Objectives. To quantify practitioner administration of the emergency contraceptive pill (ECP) among adolescent patients, and to determine if such administration is associated with physician knowledge and attitudes regarding efficacy, side effects, and appropriate use.
Design. Survey of pediatricians.
Setting. The survey address list was generated from a database of active Fellows of the American Academy of Pediatrics in the District of Columbia metropolitan area.
Main Outcomes Measures. Prescription of the ECP in the previous 12 months, or counseling of an adolescent patient about the ECP.
Results. Of the 236 questionnaires distributed, 143 (61%) were returned and 121 (51%) were usable. Twenty-four pediatricians (20%) reported prescribing the ECP, and 29 (24%) had counseled adolescent patients about the ECP. Of the practice-related variables surveyed, both the number of adolescents seen per week and the practice setting were significantly associated with these outcomes. Of the knowledge-related variables surveyed, knowledge of the timing and the Food and Drug Administration-labeled status of the ECP were significantly associated with outcomes. None of the attitude-related variables surveyed were associated with outcomes.
Conclusions. This study demonstrates that knowledge deficits, not attitude-related variables, are significantly associated with the low level of ECP administration and counseling among District of Columbia pediatricians. Because knowledge deficits are amenable to educational interventions, our data suggest that informing pediatricians about the ECP may increase its administration among their adolescent patients.emergency contraceptive pill, pediatricians, adolescents.
Despite the 1996 approval of the emergency contraceptive pill (ECP) by the Food and Drug Administration, little is known about pediatricians' ECP-prescribing practices. Of previous studies that evaluated health care providers' practices, none looked explicitly at pediatricians, and only 1 surveyed providers of adolescent health care.1 In 2 other studies involving US physicians, reproductive health care providers, family practitioners (FPs), and emergency medicine physicians,2and obstetrician-gynecologists (OB-GYNs) were surveyed.3
This study was performed to: 1) quantify the use of the ECP by pediatricians, and 2) determine if the frequency of ECP administration is associated with physician knowledge and attitudes regarding its efficacy, side effects, and appropriate use.
In a study period lasting from March 1998 to June 1998, a mailing list of pediatricians with active, voting membership in the American Academy of Pediatrics was used to enlist subjects. A questionnaire was mailed to all 236 such members in the metropolitan District of Columbia area, and 2 subsequent mailings targeted nonrespondents. The questionnaire was piloted on the emergency medicine physicians at Children's National Medical Center.
The 2-page questionnaire contained 5 categories of data demographics; variables regarding the scope of adolescent practice; ECP-related knowledge; attitudes, and practice characteristics.
The independent variables collected included practitioner gender, age, and race; practice volume; practice setting; religious and political ideology, and ECP-related knowledge and attitudes. Outcome measures of ECP-related practice included ECP administration by the practitioner in the previous 12 months and adolescent counseling by the practitioner about the ECP.
We analyzed the knowledge variables individually. We accepted as correct a range of 70% to 80% for the efficacy of the ECP.4
Outcome measures of ECP-related practice were tested for associations with independent variables using categorical analyses. χ2 analysis was performed using EpiStat software (Richardson, TX).
Of the 236 physicians surveyed, 143 (61%) responded after 3 mailings. Twenty-two surveys were excluded from further analysis: 17 were no longer in a local clinical practice, 4 had no adolescent patients, and 1 supplied only demographic information, yielding 121 questionnaires for analysis. Of these, 24 (19.8%) had given the ECP in the preceding 12 months, and 29 (24.0%) had counseled their adolescent patients regarding ECPs.
Table 1 outlines frequency distributions of the demographic and scope-of-practice variables for the responding group and displays the results of our comparison of these variables with our 2 ECP-related practice outcomes. Because of a small sample size, some demographic and scope-of-practice variables were dichotomized. These were all from numeric or multiple-choice questions, and the dichotomization point was selected to achieve 2 similarly-sized groups. Demographic variables were not associated with ECP use or counseling. Both scope-of-practice variables were significantly associated with ECP-related practice.
