Primary care

Young women's accounts of factors influencing their use and non-use of emergency contraception: in-depth interview study

Caroline Free, NHS R&D national primary care training fellow ^a, Raymond M Lee, professor of social research methods ^b, Jane Ogden, reader in health psychology ^a. 

^a Department of General Practice and Primary Care, Guy's, King's College, and St Thomas's School of Medicine, London SE11 6SP, ^b Department of Social and Political Science, Royal Holloway University of London, Egham, Surrey TW20 0EX

Correspondence to: C Free caroline.free{at}kcl.ac.uk

	Abstract

Top Abstract Introduction Methods Results Discussion References

Objectives: To explore young women's accounts of their use and non-use of emergency contraception.
Design: Qualitative study using in-depth interviews.
Participants: 30 women aged 16-25; participants from socially deprived inner city areas were specifically included.
Setting: Community, service, and educational settings in England.
Results: Young women's accounts of their non-use of emergency contraception principally concerned evaluations of the risk conferred by different contraceptive behaviours, their evaluations of themselves in needing emergency contraception, and personal difficulties in asking for emergency contraception.
Conclusions: The attitudes and concerns of young women, especially those from disadvantaged backgrounds, may make them less able or willing than others to take advantage of recent increases in access to emergency contraception. Interventions that aim to increase the use of emergency contraception need to address the factors that influence young women's non-use of emergency contraception.

What is already known on this topic Limited knowledge of, or poor access to, emergency contraception, and concerns about side effects and moral issues may reduce the use of emergency contraception in women at risk Young people can be embarrassed about using contraception services Interventions to increase knowledge of and access to emergency contraception have had limited success among teenagers What this study adds Perceptions of low vulnerability to pregnancy, negative self evaluations about the need for such contraception, and concerns about what others think deter young women from using emergency contraception These women find it difficult to ask for emergency contraception The attitudes and concerns of young women, especially those from deprived inner city areas, may render them least willing and able to obtain emergency contraception

	Introduction

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Increasing the use of emergency contraception is one means of reducing unwanted and teenage pregnancies.¹ Limited knowledge of emergency contraception among women has been identified, and campaigns have aimed to improve this.^2-4 Access to emergency contraception has been increased by providing it in advance or by increasing the range of providers. ^{5 6} Emergency contraception costs £24.00 ($38.10, 37.81) and can now be obtained over the counter by those aged 16 and over. Among teenagers in inner city areas, however, there has been low use of free emergency contraception provided by local pharmacies.⁷ Concerns about side effects may explain low usage.⁸ In a telephone survey of women aged 16-44, moral or religious reasons were given for non-usage. Some women had not used emergency contraception because they thought or hoped they would not get pregnant.⁹ The attitudes of general practitioners and pharmacists may also deter women from seeking emergency contraception.¹⁰ Although these factors are relevant to the use of emergency contraception, the area of investigation has been predefined by the researchers.

We used qualitative methods to allow women to define the issues relevant to their own use or non-use of emergency contraception. The views of non-users and women living in socially deprived areas may be different from those of users and women living in more affluent areas. We are unaware of any published qualitative work outside university settings of women's accounts of their use and non-use of emergency contraception.¹¹ We conducted in-depth interviews of young women to elicit accounts of the factors influencing their use and non-use of emergency contraception after problems with contraception. We also explored young women's experiences of seeking emergency contraception.

	Methods

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CF interviewed women aged 16-25, recruited from general practices, hostels for homeless people, youth groups, schools, and family planning clinics in the London area. We purposefully sampled young women and specifically included those living in deprived inner city areas with high pregnancy rates among teenagers.

We obtained ethical approval for our study from St Thomas's Hospital ethics committee. CF obtained informed consent from the women for the interviews. They were informed about the purpose of the study, and they were told that they could stop the interview at any point without giving a reason, that quotes would be used anonymously, and that if they did not wish to answer a question the interviewer would move on to another area. Each interview lasted about an hour. The women were interviewed in a private room either where they were recruited or at home, according to their preference. In three cases the women wanted to be interviewed with friends. Participants were asked about their use or non-use of contraception and emergency contraception. They were asked about their experiences in seeking emergency contraception.

