Emergency contraception is an effective method of postcoital pregnancy prevention.1,2 The United States Food and Drug Administration (FDA) recently approved Plan B (Duramed Pharmaceuticals Inc, Pomona, NY) as a dual status medication for emergency contraception, meaning that it is available without prescription to consumers aged 18 and older and by prescription only to females under 18 years. Plan B consists of two pills, each containing 0.75 mg levonorgestrel, that are taken 12 hours apart and within 72 hours postcoitus. A randomized controlled trial demonstrated that levonorgestrel emergency contraceptive pills (ECPs) can be taken as a single dose and up to 120 hours postcoitus without compromising efficacy or increasing adverse effects.3 If taken correctly, this regimen can reduce the risk of pregnancy substantially.3 Emergency contraception does not disrupt an established pregnancy and is therefore not an abortifacient.4,5
In an effort to increase access to emergency contraception, the Office of Population Research at Princeton University established The Emergency Contraception Website (http://ec.princeton.edu), which is now jointly sponsored with the Association of Reproductive Health Professionals. The Emergency Contraception Website is an up-to-date, evidence-based emergency contraception resource that maintains a national database of emergency contraception providers. The Web site receives approximately 100,000 visits per month and an average of 1,200 yearly e-mail inquiries.6 In 2004–2006, the Reproductive Health Fellows at the University of Rochester served as designated New York State ECP providers and provided over 1,000 ECP prescriptions to women calling the service as a result of self-referrals from the Web site.
There are several reasons to study this population of women. First, little is known about women who seek contraceptive services from an Internet site. We do not know how demographically similar this group is to general contraceptive users. The Internet is an increasingly important health resource; in 2006 there were 113 million Internet users in the United States, and 8 of 10 Internet users searched for health information online.7 These data highlight the need to explore the clinical implications of this trend in health information–seeking behavior. Second, a survey of emergency contraception callers provides first-hand information about barriers to getting emergency contraception information and pills. Prior studies have focused on patient knowledge, past use of emergency contraception,8 or the effects of advanced provision of ECPs through a purposeful intervention,9–11 but less attention has been given to assessing obstacles to emergency contraception access as perceived by women themselves.12
Given the complex psychosocial issues associated with reproductive health, we decided to incorporate qualitative methods, specifically, in-depth interviewing techniques, in the study design. We felt this approach would deepen our understanding of contraceptive decision making by eliciting responses that may not have been anticipated or are difficult to communicate through a quantitative survey. Therefore, we used a mixed-methods design, defined as the collection and integration of qualitative data (words) and quantitative data (numbers) in a single study.13 The specific study aims were 1) to describe the demographic profile and most recent contraceptive patterns of Internet-referred callers to an emergency contraception hotline in New York State; 2) to identify barriers to emergency contraception access as defined by callers; and 3) to assess attitudes toward advanced prescription and nonprescription availability of ECPs.
MATERIALS AND METHODS
We conducted telephone surveys of a convenience sample of 200 callers requesting ECPs. During study enrollment, the ECP phone line was open 7 days a week, including holidays from 8 am to 6 pm, and callers left messages at other times to be returned the next day. With each phone call, we obtained the information necessary to provide an ECP prescription per our routine clinical protocol. Women were eligible for the study if they were 1) aged 18 years or older, 2) candidates for ECPs as determined by clinical protocol, and 3) able to converse in English. At the end of the call, we informed all eligible women about the study. To minimize any concerns that receipt of the ECP prescription was contingent upon study participation, we immediately called in prescriptions to the participants’ pharmacy of choice before starting any study procedures. We obtained verbal consent over the phone from all participants and mailed written consent forms to those who desired them. The vast majority of participants consented to audio-taping of the interview. For the few participants who declined audio-taping, we completed the quantitative survey per protocol and took written notes to capture the qualitative details of the interview. For women who declined study participation, we asked permission to collect demographic information to compare nonparticipants with participants. The University of Rochester Research Subjects Review Board and Princeton University’s Institutional Review Panel for Human Subjects approved the study protocol.
We devised a 27-item survey to collect quantitative information on the following: 1) reason(s) for needing ECPs, 2) recent contraceptive and ECP use, 3) barriers to getting ECPs, 4) attitudes about advanced prescription of ECPs and nonprescription ECPs, and 5) demographics (age, race/ethnicity, education, residence, income, marital/union status, religious affiliation, health insurance, Internet access, parity). We pretested and refined the survey instrument based upon themes that emerged from qualitative data obtained in a pilot study of 15 women.