Table 2 depicts the association of knowledge variables with the 2 practice outcomes. Four of the questions are displayed; the fifth question—“Have you ever heard of the ECP?”–was answered in the affirmative by all but 1 respondent. Knowledge regarding the timing and Food and Drug Administration-labeling of ECPs was significantly associated with both practice outcomes.
Table 3 displays the results of the associations of attitude responses with the 2 practice outcomes. None of the attitude-related variables was associated with either practice outcome.
Pediatricians' knowledge regarding the ECP is significantly associated with ECP practice outcomes, and background and attitudes are not significantly associated with these outcomes. Additionally, there was a low rate of ECP administration (19.8%) and counseling (24.0%) among pediatricians in the study sample, a finding consistent with our hypothesis. These rates rise to 31.4% and 39.2%, respectively, among pediatricians with 10 or more adolescent visits per week.
The finding that 2 of the knowledge variables were significantly associated with ECP counseling and prescribing, whereas none of the attitude variables were significant predictors, suggests that the major barriers to ECP-related practices are knowledge deficits. Of the 3 studies of US physicians' ECP practices, only the Gold study1 evaluated physicians' practices in relation to their attitudes regarding the ECP. In contrast to our study, the Gold study1 found that failure to prescribe the ECP did correlate with attitude variables. None of the US studies compared physician knowledge with practices, but 1 British study of general practitioners found a similar association between low utilization and poor knowledge.5
In general, our findings are consistent with previous studies citing low rates of ECP administration. The Gold study1 found that only 59% of pediatricians prescribed the ECP, in contrast to 92% of OB-GYNs, and 28% of pediatricians had counseled adolescents about the ECP. The Grossman study2 found a prescription rate of 65% among OB-GYNs and 25% among FPs.
The importance of the ECP for adolescents is evident in the high proportion of births due to unintended pregnancies (66%),6 as well as in the high percentage of pregnancies resulting in elective abortion (35%).7 In the Netherlands, 34% of all women receiving ECPs from FPs were under age 20.8
Pediatricians care for approximately 25% of adolescents.9Our findings that pediatricians administer the ECP infrequently and that their knowledge deficits are significantly associated with nonuse indicate that knowledge deficits may represent a barrier to lowering adolescent pregnancy rates through emergency contraception.
This study had 2 principal limitations. First, the low response rate, 61%, raises the issue of selection bias. We did not have demographic information regarding most of the nonrespondents and, thus, were unable to determine the presence of such a bias. Second, we only surveyed physicians in the District of Columbia metropolitan area, which limits the extent to which our findings can be extrapolated.
A lack of knowledge was associated with nonuse of the ECP. This result is important because, of all the categories of variables tested, knowledge is the most amenable to change. This association suggests that greater education might lead to greater ECP administration. The issue merits further study with an interventional design.
- ECP =
- emergency contraceptive pill •
- FP =
- family practitioner •
- OB-GYN =
- Burton R,
- Savage W
- ↵National Center for Health Statistics, Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ. Fertility, Family planning and women's health: new data from the 1995 Survey of Family Growth. Vital and Health Statistics. Series 23. No. 19. DHS Publication No. PHS-97-1995
- ↵National Center for Health Statistics, Ventura SJ, Taffel SM, Mosher WD, Wilson JB, Henshaw S. Trends in pregnancies and pregnancy rates: estimates for the United States, 1980–1992. Monthly Vital Statistics Report. Vol. 43. No. 11(S). DHS Publication No. PHS-95-1120
- ↵Nederlands Institut vor Onderzoek van de Gezondheidszorg (Netherlands Health Care Research Institute) Continue morbiditeitsregistratie peilstations Nederland: Jaarverslaf 1993 (Continuous sentinal morbidity registration: Netherlands. Annual report 1993)
- ↵Office of Technology Assessment. Adolescent Health Volume: Summary and Policy Options, I. US Congress; 1991
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