We tape recorded and fully transcribed the interviews. All the authors discussed each stage of the analysis. We examined the transcripts to identify themes. We analysed the relation between the themes to produce a coding framework. CF coded each interview according to the framework and examined each section of the coded transcripts to identify how it confirmed or contradicted the emerging analysis. We explored the role of the broader social context of contraceptive behaviour in the differing accounts of emergency contraception use. CF conducted the interviews until saturation, when no new themes emerged.

	Results

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CF interviewed 41 women. Of these, 11 were virgins. We report here on the findings from the 30 women who were sexually active. The table gives their personal details.

Eight of the women were either pregnant or had children; of these, seven had become pregnant while a teenager. All but three of the women had experienced a problem with contraception at a time when they did not want to be pregnant. Seventeen of the women had used emergency contraception at least once. Nine of these women also reported episodes when they had not used emergency contraception after problems with other forms of contraception.

Emergency contraception was used when no contraception had been used or when women were uncertain if a condom had been used properly or had split or come off. Only one woman reported using emergency contraception after a problem with the contraceptive pill.

The data we collected were complex and varied, reflecting contradictory influences on the women's decisions about contraception. We present the key themes identified.

Safety and vulnerability
Those women who described the strongest desire to avoid pregnancy used contraception and, if necessary, emergency contraception. Such women tended to have strong aspirations for education, careers, travel, or lifestyle rather than motherhood. Typically they reported that a pregnancy would be a "complete disaster" and contraception use that was anything less than "obsessional" left them feeling highly vulnerable to pregnancy. A few women reported "extra safe" contraceptive behaviour, making use of both contraceptive pills and condoms or getting emergency contraception even though only one contraceptive pill had been late. This behaviour was reported in the context of either early sexual experience combined with the expectation of being in education for many more years or in the context of having experienced an unplanned pregnancy (box 1).

Many women reported a lower sense of vulnerability to pregnancy. Those with the lowest sense of vulnerability thought that the risk of pregnancy was small when they missed or did not use contraception. Evaluations of the risk of pregnancy conferred by different contraceptive behaviours were based on advice and experience. In particular the women cited their own or friends' experience in becoming or not becoming pregnant when contraception was missed or not used. Some experienced users of contraception said that over time they had come to believe that they were less at risk of pregnancy and consequently their use of contraception had relaxed.

Several women reported a sense of personal invulnerabilitypregnancy happened to other people and not to themeither currently or in the past. This was different to not believing that the behaviour was risky. Women who reported that their behaviour wasn't particularly risky or had a sense of personal invulnerability did not use emergency contraception. In contrast, users of emergency contraception were highly concerned that they would get pregnant (see box 1).

Negative evaluations of emergency contraception use and users
The use of contraception and the ability to use services were predominantly reported as illustrations both of the responsible way the women were behaving and of their maturity. Initial embarrassment in using general contraception services was reported by some of the younger women. In contrast, needing emergency contraception was linked to negative evaluations for many of the women (box 2). It was seen as a personal failing, and the women felt ashamed. The younger women reported being concerned about what other people might think if they asked for emergency contraception, especially for a second time. A combination of these factors was why emergency contraception had not been used (see box 2). Women who linked emergency contraception to "undesirable behaviour" wanted to dissociate themselves from any negative connotations about themselves or their relationship if they sought emergency contraception. A few women dissociated themselves from emergency contraception entirely, reporting that they were not the kind of person who would ever need it (see box 2).

In contrast some women reported use of emergency contraception in the absence of negative evaluations of either themselves or other users. Such women were older or had gone on to university.

Getting emergency contraception is an overwhelming task
Some women put the risk of pregnancy to the back of their mind. This was reported in the context of a combination of three factors: high levels of anxiety in thinking about the risk of pregnancy, a strong sense of shame about what had happened and the need for emergency contraception, and high levels of concern about what others might think of their sexual behaviour. It was easier for these women not to think about the risk of pregnancy, which might not occur, than to endure the stigmatisation over the need for emergency contraception and unplanned pregnancy (see box 2). Women describing this strategy for dealing with risk were teenagers either living in the most deprived areas or homeless. It may be that these women had the least personal resources in being able to cope with and respond to the risk that had occurred.

