AWA: Academic Writing at Auckland

Introduction

In many countries, the vast majority of pregnancies that occur amongst young people are unintended or unwanted, and adolescent pregnancy is a significant problem. Adolescent pregnancy has many negative consequences both for the mother and the child, including impacts on education and poverty. (As-Sanie, Gantt & Rosenthal, 2004). 

Common contraceptive methods are not always used by young people, and even when they are they may fail or be used incorrectly. Emergency contraception is an oral contraceptive method that is taken following sexual intercourse to prevent pregnancy. It is thought to be around 75% effective when taken within 72 hours of intercourse, but is more effective the sooner it is taken. It is hypothesized that increased use of emergency contraception could lead to a reduction in abortions and unwanted pregnancies. (Lindberg, 2003).

Emergency contraceptives are available over-the-counter from pharmacies in many countries, including the United States, Australia, and the United Kingdom (Bayley, Brown & Wallace, 2009; Calabretto 2009; Sampson et al. 2009). However, age restrictions are in place in some countries. In the United States, for example, only those over 18 can access emergency contraception without a prescription. (Johnson et al. 2010).

Adolescents and young people are more likely to face barriers to accessing emergency contraception, despite having arguably the greatest need. This review summarizes some of the evidence from the literature about the barriers that young people and adolescents face when accessing emergency contraception.

Methods

Articles were found using the Scopus database. Searches were performed on keywords “emergency contraception”, “postcoital contraception”, “emergency postcoital contraception” “adolescent”, “teen”, and “access”.  The terms “contracept*”, “teen*” and “adolescen*” were truncated to ensure inclusion of relevant articles. Search results were further narrowed by searching for “pharmacy” and “over-the-counter” and “nonprescription” to limit results to countries where emergency contraception was available over-the-counter. Initial basis for inclusion was the relevance of the title of the study to the topic. The abstract was then assessed for relevance, and finally the full text of the article.  In the process of reading the full text if a reference was noted as relevant, the article referenced as found and assessed against the inclusion criteria. Criteria for inclusion were 1) Emergency contraception was available over-the-counter in the country and at the time the study took place. 2) The study participants were either providers of emergency contraception or aged no older than 24 years. 3) If the study included participants aged older than 24 years, it must be clearly stated that not significant differences were found between older and younger age groups. 4) The original study was published in English. 5) The study described barriers to access for emergency contraception. Once a study was selected for inclusion the following information was initially recorded for analysis: study design; participants; setting; methods; results and limitations.

Results

There are two broad categories of barriers to access to emergency contraception faced by young people, particularly adolescents. The first are factors that influence whether health professional prescribe to adolescents.  The second are factors that prevent young people seeking and accessing emergency contraception. The barriers found by this review are outlined below.

Moral beliefs

Some studies found that the moral beliefs held by the health professional had an effect on how often they prescribed or provided emergency contraception to adolescents (Day 2008; Goyal, Zhao & Mollen, 2009; Upadhya, Trent  & Ellis, 2009). Some of these beliefs were concerned directly with emergency contraception and the belief that it’s use is morally wrong. For example, pharmacists may refuse to fill a prescription on moral grounds (Day 2008).  Other beliefs were less directly related to beliefs about emergency contraception but still had an effect on prescribing rates. For example, (Upadhya et al. 2009) found that paediatric residents who had more negative attitudes towards teen sex were less likely to prescribe emergency contraception than those who had more positive views.  The decision of pharmacists not to provide emergency contraception based on conscience can be a barrier to access for young people. Some pharmacies do not provide emergency contraception (Conard, Fortenberrym Blythe & Orr, 2003; Day 2008). One study found that 48% of pharmacies did not provide emergency contraception (Conard et al. 2003). This can be of particular concern in rural areas. (Day 2008). Young people also reported moral concerns about emergency contraception (Johnson et al. 2010; Calabretto 2009).

Lack of knowledge about emergency contraception

Knowledge about emergency contraception varied between health professionals and from study to study. Uphadhya et al. (2009) reported good knowledge of emergency contraception amongst paediatric residents, while Goyal et al. (2009) found that 43% emergency room physicians in the study were unable to answer more than half the specific questions relating to knowledge of emergency contraception.

Many of the studies found a general lack of knowledge about emergency contraception amongst young people. This included lack of knowledge about the timeframe in which emergency contraception could be used (Mollen et al. 2008; Calabretto 2009), confusion about whether emergency contraception caused abortion (Johnson, Nshom et al. ; Mollen et al. 2008; Calabretto 2009), as well as a lack of awareness of the existence of emergency contraception (Johnson, Nshom et al. ; Gilliam, Davis, Neustadt & Levey, 2009) and where it was available (Mollen et al. 2008; Calabretto 2009). One study, for example, found that only a third of Australian students in the study knew that emergency contraception was available over-the-counter in Australia. (Calabretto 2009).

