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Contraception failure--what remains to be done? Knowledge and attitudes regarding the use of emergency contraception among Austrian women and men during reproductive phase.

INTRODUCTION

Effective hormonal methods for preventing pregnancy after unprotected intercourse are known since the early seventies of the twentieth century. In 1974 Yuzpe et al published a pilot study in which the effectiveness of the application of two doses of ethinylestradiol and levonorgestrel within 72 hours after the unprotected intercourse was described. (1) Today emergency contraception (EC) is available in many countries and represents an important contraceptive option because it is the only form of hormonal contraception that can reduce the risk of pregnancy after unprotected intercourse or when a planned contraceptive method fails. (2,3) However, emergency contraceptives remain relatively unknown and are discussed controversially in many countries. (4-10) Several factors are thought to contribute to the low awareness und restricted utilization of EC, including a lack of knowledge and the requirement for a prescription. (11-13) In several countries such as Sweden, France, Norway, Portugal, South Africa and the United Kingdom, EC has been reclassified to a non-prescription drug and is available as an over the counter product. (14)

In Austria emergency contraception, also called "morning after pills" is available since 2000, a prescription of a physician or an outpatient department of a hospital is still required. In 2005, the Austrian Ministry for Health permitted pharmacists to sell EC over- the- counter in cases that it would be impossible for women to get a prescription in time, such as during weekends or night hours. The supporters of the reclassification of emergency contraceptives to non-prescription drugs are not satisfied with this change. They still claim that emergency contraceptives should be available over-the-counter for all women every time. But what do Austrian women and men of reproductive age think and know about EC?

The main purpose of this study was to assess the knowledge about EC and attitudes about using EC among Austrian women and men of reproductive age.

METHODS

Subjects

In total 349 subjects ranging in age between 17 and 39 years (x=24.8 +/- 4.3) were enrolled in the present study. The sample comprised 247 female participants ageing between 17 and 39 years (x=24.1 +/-3.9) and 102 male participants ageing between 19 and 39 years (x=26.4+/- 4.7). The recruitment of the study participants took place at the University of Vienna and via the snowball system. All participants originated from Austria. The majority of them were unmarried (more than 90%) and childless (about 90%). Nearly the 80% of the respondents were University students or had already completed their studies.

Questionnaire

The questionnaire was developed by the authors based on the 2003 Henry Kaiser Family Foundation (KFF) Survey. (15) The questionnaire was divided into two parts. The first part comprised questions regarding socioeconomic parameters such as educational level, professional training and marital status. Additionally, a reproductive history and the participants' experience with contraception were documented. The second part included 34 multiple choice questions on the knowledge and attitudes towards emergency contraception (EC). The study was conducted in compliance with the "Ethical principles for medical research involving human subjects" of Helsinki Declaration.

Statistical analysis

Statistical analyses were carried out using SPSS for Windows version 15.0. Also, [chi square] tests were computed to calculate group differences with respect to their statistical significance. Additionally, regression analyses were performed to assess the impact of sex, age, educational level, religion, knowledge and previous experiences with EC on attitudes against EC. The critical value for testing significance was p <0.05.

RESULTS

The socio-demographic characteristics of the respondents are shown in table 1.

Knowledge of emergency contraception

The 100% of the female and 98% of the male respondents reported that they have heard of emergency contraception before. Although nearly all respondents have already heard of EC, only 83.4% of the female and 64.7% of the male subjects know that EC is legal available in Austria. How EC is available in Austria was correctly answered by only 54.3% of the female and 36.3% of the male respondents. While 100% of the female and 93.1% of the male respondents know the recommended timing of emergency contraception, only 12.7% of the female and 8.2% of the males gave correct answers regarding the mechanism of action of EC. Up to which week of gestation an induced abortion is legal in Austria, this was correctly answered by the 84.6% of the female and the 67.6% of the male subjects. Only a 48.6% of the female and a 21.6% of the male respondents know that the emergency contraception and the abortion pill RU-486 are different ways to interrupt pregnancy (for more detailed information see table 2).The sources of information regarding EC are listed in table 3.

Experience of emergency contraception

The 30% of the female respondents have previously used emergency contraception of whom, the 5.7% has used the method more than once. Women younger than 30 years were more frequent users than women older than 30 years (31.1% versus 18.1%). The 22.2% of the male subjects reported that their partner had used EC previously. Individual experiences with EC were documented for female subjects only. The 86.4% of women with EC experience was satisfied with the effect of EC. Only a 24.2% reported side effects such as nausea (10.8%), depressive disorder (9.5%) or abdominal pains (8.1%). The 16.2% (n=12) reported that they suffered from a sense of guilt after using EC.

