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ARTICLE |
a Division of Emergency Medicine
e Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
b Departments of Pediatrics
c Family Medicine and Community Health
d School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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PATIENTS AND METHODS. We conducted an in-depth, semistructured interview study of healthy, urban-dwelling, English-speaking 15- to 19-year-old black adolescents seeking care in a children's hospital emergency department. Purposive sampling was used to recruit sexually active and nonsexually active adolescents and those with and without a history of pregnancy. Enrollment continued until saturation of key themes was achieved. Participants returned after their emergency department visit for a 1-hour interview. The interview consisted of semistructured questions based on the theory of planned behavior constructs: attitudes (including knowledge), subjective norms, and perceived behavioral control, as well as demographic data collection. Interviews were recorded and transcribed. Transcripts were coded by 2 members of the study team by using a modified grounded-theory method.
RESULTS. Thirty interviews were required for saturation. Mean participant age was 16.4 years; 53% reported being sexually active, and 17% reported a history of pregnancy. Specific knowledge gaps exist about emergency contraception pills, including misconceptions about the recommended time frame for taking the medication. Several major themes were noted for each of the constructs. Intention to use emergency contraception pills is affected by the conflicting attitudes that the emergency contraception pill works faster than birth control pills and that those who use emergency contraception pills are irresponsible; family and friends are important influences and have uninformed but generally supportive opinions; and adolescents have a perception of limited behavioral control because of their young age and concerns about confidentiality.
CONCLUSIONS. Urban, minority adolescent girls have misconceptions about emergency contraception pills, are affected by the opinions of those close to them, and express concern about specific barriers. These findings can inform specific interventions aimed at addressing the barriers to emergency contraception pill use that are of most importance to this population of young women.
Key Words: adolescent pregnancy • interviews • contraception • urban • emergency department
Abbreviations: ECP—emergency contraception pill • TPB—theory of planned behavior • ED—emergency department • RA—research assistant • NSA—nonsexually active • SA—sexually active
Unintended teenage pregnancy is a major public health issue. Although the pregnancy rate among US teenagers has decreased in the last decade, it is still the highest of any industrialized nation, and the most recent birth data available suggest that this decrease has recently reversed.1 Each year, 
750000 young women between the ages of 15 and 19 years of age become pregnant.2 Furthermore, the proportion of teenage pregnancies that are unintended is much greater than the overall rate of unintended pregnancy (
80% vs 50%).3,4
Given the high prevalence and cost of adolescent pregnancy, developing interventions aimed to reduce unintended adolescent pregnancy has the potential to have a major impact on public health. One avenue for pregnancy prevention is the emergency contraception pill (ECP). Although the ECP is widely used in many other countries, many women in the United States, particularly adolescents, are unaware of this pregnancy prevention option. In addition to a lack of knowledge about the ECP5–8; studies suggest that additional barriers to its use exist, such as concerns about what others may think, concerns about adverse effects,9 and a perceived threat to the woman's "moral identity."10 To develop interventions designed to achieve increased use of the ECP in appropriate situations, which is consistent with the Healthy People 2010 goals,11 it is important to determine how best to structure and deliver messages about ECP. Effective communication must consider which fears, concerns, and misconceptions about ECP, as well as which specific knowledge gaps, should be addressed.
