AWA: Academic Writing at Auckland

Research question

Knowledge about emergency contraception has been shown to be poor amongst some groups (Calabretto, 2009; Mollen et al., 2008). Is knowledge of emergency contraception a barrier to access to emergency contraception following contraceptive failure for adolescent girls (14-17 years) in Auckland?

Background 

Teenage pregnancy is a significant problem in many countries, including New Zealand. While fertility rates are relatively low amongst young people compared to other groups, the majority of pregnancies that occur in this group are unintended or unwanted. Teenage pregnancy can have significant negative consequences for both mother and child, for example impacting on education (As-Sanie, Gantt, & Rosenthal, 2004; Ministry of Health, 2001). Unwanted pregnancy may also lead to abortion, which can also have impacts on the mental health of the mother (Major et al., 2009). A significant proportion of abortions in New Zealand are performed on women under 24. In New Zealand, teen pregnancy rates are highest amongst Maori, with an estimated pregnancy rate of 131.8 per 1000, almost three times higher than that of non-Maori (Dickson, Sporle, Rimene, & Paul, 2000).

Emergency contraception could help to reduce the number of unwanted pregnancies and abortions. Although young people do not always use contraception, even when they do it may fail, resulting in unwanted pregnancy. The emergency contraceptive method is an oral contraceptive that is taken following sexual intercourse. It is about 75% effective at preventing pregnancy if taken within 72 hours following intercourse, but can be much more effective if taken sooner. Emergency contraceptives will not prevent pregnancy once implantation has occurred and considered safe and effective. Young people, however, face significant barriers to accessing emergency contraception. (Lindberg, 2003).  For example, many studies have found a lack of knowledge about emergency contraception amongst young people (Calabretto, 2009; Gilliam, Davis, Neustadt, & Levey, 2009; Johnson, Nshom, Nye, & Cohall; Mollen et al., 2008). This includes lack of knowledge about the availability of emergency contraception (Calabretto, 2009), the timeframe for use (Mollen et al., 2008) and awareness of the existence of emergency contraception (Gilliam et al., 2009).

This study aims to establish whether lack of knowledge about emergency contraception prevents adolescent girls in Auckland from accessing emergency contraception when it is required following a contraceptive failure. For the purpose of this study, contraceptive failure will be defined as condom breakage or missed or late oral contraceptive pill in the seven days prior to intercourse, as these are common methods of contraception that are often not used correctly.

A better understanding of the relationship between knowledge and access to emergency contraception could contribute to establishing whether increasing knowledge of emergency contraception is an effective way to improve access to emergency contraception for adolescent girls following contraceptive failure, and what level of knowledge is required to ensure that lack of knowledge does not act as a barrier to access amongst this high-risk group.

Hypotheses

[H₀]: Female high-school students (Year 11 & 12, 14-17 years) in Auckland who have less knowledge of emergency contraception including knowledge of existence, correct usage and availability will have used emergency contraception with the same frequency following self-reported contraceptive failure (condom breakage or missed or late oral contraceptive pill in the seven days prior to intercourse) as female high-school students with more knowledge of emergency contraception.

[H₁]: Female high-school students (Year 11 & 12, 14-17 years) in Auckland who have less knowledge of emergency contraception including knowledge of existence, correct usage and availability will have used emergency contraception less frequently following self-reported contraceptive failure (condom breakage or missed or late oral contraceptive pill in the seven days prior to intercourse) than female high-school students with more knowledge of emergency contraception.

Quantitative Methods

Data Sources

Quantitative data will be collected from a questionnaire. The questionnaire will consist of items intended to assess participant’s knowledge of key aspects of emergency contraception. The questionnaire will also be used to collect data about whether participants have accessed emergency contraception following contraceptive failure. This data will indicate whether there is a relationship between knowledge of emergency contraception and access to emergency contraception following contraceptive failure.  

Sample

The sampling units will be Auckland secondary schools. A cluster sampling method will be used. Using data from the Ministry of Education school directory, approximately 30 state secondary schools will be randomly selected from all state secondary schools in the Auckland region, excluding boy’s schools and schools with less than ten Maori students. Principals of selected schools will be approached to participate in the study. If schools agree to participate, a proportion of female year 11 and year 12 students will be randomly selected to participate, with weighting of Maori and Pacific students. The sample size of 30 schools is expected to give an average of approximately 40 students within each cluster resulting in approximately 1000 study participants after allowing for non-response from schools that decline to participate (Ministry of Education, 2010). This sample should be large enough to detect differences between groups.

Data collection tools

A self-complete paper questionnaire will be used to assess knowledge of emergency contraception. The questionnaire will be adapted from a questionnaire used in a previous study to assess knowledge of emergency contraception amongst university students (Calabretto, 2009). Items to assess knowledge of existence of emergency contraception, timing of use, where it is available and side effects will be included. Similar items have been used to assess knowledge of emergency contraception amongst adolescents in previous studies (Ahern, Frattarelli, Delto, & Kaneshiro; Graham, Green, & Glasier, 1996). A closed-response format will be used with respondents choosing from ‘true’, ‘false’ or ‘don’t know’. Items will also be included to assess participant’s sexual activity and contraceptive habits. These items will be in a yes/no format. Other items will assess whether the participant has ever experienced a contraceptive failure and whether they accessed emergency contraception.  Demographic information will be collected, including age and ethnicity. The questionnaire will be piloted to ensure acceptability of items by the target population.