Interviews were semistructured to collect quantitative and qualitative data simultaneously. Each interviewer began the interview with an open-ended statement (“Tell me your story of how you ended up calling us today”) and used follow-up probes (“tell me more about that…”, “and then what?”) to obtain relevant details of the narrative, consistent with in-depth interviewing techniques.14 If answers to questions from the quantitative survey were not spontaneously provided by participants, then they were formally elicited. The interview concluded with structured questions about demographics and attitudes toward ECP.
There were two advantages to this model of embedding the quantitative data collection within the qualitative narratives. First, we anticipated that women would naturally provide responses to the quantitative survey during the course of their narratives. Second, we minimized interruptions and any perceived pressure to provide socially desirable responses by giving participants the freedom to tell their stories first.
Three study members conducted all interviews (T.G., J.W., and C.M.). T.G. and J.W. are family physicians with expertise in family planning, survey design, and qualitative data collection and analysis. C.M. is a nurse with experience in reproductive health in the clinical and research setting. All three interviewers were periodically assessed for the quality and reliability of their interviewing methods under the guidance of anthropologist N.C.
We used STATA 9SE (Stata Corporation, College Station, TX) for quantitative data analyses. Based on data from 200 women, we calculated descriptive statistics. We assessed univariable relationships with Fisher exact test to explore the relationship between demographic variables and attitudes toward ECP availability. We set α at 5%.
For qualitative data evaluation, we used a purposive sampling scheme to select interviews that represented participants who varied by age, parity, race or ethnicity, education, union or marital status, and most recent contraceptive use. A purposive sampling strategy aims to select participants who represent a diverse spectrum of perspectives; this approach is in contrast to quantitative sampling strategies that emphasize random selection and seek findings that are generalizable.15 We selected and analyzed transcripts until we reached theoretical saturation (in our case, 34 transcripts), a point at which no new information or themes are identified.15
All interviews were transcribed verbatim. In the first phase of the qualitative analysis, each team member (T.G., J.W., C.M., N.C.) independently read each transcript and assigned codes to relevant text. We then discussed and resolved differences in coding to develop a uniform coding system. In the second phase of analysis, we sorted and compared codes to identify recurring patterns and themes. We compared these qualitative data (supported by quotations from participants) with quantitative data (simple frequencies gathered by the 27-item survey) to construct an interpretation of the lived experiences of the participants.
Of the 410 calls we received between February 2006 and June 2006, we were able to speak to 379 callers. Of these callers, 307 met eligibility criteria, and 200 enrolled in the study (65% response rate). Figure 1 describes study enrollment. Table 1 compares demographics of participants with nonparticipants. Of the 107 women who declined study participation, we collected demographics on 93 women (87%). There were no significant differences between participants and these nonparticipants with respect to age, area of residence, race or ethnicity, income, education, or insurance. Nonparticipants most frequently stated they were too busy (31%) or they did not want to discuss personal matters (13%) (results not shown).
Study participants were predominately white, urban, Christian, nulliparous, and single. Most notably, this group possessed considerable social capital; the majority had achieved a college education or beyond, earned $30,000 or more annually, and had health insurance. The high socioeconomic status of this group was even more striking when compared with a nationally representative sample (Table 2). Our participants had a significantly higher proportion of white, highly-educated women earning 300% or more of the federal poverty level compared with an otherwise similar group from the 2002 National Survey of Family Growth.
As seen in Table 3, women most commonly reported condom breakage, slippage, or incorrect use (55%) as the reason for needing emergency contraception, followed by not using any contraceptive method (38%). Study participants demonstrated knowledge of the time-sensitive nature of emergency contraception; 97% called within the “window of opportunity” (5 days postcoitus), and 54% called within 24 hours. The vast majority of women (95%) found our service as a result of searching the Emergency Contraception Website.
We identified two main “paths” by which women initially searched for emergency contraception. Most (67%) tried nonconventional resources as a first strategy, namely an Internet site from which women could order ECPs by mail or an Internet-referred phone service. The remainder (33%) attempted to get emergency contraception from local providers before going online. For these women, the most commonly encountered barrier was inability to contact a provider because of closed offices or unreturned phone calls. Of those who actually spoke to a provider, many reported unhelpful exchanges (eg, “You are no longer our patient,” “We do not prescribe emergency contraception”) that ultimately did not lead to an ECP prescription.
