Knowledge and Attitudes of Emergency Contraception among Medical Science Students

Introduction:

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.

 METHODS

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

RESULTS:

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

 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

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).

 DISCUSSION

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.

Conclusion

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.

Acknowledgements

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.