1Department of Midwifery, School of Nursing and Midwifery, Shahrekord University of Medical sicenses, Shahrekord, Iran
21Department of Midwifery, School of Nursing and Midwifery, Shahrekord University of Medical sicenses, Shahrekord, Iran.
Background: Emergency contraception (EC) has been available in Iran, however there has been little research into the extent of knowledge of the actions, effectiveness and attitudes of students about it .The aim of this study was to detect the Knowledge and attitudes of university students towards emergency contraception . Methods: A survey of 130 university students was conducted at Shahrekord university of Medical Sciences in Iran during the 2009- 2010 . A predesigned questionnaire was distributed to students who had passed the family planning subject and asking about their knowledge and attitudes towards emergency contraception. Findings: Ninety-four of students had heard of emergency contraception . About of 85% of them, explained the contraceptive pills and 10% stated the intra uterine device (IUD) for EC . Seventy-one percent didn,t know the mechanism of action of EC pills and 29% believed that EC worked by disrupting a newly implanted ovum and would interrupt an ongoing pregnancy. Kind of method was reported OCP in 85.2%, OCP and IUD in 5.3% of students . Finally, The awareness of students was insufficient in 15.4% of them. 76.9% of them had moderate and 7.7% had sufficient knowledge . More than 80% of students had positive attitudes towards emergency contraception . Conclusion: The level of knowledge in university students' about emergency contraception was low and there is a clear need for ECP as a pregnancy prevention method among university students and for better education about it with considering the details for each method and insertion of IUD for emergency contraception .
One of the issues in primary health care, is family planning which plays an effective role in the reduction of unwanted pregnancy (1). Unwanted pregnancies is a major public health problem in the developed and developing countries(2). About 3 million unwanted pregnancies occur in the United States. Most of these are resulted from not using contraception or noticeable contraceptive failure, (such as broken condom) which could be prevented with the use of EC (3) .In 2004, there were nearly 6.4 million pregnancies in the United States; 1.22 million ended in abortion . The greatest number of unintended pregnancies and induced abortions occur in women between the ages of 18 and 30. In 2001, it was estimated that 79% of pregnancies occurring in 18- to 19-year-olds were unintended, as were 60% in 20- to 24-year-olds (4) . Among the contraceptive methods, emergency contraception (EC) is a method of contraception that can be used to prevent pregnancies after an unprotected act of sexual intercourse(3). With using emergency contraceptive methods, the risk of pregnancy can be reduced to 75 to 99.9%(5) . Emergency contraceptive methods are convenient and the majority of women accept them . WHO reported no contraindication for EC and there are any reports for their teratogenicity in the failure of them(6,7). Emergency contraception or postcoital contraception provides an additional support whenever there is a breach in the Regular contraceptive use. A number of studies are available from the west regarding the use of emergency contraception (2). The main reasons for needing emergency or postcoital contraception are the non-use of condom, condom breakage, coitus interrupts and rhythm methods (5). Knowledge and attitudes of medical students in the given health care is important . One study reported that seventy-four percent of the students had heard of emergency contraception (EC); however, less than one-third knew the prescription status, common side effects or mechanisms of ECP (8). Another study reported that the awareness and knowledge of EC was low among the students of Mersin University in Turkey and the males are less aware about EC when compared to females(9). In recent years, the family planning subject Has been entered the school based curriculum in all of university courses. Medical students due to the nature of courses should be aware of contraceptive methods until they are able to consult with clients about the family planning. In addition, they are in reproductive age and recognition of contraceptive methods, especially emergency contraception is necessary for them. Although the EC is safe and effective, but the use of this method is low and this ratio in Tehran was 5.2% (7) . Regarding the ethical considerations in relation to abortion in Iran, emergency contraception is the only legal method for the prevention of unwanted pregnancy and medical students should be aware of this . The aim of this study was to detect the knowledge and attitudes of university students about EC in Shahrekord University Of Medical Sciences from 2009 to 2010.