Attitudes towards EC

Attitudes towards EC are listed table 5. Significantly more female respondents (11.7%) reported ethical or religious doubts for the use of EC. This was only true for the 3.0% of the male respondents. In contrast, more male respondents interpreted EC as a kind of induced abortion (15.7% versus 13.8% in women). This difference however was not of statistical significance. Nevertheless, significantly more male subjects think that EC should be available as a prescription free over-the-counter product (32.7% versus 30.0%). Significantly more men regarded contraception as an exclusively female task, 3.0 versus 0.4%. Only few factors influencing attitudes towards EC were identified (see table 6). Sex and the opinion that "EC and induced abortion are the same thing" were related significantly with ethical or religious doubts against EC. Neither religion nor age, educational level or the previous experience with EC influenced the attitudes towards EC significantly.

DISCUSSION

The awareness about emergency contraception is extremely high among the respondents of the present study although not only University students were included in the sample. All women and 98% of the men who participated have already heard about emergency contraception. This percentage is extremely high and only comparable to the results of a Finnish study, which yielded an awareness of 100% of EC among teenage girls. (16) Other comparable studies yielded lower or much lower percentages of ever hearing about EC. (4,13,17) A relatively high frequency of awareness of EC (94%) was reported by Vahratian et al (18), who analyzed students at the University of Michigan and by Corbett et al (19) who reported that the 96% of a college student population had heard about EC previously. Extremely low is the awareness of EC even among students in African countries and India. (20-23)

Regarding knowledge it turned out, that in the present study, men were generally less well- informed about EC. Although nearly all respondents have previously heard about EC and all women and more than 90% of the men know the recommended timing of EC, only the 12.7% of women and the 8.2% of men know how emergency contraception prevents pregnancy. Furthermore, there is a lack of knowledge regarding the availability of EC in Austria. Again men are themselves hesitant to be informed on contraception issues. Furthermore nearly 50% of the male participants were not aware of the high- risk period for pregnancy during the menstrual cycle. Interestingly, this also happened to almost a 20% of the female sample. This lack of knowledge is in accordance with the results of others studies. (20,21,24)

The general lack of knowledge may be attributed to the sources of information. Both sexes reported that media, school and friends were the main sources of information. The gynaecologist or physician was considered information source only by a minority of respondents. This observation is also in agreement with those of previous studies. (5,6,21) Nevertheless, the amount of women who had personal experience with the use of EC was rather high. The 30 % of the female respondents used EC in the past, although EC is not available over the-counter in Austria.

The use of EC was not statistically associated with age, educational level and religion. The majority of women who used EC were satisfied with EC and did not suffer from a sense of guilt. Side effects were also only reported by a minority of women. Regarding attitudes towards EC, male and female respondents differ significantly. In particular, more female respondents reported ethical or religious doubts against EC.

Focusing now to the initial question: should be EC available over- the- counter in Austria, as recommended by several gynaecologists and women's health centres in Austria? As indicated out in the introduction section in Austria EC is available over- the- counter, only during night hours or weekends, when women who forgot to use a contraceptive have no access to a gynaecologist or a hospital outpatient department. In this case, it depends on the pharmacist whether EC is sold over- the- counter without prescription or not.

Furthermore, it was reported that physicians have refused to write a prescription for EC because of moral or religious doubts. There is no doubt that this situation is a very unsatisfying one. Therefore women's health centres and some gynaecologists demand a new, more liberal, regulation of EC distribution. In the present study, about 30% of the respondents have previously used EC nevertheless more than 50% of the respondents confused EC with abortion pills, a misconception that was found in many previous studies and which seems difficult to change. (14,25)

Regarding the question if EC should be available as non prescription drug over-the- counter in Austria about 30% of female as well as male respondents agreed. Significantly more women were against this idea, 57.1% versus 40.6% of men. Significantly more men than women had no opinion to this question 26.7% versus 13.0%. The attitude towards EC available over -the- counter was not significantly influenced by religion, educational level, age or experience with EC. Only a third of the respondents plead for a prescription free availability of EC in Austria. In a Swedish study all participants appreciated an over the counter availability of EC, however this investigation was performed after EC was approved as an over- the- counter product. (14) Apparently, much more women would appreciate an over- the-counter availability of EC in Austria, when this possibility would be legal. On the other hand a more detailed information campaign would improve knowledge and attitudes towards EC, because we found a high frequency of misconceptions and a lack of knowledge concerning EC in our sample. Although this study has limitations such as the relatively small sample size and especially the small number of male respondents, it may initiate further discussion concerning EC in Austria and other countries as well.