Data collection procedures

Data will be collected in a classroom setting at the participant’s own school, during the course of the school day. Information about the study will be distributed to participants and written consent obtained prior to visiting schools. The researchers will visit schools during the course of a school day. A classroom will be set aside for the completion of the questionnaire. Students will complete the questionnaire in groups of up to 20 to allow for space between seats. In schools with a large number of participants, more than one session will be required to complete all questionnaires. Before completion of the questionnaire, the confidential nature of the research will be emphasized and participants will be informed that they are not required to complete the questionnaire if they do not wish to do so. Questionnaires will be completed in silence under exam conditions. Participants will then be instructed to fold their questionnaire in half and return it to a collection box. On completion of the questionnaire, participants will be given correct information about emergency contraception and be directed to the New Zealand Family Planning website for young people (www.theword.org.nz) for further information about other contraceptive methods.

Analysis

Data will be analyzed using statistical analysis software such as SPSS. Methods of analysis will include the Pearson Product-Moment Correlation Coefficient to test the relationship between knowledge of emergency contraception and frequency of use following contraceptive failure, and regression analysis to test the impact of variables such as age and ethnicity. No difference tests will be performed as the purpose of the study is not to compare groups.

Qualitative methods

Data source

Qualitative data will be collected by conducting individual interviews. One-on-one interviews will provide a setting that promotes confidentiality which is particularly important due to the sensitive nature of the data being collected. Interviews will provide data on participant’s personal experiences surrounding unprotected intercourse or contraceptive failure and the reasons they may have used or not used emergency contraception. This data will help identify whether knowledge of emergency contraception is a barrier to use or whether other barriers are more commonly reported.  

Sample

The sampling units will be students who have completed the questionnaire and who indicated in the questionnaire that they are sexually active and have experienced contraceptive failure will be eligible for participation in interviews. A purposive sampling method will be used to select participants who did and did not use emergency contraception following contraceptive failure, with varying levels of knowledge as measured by the questionnaire and participants from different ethnic groups.  Interviews will continue until data saturation point is reached.

Data collection tools

Interviews will be in a semi-structured format. Participants will be asked to describe the situation or situations which led to contraceptive failure and whether they used emergency contraception. Participants who did use emergency contraception will be asked what they knew about it at the time and where they had heard about it. Participants who did not use emergency contraception will be asked about what they knew about emergency contraception at the time and the reasons they did not access it.

Data collection procedures

Interviews will take place in five different schools around the Auckland region to minimize inconvenience to participants. Participants will be interviewed in the afternoon after school finishes in a setting that promotes confidentiality such as a counsellor’s room. Written consent will be obtained prior to the interview date. Data from interviews will be collected in both written and audio format. Recording equipment will be checked and participant information will be recorded prior to each participant entering the room. Before the interview begins, participants will be welcomed, the researcher will be introduced, participant details will be confirmed with the participant, and the confidential nature of the interview will be emphasized. The interview will be conducted based on the interview schedule. On completion of the interview, the participant will be thanked and reminded how the information they have given will be used.

Methods of Analysis

Data will be transcribed and analyzed using thematic analysis. The purpose of this analysis is to understand the factors that may influence whether an adolescent girl may or may not use emergency contraception following a contraceptive failure and how these factors vary with varying levels of knowledge of emergency contraception. 

Ethical Issues

Respect for persons

Participants will be provided with the required written information about the study prior to giving consent before the study begins. Voluntariness will again be emphasized immediately before completion of questionnaires and interviews. 

Beneficence/Non-maleficence

Following completion of questionnaires, all participants will be informed of the correct usage of emergency contraception and where it can be accessed. Participants will also be given brief information about the importance of having a regular contraceptive method and directed to the Family Planning website for young people (www.theword.org.nz) for more information. This is to prevent possible harm as a result of poor knowledge of contraception and to provide participants with a direct personal benefit. The potential benefits of this study include a better understanding of how knowledge impacts on access to emergency contraception, which could result in improved access for young people and the prevention of unwanted pregnancies.

The potential harms in this study are minimal. Possible harmful impacts that participants may face include social impacts such as embarrassment or teasing that a participant may experience if confidentiality is not maintained. Every effort will be made by the researcher to maintain confidentiality.

Justice

No group within the population of Auckland school girls is systematically included or excluded without cause from this study. School principals have the opportunity to decline to participate if they feel participation in the study will place undue burden on their students.

Bibliography

Ahern, R., Frattarelli, L. A., Delto, J., & Kaneshiro, B. Knowledge and Awareness of Emergency Contraception in Adolescents. Journal of Pediatric and Adolescent Gynecology, 23(5), 273-278.

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

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.

Dickson, N., Sporle, A., Rimene, C., & Paul, C. (2000). Pregnancies among New Zealand teenagers: Trends, current status and international comparisons. New Zealand Medical Journal, 113(1112), 241-245.

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.

Graham, A., Green, L., & Glasier, A. F. (1996). Teenagers' knowledge of emergency contraception: Questionnaire survey in south east Scotland. British Medical Journal, 312(7046), 1567-1569.

Johnson, R., Nshom, M., Nye, A. M., & Cohall, A. T. 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.

Major, B., Appelbaum, M., Beckman, L., Dutton, M. A., Russo, N. F., & West, C. (2009). Abortion and Mental Health: Evaluating the Evidence. American Psychologist, 64(9), 863-890.

Ministry of Education. (2010). July School Roll Return.   Retrieved 9th October, 2010, from http://www.educationcounts.govt.nz/data_collections/july_school_roll_return#key

Ministry of Health. (2001). Sexual and Reproductive Health Strategy. Wellington: Ministry of Health.

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.