One conceptual framework that can be used to model this complex contraceptive decision-making process is the theory of planned behavior (TPB).12 The theory states that personal and social beliefs and values determine personal attitudes and perceived social expectations ("subjective norms") and that various additional factors can influence perceived behavior control. These attitudes, subjective norms, and perceived behavior control in turn influence behavioral intention, which then influences actual behavior. The TPB is a comprehensive model that has been assessed and validated for understanding a variety of health conditions, including rule following in homeless youth, promotion of physical activity, and healthy eating.13–16 More recently, the TPB has also been used to understand sexual risk behaviors in adolescents.17–19 The objective of this study was to use the framework of the TPB to explore the knowledge, attitudes, and beliefs of urban, minority adolescents about intention to use ECP and to identify barriers to ECP use.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Participants
Participants were selected for inclusion if they were girls between the ages of 15 and 19 years (inclusive); if they resided in 1 of the 11 zip codes surrounding the hospital; and if they were black and English speaking. These criteria were selected to reflect a somewhat culturally homogeneous population, given the potentially diverse range of opinions related to teen pregnancy and emergency contraception use, and to reflect the demographics of the population that lives around the hospital. According to 2000 US Census Bureau statistics, 60% of the population in these zip codes is black, and <13% speak a language other than English in the home.20 Participants were excluded if they were determined to be too ill by the treating physician, if they were being evaluated for a psychiatric complaint such as a suicide attempt, or if they had a chronic condition that could significantly impact reproductive decisions, such as significant developmental delay.
A purposive sampling method was used to balance the sample between young women who reported sexual activity and those who did not, as well as between those who had a history of pregnancy and those who did not. A goal was set a priori of 50% to 75% of the sample reporting a history of sexual activity and of 10% to 25% reporting a history of pregnancy, again to reflect the demographics of the adolescent population around the hospital. According to the 2003 Youth Risk Behavior Survey, 57% of Philadelphia high school girls reported having had sexual intercourse at least once; with respect to pregnancies, 10% of 15- to 19-year-olds in Philadelphia have a history of pregnancy.20,21 Participants were enrolled over a 6-month period until saturation of the key themes was achieved.
Trained research assistants (RAs) identified potentially eligible patients through the computerized ED tracking board, which logs information about all of the patient visits in real time, including age and zip code. Once a potential subject was identified, an RA determined whether the patient met inclusion criteria and obtained informed consent from the parent and assent from the patients who were <18 years old. Next, a brief screening interview was conducted in private by the RA. The screening interview confirmed the patient's age, race, and zip code; assessed the patient's grade in school; and whether she had a history of sexual activity or a history of pregnancy. The results of this screening interview were then used to determine whether the patient would be invited to participate in the in-depth interview, based on the recruitment goals described above. If she met criteria to be included in the interview portion, the participant was invited to return for an interview. A convenient time was then arranged for the patient to return, with specific instructions about where and whom to meet.
Data Collection: Qualitative
Participants were interviewed in a private office at the hospital by a trained interviewer. A detailed interview guide was developed based on the TPB adapted to model ECP use12 (Fig 1). Interviewer training consisted of multiple meetings to develop and discuss the interview guide, as well as mock interviews with feedback from one of the investigators (Dr Barg) with expertise in this area. The first patient interview was videotaped, with the patient's permission, to evaluate areas for improvement in interviewing technique. Finally, throughout the data collection period, the study team met biweekly to discuss interview progress, recruitment, and quality control issues.
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After completion of the entire interview, the participant received a gift certificate to a large national chain clothing store and reimbursement for transportation. The interviews were digitally recorded and transcribed by a professional transcription service that was trained in issues of confidentiality and had signed a Health Insurance Portability and Accountability Act collaborator agreement.
Data Analysis: Qualitative
Transcripts were entered into NVIVO 7 software (QSR International, Melbourne, Australia) for organization and coding, and transcripts were tagged with selected demographic data to allow for subgroup analyses. A priori codes based on the TPB and the interview guide were used to label specific phrases from the interviews. The codes could then be combined using NVIVO 7 to provide succinct examples of interviewee comments related to specific themes. The first interview was coded together by 4 members of the study team to develop mutually agreed on definitions for each code and to establish examples of each code; codes were reviewed and revised, and the first interview was again coded by the same 4 members of the study team. Any disagreements in coding were resolved by consensus. Each interview was then coded separately by 2 members of the study team. After coding, the 2 team members met to discuss the results; again, any disagreements in coding were resolved by consensus. Memos of coding decisions were kept to provide consistency in coding as the coding progressed. The transcripts and codes were then reviewed for themes by the study team.