A descriptive cross-sectional study on knowledge and attitudes about emergency contraception was conducted among 130 of nursing, midwifery, health and paramedical students in last year of education, who had passed the Population and Family Planning Course in Shahrekord University Of Medical Sciences. The guest and transfer students due to special conditions, were excluded from the study. The 36-item survey instrument used for this study was developed by the author, based on results of a previous study (10) . The current survey instrument comprised eight demographic items, eleven knowledge items , fifteen attitude items and one information resource item . The awareness of students was classified in to low, moderate , and high and a Likert scale was used to assess the attitudes of students with which positive, disorderly, and negative attitudes were detected. The validity of the questionnaire was detected by content validity and its reliability was determined by Alpha-Cronbakh (r=0.82) .Cronbach's alpha is “a measure of internal consistency, which expresses how closely a set of items are related as a group. A ‘high’ value of alpha is often used as a piece of evidence that the items measure an underlying (or latent) construct. A reliability coefficient of .70 or higher is considered ‘acceptable’ in most social science research situations” (7) . Data was collected in person by the researcher. After the permission was granted from each class professor, the researcher asked the students for their participation in the study. The researcher distributed the survey instrument and an informed consent form among all participants. The participants were reminded that participation in the study was voluntary and anonymous and were then instructed to sign the informed consent form and to complete the survey instrument if they agreed to participate in the study. The letter of approval from a Human Subjects Committee :The Institutional Review Board of University Medical Center of Shahrekord approved the study protocol and all subjects gave written informed consent . Data was analyzed using SPSS 16.0 for Windows and P
We distributed a total of one-hundred-thirty questionnaires among female students. All of them agreed to participate in the study and completed the questionnaire. The average age of participants was 22.3±2 , although respondents ranged in age from 19 to 32, all of them were in the third or fourth year of study . Seventy-two percent of participants were nursing students, 12.3% were midwifery students, 4.5% were operation room students, 8.5% were paramedical students, and 3.1% were health students .The majority of respondents (95.4%) reported that they had heard of emergency contraception previously . Kind of method was reported oral contraceptive pills (OCP) in 85.2%, OCP and intra uterine device (IUD) in 10.1% of students . OCP and Depo-Medroxy –Progesteron Acetate (DMPA) in 4.7% of students . Only 48.5% of students knew that a woman must take the first dose within the first 72 hours after unprotected sex and more of them believed a woman had little time after unprotected sex to initiate ECPs . Regarding the number of high-dose pills (HD), 59.2% of students reported taking 2 pills at first and repeating after 12 hours and others answered incorrectly. About the number of low dose pills (LD), 54.6% of students reported 4 pills at first and repeating after 12 hours and others answered incorrectly . In about of distance between two doses of pills, 57.7% of participants reported the 12 hours and others didn’t know . The adverse effects of emergency pills that the students related to EC, were nausea and vomiting, vaginal bleeding, obesity, infertility and increasing the weight. Seventy-One percent of students didn’t know the mechanisms of the action of emergency contraceptive pills and 29% believed that EC worked by disrupting a newly implanted ovum and would interrupt an ongoing pregnancy. About intra uterine device (IUD), for emergency contraception, nearly 90% of students were not aware of this method and only 10% of them knew this. Among those, 3.8% said 3 days, 2.3% reported 7 days and 1% reported 5 days for insertion of IUD after unprotected sex. About the mechanism of the action of IUD, deteriorating the endometrial was reported by 4.6%, prevention of fertilization was reported by 2.3% of students and others didn’t answere the question. Regarding the other benefits of IUD, except the emergency contraception, 3.1% of participants believed that the woman can keep the device to prevent pregnancy all the time, 3.1% reported that the this method does not have not the adverse effects of pills. Finally, the knowledge of students about EC was insufficient in 15.4% of students, moderate in 76.9% ,and sufficient in 7.7% of students. Mean and standard deviation of knowledge was 4.6±1.8 in Nursing students, 6.6±1.4 in Midwifery students, 3.2±2.2 in Paramedical students, and 5.9±0.2 in Health students and in Operation Room students was 2.7±1.5. The awareness of students based on different courses which are shown in table I .
Table I. The awareness of students about the emergency contraception in different courses
Operation Room students
There was no significant association between the knowledge of emergency contraception and age of respondents and the year of study. A significant correlation was found between the course and the knowledge of participants. The Midwifery students had the most and the Operation Room and Health students had the least knowledge about the emergency contraception (P=0.003). The attitudes of participants about the emergency contraception are shown in table II.
