The United States has the highest teen birth rate of any developed country.1 One in three girls under the age of 20 will get pregnant, and 80% will be unintended.2 Emergency contraception (Plan B; levonorgestrel, Duramed Pharmaceuticals, Montvale, NJ) is a safe and effective means to prevent unplanned pregnacies.3–5 Levonorgestrel currently has a dual label: It is available over-the-counter to men and women aged 18 or older, while adolescents under the age of 18 require a prescription.
Timing significantly affects efficacy. In fact, waiting longer than 12 hours after unprotected sex increases the chance of pregnancy by almost 50%.6 Requiring teens to wait to get a prescription before obtaining emergency contraception could significantly delay their ability to use it when it can be most effective. There is no evidence that giving teens access to emergency contraception increases risk-taking behavior. Teens that were given advanced prescriptions for emergency contraception had similar condom use to those who were not given the prescription. They were not more likely to contract sexually transmitted infections or have multiple sexual partners.7–9
Several studies have been conducted to assess the safety and comprehension of emergency contraception use.10–12 In 2002, Raymond et al12 demonstrated excellent label comprehension by adults in eight urban areas in the United States. Of the 663 women surveyed, only 76 (11.4%) were between the ages of 12 and 16.12 In an actual-use study by Raymond et al11 only 5% of participants were between the ages of 14 and 16, and none were under 14 years of age. Similarly, in a 1994 British study by George et al10 exploring women’s knowledge of emergency contraception, 6.5% of the 878 participants were between 16 and 19, and none were under the age of 16.10 The purpose of this study was to estimate adolescents’ comprehension of the over-the-counter emergency contraception label and to contribute to the literature regarding emergency contraception knowledge and comprehension in the 12–17 year old age group.
MATERIALS AND METHODS
A questionnaire was designed to estimate participants’ comprehension of the indication for emergency contraception as well as to estimate knowledge about the timing of emergency contraception’s intended use, use in pregnancy, protection against human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and long-term use of emergency contraception. Information about age, race, sexual activity, and knowledge/use of contraception was also collected from participants. The girls were not compensated for participation. However, participants and friends who declined to participate or were ineligible to participate were offered a small piece of candy after participants competed the surveys. Institutional review board approval was obtained from the New York University School of Medicine.
A sample size calculation was made based on an estimate of the female adolescent population in New York City of at least 500,000.13 Raymond et al12 demonstrated that 93% of women understand that emergency contraception is used for the prevention of pregnancy after unprotected intercourse. The minimal sample size required to show a similar comprehension among adolescents, with a 95% confidence interval (CI) half-width of 1.5 percentage points (95% CI 91.5–94.5%) was 1,065.14 The other key points were compared with percentage and confidence intervals that were found in the Raymond study.
Female adolescents were recruited in New York City private high schools as well as public venues such as malls, movie theaters, and parks where adolescents are known to congregate. The original study was designed to be conducted in New York City public schools. However, we did not receive approval by the Board of Education to administer the surveys because of the controversial nature of the subject. Participants were provided with a six-page copy of the levonorgestrel label and asked to look over the label/package insert before the survey was administered. After the teens had indicated that they had read the insert, the research coordinator distributed the two-page survey and told participants that they could use information from the label to answer questions. The research coordinator also reminded participants that they should not write their names or any other identifying information on the survey.
Surveys included in the analysis were completed by girls aged 12–17. There were approximately 15 surveys that were not included because they were outside of the age range. These surveys were destroyed. All surveys were entered even if several of the responses were missing. Data were entered onto an Excel (Microsoft Corporation, Redmond, WA) spreadsheet using numerical coding and transferred to SPSS (Chicago, IL) for analysis. Confidence intervals were calculated online.15 Comparisons were made in SPSS 13.0 using χ2 tests of independence and Fisher exact tests for sparse data. No adjustments were made to the significance level to account for multiple comparisons because the comparisons are of particular interest and thus were carefully specified before data analysis.
A total of 1,085 adolescents between the ages of 12 and 17 participated in the study. Demographics of this population are shown in Table 1. There was a large number of girls aged 14–17 but a lower percentage (9.0%) of girls aged 12 and 13. The teens surveyed were a diverse group: 38.8% white, 16.6% African American, 21.1% Hispanic, and 11.1% Asian/Pacific Islander. Many teens (12.1%) described themselves as “other.” More than a quarter of the teens were sexually active (26.1%), and 9.9% of this group reported that they had been pregnant. Overall, only 2.8% admitted to a previous pregnancy. The percentage of teens that reported ever using birth control pills was 10.7% and 26.0% for condoms. A majority, 67.8%, stated that they had heard of emergency contraception.
Overall, teens knew as much about emergency contraception as their adult counterparts in the Raymond et al12 2002 study (Fig. 1). High percentages in both groups comprehended that emergency contraception is used as a way not to get pregnant after unprotected intercourse 92% (CI 91–94%) in our study and 93% (CI 91–95%) in Raymond et al12 2002 study. They also knew that they should take it within 72 hours at the same level as adults, 83% (CI 83–87%) compared with 85% (CI 82–88%). A high percentage of teenagers knew that emergency contraception should not be used if you are already pregnant 87% (CI 85–89%), but more adults were aware of this 98% (CI 97–99%). Teens also knew that emergency contraception did not protect from HIV/AIDS at the same level as adults, 95% (CI 94–96%) compared with 94% (CI 92–96%). A higher percent of teenagers knew that emergency contraception should not be used as long-term birth control, 85% (CI 83–87%) compared with 67% (CI 64–71%).