Data Analysis: Quantitative
Demographic data were entered into a Microsoft Access database (Redmond, WA). The literacy measure was scored based on the instructors' manual, and this score was also entered into the Access database. Descriptive statistics (means, frequencies, and percentages) were used to summarize age, sexual and pregnancy histories, and literacy and religiosity measure results. The Likert-scale responses of the religiosity measure were combined into dichotomous variables (strongly agree/agree or disagree/strongly disagree) for this analysis. Stata 9.2 (Stat Corp, College Station, TX) was used for these analyses.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Twenty-nine subjects completed the Test of Adult Basic Education; 1 subject declined to complete it because she stated she was too tired by that point in the interview. All 29 of the subjects had completed at least ninth grade; however, only 9 (31%) scored at the 8.6 to 14.9 grade level. Twelve (41%) scored at the 6.6 to 8.9 grade level, 5 (17%) scored at the 3.6 to 6.9 grade level, and the remaining 3 (10%) scored at the 1.6 to 3.9 grade level. These results are similar to published data of reading proficiency among 11th-graders in Philadelphia, with only 36% scoring at or above proficiency on standardized reading tests in 2006.24
Knowledge About Emergency Contraception
Of the nonsexually active (NSA) participants (n = 14), 50% reported that they had never heard of the ECP or the morning-after pill. Of the 7 participants who stated they had heard of the ECP, 4 were unable to answer any follow-up questions about the ECP, such as when to take it or how to get it. In contrast, 15 (94%) of the sexually active (SA) participants said that they had heard of the ECP or the morning-after pill, although almost half (40%) of these young women were also unable to answer any follow-up questions. One SA participant confused ECP with RU486. Only 2 (14%) of the NSA participants were aware of the recent Food and Drug Administration approval of the sale of Plan B (a brand-name ECP) without a prescription to women aged 
18 years compared with 5 (31%) of the SA group.
Interview Themes
Attitudes About Emergency Contraception
Participants who had heard of ECP used phrases such as "miracle drug" and "it saved my friend" to describe it. The majority of the NSA group thought that the ECP sounded like an important medication to have available because it can prevent pregnancy. They identified several qualities of the ECP, including that it is "easier to use" and "works faster" than oral contraceptives and that it is more effective than oral contraceptives. However, as a group, they were concerned with the possibility of the ECP failing to prevent pregnancy and also reported concerns about short-term adverse-effects, such as feeling sick or vomiting. Adolescents who were not SA also reported concerns about long-term adverse effects. Similarly, the majority of the SA group also endorsed the idea that the ECP is an important option for preventing pregnancy and described the idea that the ECP is somehow stronger and faster than oral contraceptives. This subgroup also reported concerns about short-term adverse effects, although fewer of this group discussed long-term adverse effects (Table 3 provides illustrative quotes for the themes described in this section).
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Subjective Norms About Emergency Contraception
Overall, there was not one unique group of people that influenced the attitudes and decisions of the respondents with respect to the ECP. However, it was clear that the participants were each influenced by someone important in their lives: female friends, mothers, sisters, community members, boyfriends, and male friends. Among NSA participants, mothers were particularly important in influencing their decisions, with almost all listing either their mother or stepmother as an adult who plays an important role in the decisions she makes. Specifically, this group spoke about how their mother would want to discuss major decisions with them before they determined what to do in a particular situation. Furthermore, they discussed how, although their mothers might not approve of using the ECP, they would be supportive if the situation arose. SA participants were less likely to name their mother as an important influence. In addition, they perceived that their boyfriends and teenage boys in general want to have children.
Perceived Behavioral Control About Emergency Contraception
Although most of the participants felt that they could get ECP if necessary, several potential barriers were discussed repeatedly. The most commonly cited barrier was their young age; both NSA and SA young women were concerned that being <18 years old would prevent someone from obtaining the ECP. In addition, concerns about confidentiality, being embarrassed, and finding transportation to the doctor or pharmacy were mentioned by a number of participants.