ACKNOWLEDGEMENTS

The authors would like to express their gratitude to the participants of the study.

Conflict of interest: None declared

REFERENCES

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(2.) Trussell J, Ellerson C, Dorflinger L. Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action Contraception 2003;67:167-171.

(3.) Black KI. Developments and challenges in emergency contraception. Best Pract Res Clin Obstet Gynecol 2009;23:221-231.

(4.) Baldwin SB, Solorio R, Washington DL, Yo H, Huang YC, Brown ER. Who is using emergency contraception? Awareness and use of emergency contraception among Californias women and teens Women's Health Issues 2008; 18: 360-368.

(5.) Campbell JW, Busby SC, Steyer TE. Attitudes and beliefs about emergency contraception among patients at academic family medicine clinics. Ann Fam Med 2008; 6: 23-27.

(6.) Gee RE, Delli-Bovi LC, Chuang CH. Emergency contraception knowledge after a community education campaign. Contraception 2007;76:366-371.

(7.) Wallace JL, Wu J, Weinstein J, Gorenflo DW, Fetters MD. Emergency contraception: Knowledge and attitudes of family medicine providers Fam Med 2004;36: 417-422.

(8.) Williamson LM, Buston K, Sweeting H. Young women's perceptions of pregnancy risk and use of emergency contraception: finding from a qualitative study. Contraception 2009;79: 310-315.

(9.) Soon JA, Meckley LM, Levine M, Marciante KD, Fielding DW, Ensom MHH. Modelling costs and outcomes of expanded availability of emergency contraceptive use in British Columbia. Can J Clin Pharmacol 2007; 14: 326.338.

(10.) Kavanaugh ML, Schwarz EB. Counselling about and use of emergency contraception in the United States. Perspect Sexual Reprod Health 2008;40: 81-86.

(11.) Konsunen E, Sihvo S, Hemminki E. Knowledge and use of hormonal emergency contraception in Finland. Contraception 1997; 55: 153-157.

(12.) George J, Turner J, Cooke E, Hennesey E, Savage W, Julian P, Cochrane R. Women's knowledge of emergency contraception. Brit J Gen Practice 1994; 44: 451-454.

(13.) Foster DG, Ralph LJ, Arons A, Brindis CD, Harper CC. Trends in knowledge of emergency contraception among women in California, 1999-2004. Women's Health Issues 2007;17:22-28.

(14.) Aneblom G, Larsson M, von Essen L, Tyden T. Women's voices about emergency contraceptive pills "over-the-counter": a Swedish perspective. Contraception 2002;66:339-343.

(15.) Salganicoff A, Wentworth B, Ranji U. Emergency contraception in California. The Henry J.Kaiser Family Foundation Survey,2004.

(16.) Falah-Hassani K, Kosunen E, Shiri R, Rimpela . Emergency contraception among Finnish adolescents: awareness, use and the effect of non-prescription status. BMC Public Health 2007;7: 201-213.

(17.) Sorhaindo A, Becker D, Fletcher H, Garcia SG. Emergency contraception among university students in Kingston, Jamaica: a survey of knowledge, attitudes and practices. Contraception 2002;66: 261-268.

(18.) Vahratian A, Patel DA, Wolff K, Xu X. College students perceptions of emergency contraception provision. J Women's Health 2008;17: 103-111.

(19.) Corbett PO, Mitchell CP, Taylor JS, Kemppainen J. Emergency contraception knowledge and perception in a university population. J Am Acad Nurse Pract 2006;18:161-168.

(20.) Addo VN, Tagoe-Darko ED. Knowledge, practices and attitudes regarding emergency contraception among students at a university in Ghana. Int J Gynecol Obstet 2009;105:206-209.

(21.) Akani CI, Enyindah CE, Babatunde S. Emergency contraception: knowledge and perception of female undergraduates in the Niger delta of Nigeria. Ghana Med J 208;42:68-70.

(22.) Myer L, Mlobeli R, Cooper D, Smit J, Morroni C. Knowledge and use of emergency contraception in Western Cape province of South Africa: a cross-sectional study. BMC Women's Health 2007;7:14-20.