Although women who first searched the Internet did not experience such barriers, they did anticipate these problems. In doing so, they decided to “jump online” to bypass what they considered to be a slow and inconvenient health care system. In particular, a theme of discomfort and frustration with health care providers and staff emerged as another compelling reason to search for emergency contraception online. (In all narratives reported, no participant is quoted more than once.)
- As soon as I said emergency contraceptive, it sounded like…that I was bothering her [the after-hours operator]…she treated me like, you know, like such a degenerate. So I called the hospital, but that sounded like a long process before I could get peace of mind.
- It’s just a pain to have to go in to the doctor’s office…it’s inconvenient and it’s still a little bit embarrassing. I’ve gotten emergency contraception several times and there are times when the doctors are…not very understanding. I got a sense of condescension from the doctor…a stern expression. I felt like I was in like middle school again and I did something really bad.
In addition to concerns about difficult interactions with health care providers, the second most common reason women cited for going online was a preference for the Internet (Table 3). For a small but sizable group (12%), preference for the Internet was the only reason they went online (results not shown). The phrase “I google everything” frequently appeared, indicating the importance of the Internet as a first-line resource to these women.
- We don’t have a Yellow Pages Book…that’s kind of ancient, I guess. You can basically Google anything….
- I’ve always used the Internet as, like, a source for knowledge and I just Googled the search engine to see what would come up.
- I don’t use the telephone books I got. And so I just pretty much use Google for everything. I use the Internet for everything.
Fifty-eight percent of participants had never used ECPs before. Of those who had used ECPs in the past (42%), the majority (67%) had used ECPs only once before. Women reported male condoms (48%), oral contraceptive pills (34%), patch or ring (6%), and withdrawal (5%) as the most effective contraceptive method used during the past year. A minority (4%) reported no contraceptive use at all (data not shown).
Figure 2 summarizes participants’ attitudes toward advanced prescription and nonprescription ECPs. Most participants (71%) fully supported advanced prescription of ECPs for future use. The remainder either had reservations or did not support the practice at all. There was considerably less enthusiasm for nonprescription ECPs; less than half of women (43%) expressed full support of this measure. Univariate analyses identified only one factor related to support for nonprescription ECP: women with post-college education were more likely than those with less education to approve of nonprescription ECP availability.
We asked those who were not fully supportive of advanced prescription ECPs or nonprescription ECPs to identify their greatest concern. The most frequent concern was that increasing ECP availability could promote risky sexual behavior and poor contraceptive practice. Qualitative data from the interviews provided further insight into the complexity of women’s attitudes toward ECPs. Women described shame about needing to use ECPs (“it was very, very stupid of me,” “it was an instance of being not smart, not safe, and not responsible”) as ECPs were considered morally and clinically inferior to other contraceptive methods (“the term ‘emergency’ means something is wrong,” “emergency contraception is not 100% effective”). Yet these women also acknowledged that having ECPs as a back-up method in case of “emergencies” for themselves was an important contraceptive option. However, many were reluctant to extend this right to “others” (in particular, adolescents) who may be less responsible and “abuse” the medication.
- I understand that younger girls might have just as equal of a need as I do for it. But at the same time, yeah, there are some prejudices, as much as I hate to admit it. I wouldn’t want my 11-year-old daughter just getting up and going to get this…and just abusing.
- I probably think it’s a double-edged sword. I’d like to think I am on the good side of it being…that I’m not out there using it instead of like condoms and just going, “oh well, I can just do this later….” Some people are extremely, extremely irresponsible.
In contrast, those women in full support of nonprescription ECPs argue that it is precisely those “other” women who need ECPs the most.
- It should be more readily available [ECPs]. I am an adult, I am secure, and yet it felt a little bit difficult getting to it. I would think that for a girl of 18 this would feel even much more daunting. It should be available to her.
- For a young girl to get, you know, pregnant at 15, 16, 17, …not be able to do anything after a certain time, or have to go through an abortion, than just taking a simple pill that is not going to do any damage. The answer is yes, it [ECPs] should be available.
Because this study was conducted before nonprescription availability of ECPs in the United States, we were interested in what women thought they would have done had ECPs been available without prescription on the day they needed it. Not surprisingly, almost all women (98%) agreed they would have taken advantage of nonprescription access in this hypothetical situation. However, 42% of women stated they would have still consulted a clinician, even if they independently obtained ECPs. These women valued having the opportunity to have “someone to talk to” for individualized support and guidance during a stressful situation.