Intention to Use Emergency Contraception
Of the 10 NSA participants who responded to the intention-to-use question, 50% stated that they would consider using it in the future, 1 said she would if it was necessary, and 4 said they would not consider using it. In contrast, 11 of 13 SA participants said they would consider using the ECP in the future.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Published literature also supports the idea that knowledge about the existence of ECP is not the only factor that determines whether a woman will choose to use the ECP. In a study of adult women, Romo et al31 identified specific knowledge gaps that affected willingness to use the ECP. They found that women who believed that the ECP prevents pregnancy at implantation were less likely to be willing to use the ECP than women who believed that the ECP affects ovulation. In addition, studies have found that women, including adolescents, may not choose to use the ECP because they feel ashamed or embarrassed, are worried about what others think, and have concerns about adverse effects.9,32 Our results mirror some of those from previous studies; for example, the participants in our study had limited knowledge about the ECP; although many of the interviewees reported they had heard of the ECP, when pressed about any details, they were often unable to provide answers about the proper timing of ECP use and whether they needed to see a doctor for a prescription. Furthermore, many participants seemed to feel that a user of the ECP is someone who should be embarrassed.
To address these concerns, conversations with adolescents about the ECP need to provide particular facts about the ECP, aimed at addressing specifically the issues that adolescents are concerned about, such as adverse effects of the medication and confidentiality issues. Furthermore, providers should address attitudes about the ECP; given that many participants in this study described a negative opinion of ECP users, a provider could focus education on portraits of actual users and on the similarity between the ECP and oral contraceptives. In addition, providers should account for important influences in the adolescent's life; those influences, such as mothers and boyfriends, may have competing opinions that could be difficult to address. Finally, barriers to obtaining the ECP, such as concerns about confidentiality and young age, should also be considered. Interestingly, despite the concerns and negative attitudes expressed by the participants in our study, many stated that they would consider using the ECP in the future. This suggests that there is the potential to alter adolescent behavior by addressing gaps in knowledge and misconceptions about the ECP.
This group of urban, minority adolescent girls provided insight into some of the issues facing adolescents as they consider pregnancy prevention options. The cultural homogeneity of our sample allowed us to delineate specific themes within this group to begin to describe specific attitudes about the ECP; however, these results may not be generalizable to other populations. Importantly, given the large percentage of eligible participants who either refused to participate or did not return for the interview, we may have selected a sample of young women with particular thoughts and opinions about the ECP. However, we did maintain some diversity with respect to age and sexual histories. In the future, larger studies with more random samples of adolescents are needed to continue to refine the attitudes and beliefs of adolescent girls with respect to ECP use.
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CONCLUSIONS |
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ACKNOWLEDGMENTS |
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We gratefully acknowledge the assistance of Erica Kane for work with transcript analysis.
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FOOTNOTES |
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Address correspondence to Cynthia J. Mollen, MD, MSCE, Children's Hospital of Philadelphia, 3535 Market St, Room 1543, Philadelphia, PA 19104. E-mail: mollenc{at}email.chop.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr Gotcsik's current affiliation is Department of Pediatrics, University of Washington, Seattle, WA.
Ms Blades' current affiliation is Alan Guttmacher Institute, New York, NY.
Dr Schwarz's current affiliation is the Philadelphia Department of Public Health, Philadelphia, PA.
| What's Known on This Subject ECPs are a safe and effective way to prevent unintended pregnancy. Use of ECPs by adolescents has been limited, in part because of their lack of knowledge.
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| What This Study Adds Urban, minority adolescent girls have misconceptions about ECPs, are affected by the opinions of those close to them, and express concern about specific barriers. By describing these specific issues related to ECP use, we can inform specific interventions.
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