(23.) Puri S, Bhatia V, Swami HM, Singh A, Sehgal A, Kaur AP. Awareness of emergency contraception among female college students in Chadigarh, India. Ind J Med Sci 2007;61:338-346.

(24.) Kang HS, Moneyham L. Use of emergency contraceptive pills and condoms by college students: A survey. Int J Nurs Stud 2008;45:775-783.

(25.) Aneblom G, Larsson M, Odlind V, Tyden T. Knowledge, use and attitudes towards emergency contraceptive pills among Swedish women presenting for induced abortion. Br J Obstet Gynecol 2002;109:155-160.

Claudia Mayerhofer, Sylvia Kirchengast

Department of Anthropology, University of Vienna

Corresponding author: Sylvia Kirchengast, Department of Anthropology

University of Vienna

Althanstrasse 14

A-1090 Vienna, Austria

Email: sylvia.kirchengast@univie.ac.at
Table 1. Demographic characteristics of the study sample

Characteristic All subjects Males
 (n = 349) (n = 102)
 n (%) n (%)

Age (years)
< 30 a 307 (88.0%) 82 (80.4%)
30-40a 42 (12.0%) 20 (19.6%)

Highest level of education
Primary school 2 (0.6%) 1 (1.0%)
Professional training 30 (8.6%) 12 (11.8%)
College 240 (68.8%) 65 (63.7%)
University degree 41 (11.7%) 17 (16.7%)
Others 36 (10.3%) 7 (6.9%)

Religion
None 121 (35.0%) 40 (40.4%)
Roman-Catholic 202 (58.4%) 52 (52.5%)
Protestant 17 (4.9%) 6 (6.1%)
Others 6 (1.8%) 1 (1.0%)

Civil status
Single 111 (31.8%) 42 (41.2%)
Married 21 (6.0%) 7 (6.9%)
Unmarried, steady
relationship (> 1 year) 171 (49.0%) 40 (39.2%)
Unmarried, short 1
relationship (< 1 year) 46 (13.2%) 3 (12.7%)

Civil status
none 315 (90.5%) 86 (85.1%)
1 21 (6.0%) 9 (8.9%)
2 8 (2.3%) 5 (4.0%)
3 2 (0.6%) 1 (1.0%)
4 1 (0.3%) 1 (1.0%)
7 1 (0.3%) 0 (0.0%)

Characteristic Females Significance
 (n = 247)
 n (%)

Age (years)
< 30a 225 (91.1%) <0.01
30-40a 22 (8.9%)

Highest level of education
Primary school 1 (0.4%) n.s.
Professional training 18 (73%)
College 175 (70.9%)
University degree 24 (9.7%)
Others 29 (11.7%)

Religion
None 81 (32.8%) n.s.
Roman-Catholic 150 (60.7%)
Protestant 11 (4.5%)
Others 5 (2.0%)

Civil status
Single 69 (27.9%) n.s.
Married 14 (5.7%)
Unmarried, steady
relationship (> 1 year) 131 (53.0%)
Unmarried, short
relationship (< 1 year) 33 (13.4%)

Civil status
none 229 (92.7%) n.s.
1 12 (4.9%)
2 4 (1.6%)
3 1 (0.4%)
4 0 (0.0%)
7 1 (0.3%)

Table 2. Knowledge about EC: Absolute and relative
amount of correct answers according to gender

Knowledge All subjects Males
 (n = 349) (n = 102)

Heard of EC? 347 (99.4%) 100 (98.0%)

Is EC available 272 (77.9%) 66 (64.7%)
in Austria?

How is EC in Austria 171 (49.0%) 37 (36.3%)
available?

Know the mechanism 39 (11.4%) 8 (8.2%)
of action

Identifying the 342 (98%) 95 (93.1%)
recommended timing
of EC

Know when in the 256 (73.6%) 52 (51.5%)
menstrual cycles
risk/possibility of
pregnancy

Know how long 277 (79.6%) 69 (67.6%)
induced abortion is
legal in Austria

Is EC the same 142 (40.7%) 22 (21.6%)
like the abortion
pill RU-486?

Knowledge Females Significance
 (n = 247)

Heard of EC? 247 (100.0%) n.s.

Is EC available 206 (83.4%) < 0.001
in Austria?

How is EC in Austria 134 (54.3%) <0.001
available?