Lack of knowledge about own risk of pregnancy

Some studies found that risk of pregnancy was misperceived by young people who did not seek emergency contraception. This misperception took a variety of forms. (Johnson, et al. 2010; Calabretto 2009; Williamson, Buston et al. 2009). One study, for example, found that while adolescents wished to avoid pregnancy, they were not necessarily prepared to take measures to avoid pregnancy (Johnson et al. 2010), while another study found that young people had inaccurate knowledge about when their most fertile time was (Calabretto 2009). There was also a belief amongst those who did not seek EC that “it won’t happen to me”. It is worth noting that those who held these beliefs were more likely to come from disadvantaged backgrounds. (Williamson et al. 2009).

Negative perceptions about emergency contraception

Attitudes towards the use of emergency contraception were mixed. Some studies found that use of emergency contraception had negative connotations amongst young people (Johnson et al. 2010; Mollen et al. 2008; Williamson et al. 2009). One study, for example, reported that young people felt irresponsible for needing to use EC (Williamson et al. 2009). Other studies found that the types of people who used emergency contraception were viewed negatively (Johnson et al. 2010; Mollen et al. 2008). Several studies reported favourable views of emergency contraception amongst young people (Johnson et al. 2010; Mollen et al. 2008; Calabretto 2009; Gilliam et al. 2009). For example, one study found that 59% of respondents would consider using emergency contraception following future unprotected sex (Calabretto 2009).

Embarrassment and fear of judgement

Embarrassment and fear of being judged were commonly reported concerns about seeking emergency contraception, especially amongst younger adolescents. (Johnson et al. 2010; Mollen et al. 2008; Bayley et al. 2009; Williamson et al. 2009). However, most reported that they would find some way to overcome these barriers and would not be prevented from accessing emergency contraception if they wanted to, for example by telling the health professional that the condom broke rather than saying they had unprotected sex (Bayley et al. 2009).

Age

While young age was reported as a significant barrier by one study (Mollen et al. 2008), other studies found that young people believed age restrictions could be easily overcome (Johnson et al. 2010).

Practical barriers

Practical factors such as cost, distance, transportation and language were frequently mentioned as barriers that contributed to limiting access. (Johnson et al. 2010; Day 2008; Mollen et al. 2008; Bayley et al. 2009; Sampson et al. 2009). However, the significance of these concerns varied. While one study found that cost was the most significant perceived barrier to access, with emergency contraception perceived as a waste of money (Johnson et al. 2010), another found that emergency contraception  was “a small price to pay” (Williamson et al. 2009). A case study illustrates how practical factors can contribute to limiting access to emergency contraception in rural areas where there may only be one pharmacy nearby. If that pharmacy does not provide emergency contraception, then transport and cost of both transport and medication can be crucial (Day 2008).

Confidentiality

Confidentiality, privacy and risk of being found out were significant concerns for young people when accessing emergency contraception (Johnson et al. 2010; Mollen,et al. 2008; Bayley et al. 2009; Gilliam et al. 2009).  These concerns were heightened in a pharmacy setting, with many young people reporting that they would be worried about being recognised by family or friends if they went to a pharmacy for emergency contraception.  To avoid this situation, some reported that they would prefer to visit a pharmacy outside their neighbourhood. (Johnson et al. 2010). Others were concerned that pharmacist would tell their parents or that their parents would later see their file and find out they had used emergency contraception (Bayley et al. 2009).

Discussion

The studies in this review include a wide variety of approaches. Some took a qualitative approach. These studies used interview, focus groups, or a combination of the two to provide in-depth information about the attitudes and beliefs of young people toward emergency contraception, as well as information about barriers that adolescents themselves say they experience (Johnson et al. 2010; Day 2008; Mollen et al. 2008; Bayley et al. 2009; Gilliam et al. 2009; Williamson et al. 2009). Although qualitative data is not representative and therefore has limited generalizablilty, many of the studies found similar results amongst different populations, providing increased support for their findings. For example, confidentiality was found to be a concern both for school students aged between 13-16 years in Central England, and for black women aged 15-19 years in an urban setting in the United States (Mollen et al. 2008; Bayley et al. 2009).

Some studies used quantitative methods (Conard et al. 2003; Goyal, et al. 2009; Sampson et al. 2009; Upadhya et al. 2009). These studies were primarily cross-sectional, self-administered surveys. As Upadhya (2009) noted, this is problematic because the direction of the relationships cannot be determined. Many of the studies in this review were also subject to self-selection bias, as participants decided whether to take part in the study. (Gilliam et al. 2009; Calabretto, 2009; Johnson et al. 2010; Goyal et al. 2009). This is problematic because those who chose to take part may have had stronger views about emergency contraception that those who did not, and this means that the results may not be representative. Some studies also used a convenience sampling method, where participants approached the researcher (Calabretto, 2009; Johnson et al. 2010). This means that as well as the potential for the sample to not be representative, the researcher was also unable to estimate the level of non-response. Non-response bias was also a problem for some of the studies (Goyal et al. 2009; Conard et al. 2003). This is because those who did not respond may differ in respect to their beliefs about emergency contraception to those who did respond. Some of the studies reported differences in education levels of participants compared with the general population (Calabretto, 2009; Johnson et al. 2010; Gilliam et al. 2009). For example, in one study a significant proportion of participants had heard about emergency contraception at “a women’s rights march”, an experience that the general population is unlikely to have had (Gilliam et al. 2009). One study took a mixed-methods approach (Sampson et al. 2009).