- I am much more comfortable speaking to someone. Either on the phone or in person. It just…it seems more valid to me.
- I think I would rather use the help of somebody like you because what I was mostly worried about yesterday is lack of information and I was confused by the fact that I cannot really talk to anybody and ask questions. And I wouldn’t just want to take this decision on my own.
- I think the best way [to get ECPs] would be to call. Because they [health professionals] are more able, they’re able to explain and tell you how to take it and the side effects and stuff. Even though you read it. You go online and you read it and you read it, you read all about it. It’s better hearing it and let them explain.
Our study participants were urban, mostly white women of high socioeconomic status. The majority relied upon male condoms only or used no method at last intercourse, contributing to their need for ECPs in the first place. Women were resourceful and knowledgeable about the time-sensitive nature of ECPs and, accordingly, used the Internet to circumvent traditional health care settings and expedite their search. Those who attempted to seek ECPs through routine channels experienced barriers that were largely structural. However, negative interactions with providers and fear of stigmatization also posed formidable barriers. Women who had reservations about advance prescription and nonprescription ECPs were mainly concerned that widely available ECPs could encourage promiscuity and abandonment of routine contraception by “others.” Women showed little concern that their own behavior would be affected.
Participants highly valued and even preferred the Internet as a first-line source of information, a finding that underscores the potential value of online contraceptive resources. Furthermore, almost all callers had access to high-speed Internet, which has been reported to be an important predictor of Internet use, even more so than online experience.16 Not surprisingly, our participants had a significantly higher percentage of white, well-educated women with higher income compared with an otherwise similar national cohort. Our data appeared to be consistent with findings of other researchers who have described the phenomenon of a growing “digital divide” in the United States,17,18 that is, a widening gap between the traditional “haves” and “have-nots” with respect to Internet access and literacy. Any efforts to develop educational campaigns about ECPs must consider appropriate mediums of communication to reach “electronically disadvantaged” sub-populations.
Theoretically, the structural and administrative barriers to obtaining ECPs should be largely mitigated by nonprescription availability of Plan B. However, there remain individuals who will not benefit from recent FDA approval of Plan B for dual-status use, including women under 18, those without government-issued identification cards, and those who cannot afford the cost of nonprescription ECPs, which currently average $40–50 per package. Furthermore, obtaining ECPs in traditional health care settings can be daunting for those who have either experienced or fear negative encounters with the health providers. Our data suggest that many women who are in the position of purchasing ECPs without a prescription would still value the opportunity for a personal consultation with a clinician. With ECPs now available without prescription to those 18 years and older, the medical community should consider creative outreach strategies that will continue to make ECPs a “bridge” to link women back to regular contraceptive services and relevant preventive care.
There is a reasonable assumption among health professionals that FDA approval of Plan B sends a strong message to the public that ECPs are medically safe to use. Although safety concerns may or may not be allayed by the availability of nonprescription ECPs, evidence from our study and others suggest that concerns about ECP use negatively affecting sexual and contraceptive behavior must be addressed.12,19 The fact that the FDA approved Plan B as a dual-label product may reinforce the ambivalence held by our study participants about the consequences of ECP availability on behavior. Based upon numerous clinical trials, there is no evidence to support these beliefs. In several randomized controlled studies, women (including teenagers) who received advance supplies of ECPs did not report higher rates of unprotected intercourse and were more likely to use ECPs when indicated.10,20–25 Providing the public and health providers with such evidence-based information is crucial to gaining widespread support and acceptance of ECP use.
The integrated analysis of qualitative and quantitative data in this study distinguishes our work from prior literature on emergency contraception. The details of participants’ stories offered more nuanced and complex explanations regarding women’s ambivalence toward emergency contraception that may not have been apparent based upon quantitative analysis alone.
There were several limitations to this study. We surveyed a convenience sample of callers from New York State, and thus, our findings may not be generalizable. The timing of this study was fortuitous because FDA approval of Plan B as a dual-status medication occurred shortly after completion of our interviews. Therefore, we captured attitudes toward ECPs that may be changing in response to recent events. Further studies are needed to assess national attitudes toward ECPs and to determine whether these attitudes evolve as we enter this interesting era of dual-status labeling.
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