The data are broken down by age in Table 2. As expected, girls tended to be more sexually active and at higher risk for unplanned pregnancy as they got older. A much higher percentage of teens aged 14–15 (19.8%) and 16–17 (37.5%) reported that they were sexually active than the 12- to 13-year-olds (2%). Older girls (15–17) were much more likely (P<.001) to have heard of emergency contraception than their younger counterparts (76.5% compared with 42.9%). Although the numbers were small, the 15- to 17-year-olds were also more likely (P<.01) to have been pregnant (4.1% compared with 0%).
Girls aged 16–17 (95%) were more likely than the 12- to 13-year-olds (88%) or the 14- to 15-year-olds (90%) to understand the reason to use emergency contraception. These older girls were also more likely to know that emergency contraception does not protect against HIV/AIDS, although the percentage correct was high for all three groups (89%, 93%, and 98%, respectively). The older girls were more likely than the 14- to 15-year-olds to understand that emergency contraception needs to be used within the first 72 hours, 89% compared with 81% (P=.001) and 86% in 12- to 13-year-olds, although this difference was not statistically significant (P=.49). The very young girls were less likely (73%) to understand that emergency contraception should not be used as long-term birth control than were their older counterparts (88%) for 14- to 15-year-olds and 16- to 17-year-olds (P=.02 and .001). There was no difference among the three groups as to knowledge about use of emergency contraception if you are already pregnant. A trend test showed significance for all comprehension points in terms of age, except for the point that emergency contraception will not be beneficial if you are already pregnant.
In terms of ethnicity, adolescents of differing ethnic groups were similar in their understanding of emergency contraception (Table 3). There were no differences among whites, African Americans, Hispanics, or Asians in the majority of key comprehension points. All groups were similar in understanding of the purpose of emergency contraception (90–94%; P values not significant). They were also similar in understanding that emergency contraception should be used within 72 hours (82–88%) and that it should not be used if already pregnant (84–89%) or to protect against HIV/AIDS (93–97%). None of the P values were significant. A higher percentage of whites understood that emergency contraception should not be used as long-term birth control (92%) than African Americans (81%, P=.001), Hispanics (80%, P=.001) or Asians 77% (P=.001.) (These differences were not significant. There were no significant differences between African Americans, Hispanics, and Asians.
After reading the emergency contraception (levonorgestrel) package insert, adolescent girls aged 12 through 17 years understood the concepts necessary for safe and effective use as well as the adults in the Raymond et al 200212 study.
There were some differences in comprehension among age groups in our study. The older teens, 16–17 years old, were more likely to understand key comprehension points than the younger girls, but the younger girls did understand the majority of points with high accuracy (more than 80%). Teens that had heard of emergency contraception were more likely to understand the key comprehension points, but these teens were more likely to be older and sexually active. The number of very young girls in this study was relatively small, and the majority of them were not sexually active. Overall, however, more than one quarter of adolescent girls were sexually active, putting them at risk for unplanned pregnancy.
Ethnicity did not play a major role in comprehension. For one question, regarding use of emergency contraception as long-term birth control, whites had a higher proportion of correct responses. However, for all of the other questions, ethnicity did not play a role. No data were collected about participants’ level of education or socioeconomic status, so it is unclear if these factors played a role. The study also did not assess reading comprehension which may have played a factor in understanding the survey. The survey was conducted in several different ethnically and socioeconomically diverse neighborhoods, which likely decreased this bias.
This study is the first research designed to assess emergency contraception comprehension specifically among adolescents. It was conducted with a large and diverse group of teens. All of the study coordinators responsible for collecting information from teens were female, which likely increased participants’ level of comfort and the chance that sensitive questions were answered honestly as opposed to if coordinators had been male. Although most teens completed the survey in a public space, where they might have been less likely to take time to answer questions carefully, they still answered the majority of questions correctly. Another strength of the study was that the questionnaire was based on the actual levonorgestrel package insert that individuals receive when purchasing emergency contraception.
The study had several limitations. The most important limitation was that it was not a random sample. The survey was done on adolescents, and because surveys were completed in public areas and often with peers nearby, adolescents may not have answered all questions truthfully. As a result, study data may not accurately reflect the percentage of teens who are sexually active or who have had a previous pregnancy. Some participants also compared answers with peers despite study coordinator instructions to complete the surveys individually. This may have led girls in groups to answer questions differently than they might have on their own. The research coordinators separated girls who appeared to be discussing answers.
While study coordinators handed out the emergency contraception package insert for girls to read before completing the survey, not all teens read the information with the same attention that they might have if they were actually about to take an emergency contraceptive pill. Despite this, teens demonstrated a high comprehension of key concepts. Adolescents are likely to score even higher in an actual use setting. This study was conducted among adolescent girls in New York City and data may not be representative of U.S. adolescents as a whole. Given the diverse group of teens, however, the results are likely generalizable to any large urban setting.
This study shows that adolescents demonstrate comprehension equal to adults of the key points necessary for safe and effective use of emergency contraception (levonorgestrel).
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