Table II. The attitudes of participants towards emergency contraception
EC must be educated to all woman
EC must be considered to abortion
Adverse effects must be doubted in using of EC
EC has ethical problems
EC is ideal for woman who have no contraception
EC didn’t have enough certainly
If within the use of EC, pregnancy occurred, it is tetragon for fetus
EC is inexpensive
EC is convenience and possible without referring to physician
EC encourage the non-responsible behavior
EC doesn’t prevent the transmitted infections
I like use of EC
If pregnancy occurred during use of EC , abortion must be considered
The majority of students first learned about the emergency contraception from a variety of sources, including population and family planning subject (56.2%), family planning subject and clinical education (18.5%), health care providers (6.2%), and family members and friends (6.4%) and other sources. To detect the association of knowledge and attitudes of students, knowledge was classified in to adequate and in-adequate and the findings showed a significant association between the knowledge and attitudes of university students towards emergency contraception and those with adequate knowledge, generally showed favorable attitudes regarding emergency contraception (P<0.05).
Although emergency contraception (EC) has been available in Iran, there remains clear evidence of the need for continued health education about EC. Findings from this study support those from previous studies on emergency contraception knowledge and use to show that, although most university students had heard of ECP, they generally lack sufficient knowledge about what it is, and how it works (10 11, 12) . The results for the knowledge questions indicated that the students of Shahrekord University Of Medical Sciences have a moderate of knowledge about emergency contraception. These findings are similar to the findings from Faraj Khoda and et al . In their study the awareness of students in medical university in Yazd was adequate in 30.7% and moderate in 50% of students (13). Khalid and et al. reported that most of the students have enough awareness about emergency contraception (14).In Pakistan, Abdulghani and et al. reported that the majority of gynecologists, general physicians, and medical students have little knowledge of emergency contraception(15). Since all of contraceptive users can’t use oral contraceptive pills for emergency contraception , the use of intra uterine device (IUD) is an ideal method for EC. However a woman must take the pills in the first 72 hours after unprotected sex, the use of IUD is possible in the first 5 days after unprotected sex (5), thus the awareness of students of this method is necessary . In the present study less than half of the participants failed to identify the correct time frame for which ECP should be taken to be effective . This is particularly troublesome , given that efficacy is higher the earlier that ECP is taken, and that the effectiveness of ECP is markedly decreased after 72–120 h (16, 17, 18) . Awareness of the correct time frame for which ECP should be taken to be effective was 28% .In Khalid study (14), 9% in Foster study (19) and 38% in Takker study (20). Almost 80% of the students did not know how ECP actually worked, and two-third of them failed to identify the most common side effects or the effectiveness rate of ECP. The adverse effect of OCP pills are different, but the most common is nausea and vomiting that could be resulted to dis-continue the second dose ,and thus the effectiveness is reduced(5,21). For this reason some of physicians usually administer the anti-emetic drugs (5). In Graham’s study, the adequate knowledge of side effects of OCP was reported 59% (22), Faraj-Khoda and et al. reported 39.2% (13) . This difference maybe due to the fact that students were in first and second year of study. For example in Khalid’s study, most of respondents were in their first or second year of study (14) and in the present study, most of students were in their third or fourth year of study and their awareness was greater. In the present study most of the respondents knew the correct number of contraceptive pills which could be used for emergency contraception. Faraj-Khoda and et al. reported similar findings(13). In our study however, 90% of students were aware of emergency contraception, but only 10% of them knew about the intra uterine device (IUD) for EC, the mechanism of action and other benefits except the emergency contraception . Since all of the contraceptive users can not use the OCP for emergency contraception due to adverse effects, use of IUD is ideal method for them. Other studies have reported that the most of health care providers are not aware of IUD for emergency contraception (8). More than 80% of respondents had positive attitudes to EC and believed that is necessary to educate women about this method, emergency contraception are not abortion and women must not doubt in using them. In Khalid’s study, more than 50% of students described ECPs “a good method” (14). Positive attitudes toward emergency contraception were reported 61% in Jamaly’s study (8). Faraj-Khoda et al. also reported that 100% of married students and their partners had positive attitudes to EC (13). In the present study, approximately 75% of students obtained information about EC from the school-based curriculum, 20% from health care providers, and 5% from friends and family members. These findings are similar to the other studies (23, 24, 25) . There were several limitations to this study that could affect the validity of the findings. The participants of this study consisted a convenience sample of students and may not reflect the knowledge or opinions of university students in general. A second limitation is that of any survey research, as the results of this study are dependent on the accuracy of the participants' responses, and response or recall bias is certainly a possibility.
This study indicated that university students have low practical knowledge about emergency contraception pills, how they work, and how effective they are Nonetheless, many students had incorrect information about important specific details of the method such as its time frame, effectiveness, mechanism of action, and adverse effects. We recommend the better educational program about emergency contraception with clear detailed information for each method and insertion of IUD for EC. Strategies to promote the awareness of EC should focus on spreading accurate information through informational sources, which have been found to be reliable and associated with good knowledge on emergency contraceptive methods.
