carry much weight with any of the students who, by and large, believed the beginning of pregnancy was a matter of personal opinion. Finally, many students had the impression that ECPs reduced the risk of pregnancy by more than they actually do. Many were disappointed to leam the true pregnancy risk reduction of the method. lt is important that students realize that e ven the Yuzpe regimen 's 75% reduction in the risk of a pregnancy would help to prevent a large number of unplanned pregnancies (23) and that they should not exclude the method because they think it would not work. However, the comparatively low pregnancy risk reduction of ECPs when compared to other hormonal contraceptives may be an important message to help convince students that ECPs should only be used as a back-up method, and that other more effective methods should be used regularly. Additional areas that arose in the focus groups and that would be worth special attention in future educational campaigns are the long term safety ofthe method and the issue of routine use. A number of students were confused by the idea that ECPs were indicated for ..emergency use" and felt that the definition of an emergency can vary from person to person. It is important to clarify what exactly is meant by this concept and other issues regarding the repeated use of ECPs, including the method's safety and effectiveness when used frequently. Despite sorne confusion, the vast majority of students expressed support for ECPs. Even among participants with initially conservative views, many became supportive of the method when given correct inforrnation. This suggests that with increased information about the method and clarification of a few details, the method would be widely popular in this population and could potentially go a long way in preventing unplanned pregnancies.

Emergency Contraceptive Pills

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An important limitation of this study is that the tindings are not representative of university students at the Mona campus. Only 71 students in total participated in the focus groups and they were not randomly selected to be representative of the larger student body. Nevertheless, the tindings are comparable to those of other studies with university students worldwide (4,7) and a study on ECPs with a random sample of students living on-campus at UWI is warranted (14). Finally, as a warning, the findings from this study should not be generalized to the larger population of Jamaica. In tact, only 8% of Jamaicans go on to tertiary leve] education (14). Those who do study at the tertiary leve) have important characteristics which make them different from the rest of the population, such as higher social and economic status and lower levels offertility. We recommend continued research on ECPs with other groups of Jamaicans, in particular, adolescents and family planning dinic users. This research could help to infonn policies and programmes to introduce and popularize EC in Jamaica, and might be relevant to other countries of the English-speaking Caribbean.

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ACKNOWLEDGEMENTS The authors are grateful to Charlotte EJJertson for proposing the study, Nicole AppeJJe, Abigai1 Norris Turner and Kiyomi Tsuyuki for reviewing drafts of the paper and Andrea BrownDennis for her help with transcription. This study was supported by the William and Flora Hewlett Foundation.

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