Know the mechanism 31 (12.7%) n.s.
of action

Identifying the 247 (100.0%) <0.001
recommended timing
of EC

Know when in the 204 (82.6%) <0.001
menstrual cycles
risk/possibility of
pregnancy

Know how long 208 (84.6%) <0.005
induced abortion is
legal in Austria

Is EC the same 120 (48.6%) <0.001
like the abortion
pill RU-486?

Table 3. Sources of information of EC by sex

Source All subjects Males
 (n = 349) (n = 102)
 n (%) n (%)

TV 72 (20.6%) 25 (24.5%
Media (incl Internet) 114 (32.7%) 26 (25.5%)
Friends 104 (29.8%) 18 (17.6%)
Relatives 21 (6.0%) 6 (5.9%)
School 83 (23.8%) 22 (21.6%)
Gynecologist 33 (9.5%) 5 (4.9%)

Source Females Significance
 (n = 247)
 n (%)

TV 47 (19.0%) n.s.
Media (incl Internet) 88 (35.6%) n.s.
Friends 86 (82.7%) <0.001
Relatives 15 (6.1%) n.s.
School 61 (24.7%) n.s.
Gynecologist 28 (11.3%) n.s.

Table 4. Experiences with ECP (females only)

Questions n (%)

Have you ever use EC? never 173 (70.0%)
 One 60 (24.3%)
 Several times 14 (5.7%)

Do you know somebody yes 155 (62.8%)
who has used EC? no 74 (30.0%)
 I don't know 18 (7.3%)

What was the reason for EC use? Contraception failure 58 (78.4%)
 unprotected intercourse 16 (21.6%)

Were you satisfied with EC Yes 64 (86.4%)
 No 5 (6.8%)
 I don't know 5 (6.8%)

Did you suffer from Yes 18 (24.2%)
side effects of EC? no 56 (75.8%)

Experienced side effects Nausea 8 (10.8%)
 Vomiting 0 (0.0%)
 Head aches 1 (1.4%)
 Depression 7 (9.5%)
 Abdominal pains 6 (8.1%)
 others 0 (0.0%)

Did you suffer from sense no 60 (81.1%)
of guilt? yes 12 (16.2%)
 I don't know 2 (2.7%)

Table 5. Attitudes towards contraception and EC
according to sex

Questions males females Significance
 n (%) n (%)

Would you have Yes 3 (3.0%) 29 (11.7%) <0.03
ethical or No 88 (87.1%) 200 (81.0%)
religious doubts I don't know 10 (9.9%) 18 (7.3%)
to use EC?

Should be EC be Yes 33 (32.7%) 74 (30.0%) <0.003
available over No 41 (40.6%) 141 (57.1%)
the counter? I don't know 27 (26.7%) 32 (13.0%)

Is EC an induced Yes 16 (15.7%) 34 (13.8%) n.s.
abortion? No 73 (71.6%) 189 (76.8%)
 I don't know 13 (12.7%) 23 (9.3%)

Should Yes 3 (3.0%) 1 (0.4%) <0.04
contraception be No 87 (96.0%) 246 (99.6%)
an exclusively I don't know 1 (1.0%) 0 (0.0%)
female task?

Table 6. Regression analyses

 Coefficient Significance 95% confidence
 interval

Ethical or religious doubts
 Sex -0.14 <0.01 -0.23-0.03
 Religion 0.05 n.s. -0.05-0.13
 Educational level 0.03 n.s. -0.09-0.14
 Age -0.03 n.s. -0.01-0.01
 Experience with EC -0.08 n.s. -0.09-0.01
 EC is a kind of induced 0.17 <0.001 0.06-0.23
 abortion

Should EC be available over the counter?
 Sex -0.06 n.s. -0.26-0.08
 Religion -0.05 n.s. -0.21-0.09
 Educational level -0.04 n.s. -0.25-0.12
 Age 0.04 n.s. -0.01-0.02
 Experience with EC 0.01 n.s. -0.08-0.09
 EC is a kind of induced 0.01 n.s. -0.13-0.16
 abortion

Is EC a kind of induced abortion?
 Sex -0.02 n.s. -0.15-0.10
 Religion -0.01 n.s. -0.12-0.11
 Educational level 0.03 n.s. -0.09-0.17
 Age 0.01 n.s. -0.01-0.01
 Experience with EC -0.06 n.s. -0.09-0.03
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Title Annotation:original article
Author:Mayerhofer, Claudia; Kirchengast, Sylvia
Publication:International Journal of Health Science
Article Type:Report
Geographic Code:4EUAU
Date:Apr 1, 2009
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