The authors would like to thank Deputy of Research Affairs of Shahrekord University Of Medical Sciences and the students who tooke part in the study.
1 -Byamugisha JK, Mirembe FM, Faxelid E, Tumwesigye NM, Gemzell-Danielsson K. A randomized clinical trial of two emergency contraceptive pill regimens in a Ugandan population. Acta Obstet Gynecol Scand 2010; 89(5): 670-6.
2-Tilahun D, Assefa T, Belachew T. Knowledge, attitude and practice of emergency contraceptives among Adam university female students. Ethiop J Health Sci 2010; 20(3): 195-202.
3-Tajure N, Pharm B. Knowledge, attitude and practice of emergency contraception among graduating female students of jimma university, southwest ethiopia. Ethiop J Health Sci 2010; 20(2): 91-7.4-Hickey MT. Female college students' knowledge, perceptions, and use of emergency contraception. J Obstet Gynecol Neonatal Nurs 2009; 38(4): 399-405.
6-Ragland D, Payakachat N, Ounpraseuth S, Pate A, Harrod SE, Ott RE. Emergency contraception counseling: An opportunity for pharmacists. J Am Pharm Assoc 2011; 51(6): 756-61.
7-Miller LM. College student knowledge and attitudes toward emergency contraception . Contraception 2011; 83(1): 68-73.
8-Jamili B, Azimi H. Knowledge attitude and practice of practitioners and midwives working at health centers of main cities of Mazandaran province about emergency contraception. Journal of Mazandaran University of Medical Sciences 2007; 17(57): 75-81. [In Persian].
9-Yapici G, Oner S, Sasmaz T, Bugdayci R, Kurt AO. Awareness of emergency contraception among university students in Mersin, Turkey. J Obstet Gynaecol Res 2010; 36(5): 1087-92.
10-Sawyer RG, Thompson E . Knowledge and attitudes about emergency contraception in university students. Coll Stud J 2003; 37: 523-30.
11-Vahratian A, Patel DA, Wolff K, Xu X. College students' perceptions of emergency contraception provision. J Womens Health 2008; 17: 103-11.
12-Evans E, Patel M, Stranton D. Student pharmacist knowledge and attitudes regarding oral emergency contraception .J Am Pharm Assoc2007; 47: 711-16.
13-Farajkhoda T, Enjezab B, Bokaie M. Educational needs of medical science students about emergency contraception. Iranian journal of medical education 2002; 2: 23. [In Persian].
14-Khalid AK, Abd Halim H, Kenny L. Usage of emergency contraception between medical related and non-medical related students. Ir Med J 2009; 102(4): 104-8.
15-Abdulghani HM, Karim SI, Irfan F. Emergency contraception: Knowledge and attitudes of family physicians of a teaching hospital, Karachi, Pakistan. J Health Popul Nutr 2009; 27(3): 339-44.
16-Wertheimer RE. Emergency postcoital contraception. Am Fam Physician2000; 62: 2287-92.
17-Grimes DA, Raymond EG. Emergency contraception. Ann Intern Med 2002; 137: 180-9.
18-Allen RH, Goldberg AB. Emergency contraception: A clinical review. Clin Obstet Gynecol; 2007: 50: 927.
19-Foster DG, Ralph LJ, Arons A, Brindis CD, Harper CC. Trends in knowledge of emergency contraception among women in California, 1999-2004. Womens Health Issues 2007; 17(1): 22-8.
20-Takkar N, Goel P, Saha PK, Dua D. Contraceptive practices and awareness of emergency contraception in educated working women. Indian J Med Sci 2005; 59(4): 143-9.
22-Graham A, Moore L, Sharp D, Diamond I. [Improving teenagers' knowledge of emergency contraception: cluster randomised controlled trial of a teacher led intervention]. BMJ 2002; 324(7347): 1179.
23-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(4): 261-8.
24-Addo VN, Tagoe-Darko ED. Knowledge, practices, and attitudes regarding emergency contraception among students at a university in Ghana. Int J Gynaecol Obstet 2009; 105(3): 206-9.
25-Kebede Y. Emergency contraception: knowledge and practice of Gondar University students, northwest Ethiopia. Ethiop Med J 2006; 44(3): 221-30.