Other than these, individual studies had their own particular limitations. However, overall the various approaches to studying barriers to access to emergency contraception provide a good understanding of the topic, from the perspective of both the young people themselves and the health professionals who treat them. A range of different population groups have participated in studies in this area which gives a broad picture of barriers faced by many young people. As it is unethical to collect experimental data relating to emergency contraception, to further knowledge about this topic follow-up studies would be beneficial. This could help clarify whether the barriers adolescents believe they face actually prevent them from accessing emergency contraception. More research is needed to evaluate the effects of different interventions on reducing barriers to access for young people, as well as better awareness of the differences between population groups, particularly those who are socially disadvantaged, as this group is likely to be more adversely affected by adolescent pregnancies as their education and levels of poverty are already lower than those who are more socially advantaged. It could also be beneficial to compare the barriers faced by adolescents in countries where pharmacy access to emergency contraception is available with those in countries where pharmacy access is not available. This could provide an understanding of whether pharmacy access has an influence on barriers.

Emergency contraception is an important part of contraception that has the potential to reduce unwanted pregnancies amongst young people. However, its importance should not be overstated, as ensuring young people use regular contraception should be the focus when considering contraceptive use amongst young people, as these methods are more effective at preventing pregnancy. Emergency contraception remains an important back-up method that has been proven safe and relatively effective, and as much as possible should be done to make it more accessible to young people.

References

As-Sanie, S., Gantt, A., Rosenthal, M.S.  (2004). "Pregnancy prevention in adolescents." American Family Physician, 70(8): 1517-1524.

Bayley, J., Brown, K., Wallace, L. (2009). "Teenagers and emergency contraception in the UK: A focus group study of salient beliefs using concepts from the Theory of Planned Behaviour." European Journal of Contraception and Reproductive Health Care, 14(3): 196-206.

Calabretto, H. (2009). "Emergency contraception - Knowledge and attitudes in a group of Australian university students." Australian and New Zealand Journal of Public Health, 33(3): 234-239.

Conard, L. A. E., Fortenberry, J. D., Blythe, M. J., Orr, D. P. (2003). "Pharmacists' attitudes toward and practices with adolescents." Archives of Pediatrics and Adolescent Medicine, 157(4): 361-365.

Day, A. S. (2008). "Emergency contraception: when the pharmacist conscience clause restricts access." Nursing for women's health, 12(4): 343-346.

Gilliam, M. L., Davis, S. D., Neustadt, A. B., Levey, E. J. (2009). "Contraceptive Attitudes among Inner-City African American Female Adolescents: Barriers to Effective Hormonal Contraceptive Use." Journal of Pediatric and Adolescent Gynecology, 22(2): 97-104.

Goyal, M.,  Zhao, H., Mollen, C. (2009). "Exploring emergency contraception knowledge, prescription practices, and barriers to prescription for adolescents in the emergency department." Pediatrics, 123(3): 765-770.

Johnson, R., Nshom, M., Nye, A., Cohall, A. (2010).  "There's always Plan B: adolescent knowledge, attitudes and intention to use emergency contraception." Contraception, 81(2): 128-132.

Lindberg, C. E. (2003). "Emergency contraception for prevention of adolescent pregnancy." MCN The American Journal of Maternal/Child Nursing, 28(3): 199-204.

Mollen, C. J., Barg, F. K., Hayes, K. L., Gotcsik, M., Blades, N. M., Schwarz, D.F. (2008). "Assessing attitudes about emergency contraception among urban, minority adolescent girls: an In-depth interview study." Pediatrics, 122(2): e395-e401.

Sampson, O., Navarro, S. K., Kahn, A., Hearst, N., Raine, T., Gold, M., Miller, S., Thiel de Bocanegra, H. (2009). "Barriers to adolescents' getting emergency contraception through pharmacy access in California: Differences by language and region." Perspectives on Sexual and Reproductive Health, 41(2): 110-118.

Upadhya, K. K., Trent, M.E., Ellen, J.M. (2009). "Impact of individual values on adherence to emergency contraception practice guidelines among pediatric residents: Implications for training." Archives of Pediatrics and Adolescent Medicine, 163(10): 944-948.

Williamson, L. M., Buston, K., Sweeting, H. (2009). "Young women's perceptions of pregnancy risk and use of emergency contraception: findings from a qualitative study." Contraception, 79(4): 310-315.