Knowledge, service barriers, side effects, and moral concerns
Limited knowledge and service barriers were each reported to have contributed to non-use of emergency contraception by two women. Side effects of emergency contraception were reported by more than half of the women. Concerns about the harmful effects of emergency contraception had contributed to a decision not to use emergency contraception in a few women. One woman who had used emergency contraception was concerned that it was similar to having an abortion (box 3).

Experiences with healthcare professionals and services
The women reported both positive and negative experiences of interactions with healthcare professionals (box 4). Although some encounters were described in a matter of fact way, those that concerned asking for emergency contraception were inherently difficult for many prospective recipients. Interactions where the healthcare professional was matter of fact, friendly, and understanding were easiest. For some of the women a good relationship with a healthcare professional made it easier to get emergency contraception.

Consultations that focused largely on the risks that had been taken made the women feel told off and reluctant to reattend (box 4). Such women resorted to a different service or chose not to use emergency contraception. A few encounters were described in the most negative terms (box 4). A few women reported being angry about the way healthcare professionals had treated them.

	Discussion

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Young women's accounts of their non-use of emergency contraception mainly concerned evaluations of the risk conferred by different contraceptive behaviours, their evaluations of users of emergency contraception and of themselves in needing it, and personal difficulties in asking for emergency contraception. Limited knowledge, problems in gaining access to emergency contraception, and concerns about side effects also contributed to non-use of emergency contraception.

The importance of perceived vulnerability is pivotal to the adoption of behaviour that is protective to health.¹² We identified links between a strong motivation to avoid pregnancy and the perception that the risk of pregnancy is high. These factors in turn were related to both consistent use of contraception and compensatory behaviour for using emergency contraception. Some women reported a lower sense of vulnerability to pregnancy. These women used contraception but acknowledged that they sometimes forgot to take their contraceptive pill or did not use contraceptives. Optimism about personal risk results from selective focus on safe behaviours.¹³ A similar process may be occurring with risks of pregnancy. Some of the women believed that they were invulnerable to pregnancy. Personal invulnerability and the tendency to perceive that others are at greater risk of disease than yourself have been well documented in a range of behaviours.¹³

In public discourse the risks associated with particular courses of action are often discussed in a way that renders their situational and contigent character invisible.¹⁴ In this way, environmental risks become "closed to decision." This was the case in our study, because although the women knew about emergency contraception, their understandings of the risks of pregnancy after problems with contraception meant that the use of emergency contraception was not considered. Many of these women also felt ashamed about what had happened and about needing emergency contraception. They found it particularly difficult to ask for emergency contraception. Some healthcare professionals had shown good communication skills, but there were also some negative experiences. Those women who sought emergency contraception were inherently those who knew they had been at risk. Consultations that focused on the risks that had been taken deterred women from reattending for emergency contraception.

For some women the fear associated with a possible pregnancy and the shame and anxiety in asking for emergency contraception was overwhelming. Interventions that arouse further fear would not be effective for such women and might even be counterproductive. For these women educational interventions need to focus on increasing the resources for obtaining emergency contraception. In addition, interventions could focus on providing emergency contraception in a way that avoids young people having to ask for it or that improves their use of other forms of contraception.

Personal invulnerability to pregnancy or concerns about what other people think were predominantly reported by the younger women or those reporting their views as teenagers. The attitudes and concerns held by many younger women may render them less able than others to take advantage of recent increases in access to emergency contraception.

Those women who thought it easier to avoid emergency contraception rather than face their own anxiety, sense of guilt, and concern about what others might think were teenagers who either lived in disadvantaged areas or were homeless. The concerns and personal resources of such women may render them least willing and able to obtain emergency contraception. They will also be least able to afford over the counter emergency contraception.

In addition to increasing knowledge and access to emergency contraception, interventions to increase the use of emergency contraception in at risk populations should take into account factors influencing women's non-use of contraception and emergency contraception. Educational interventions should aim to promote the attitudes and personal skills needed to obtain emergency contraception.

	Acknowledgments

We thank the staff in the hostels for homeless people, youth groups, schools, family planning clinics, and surgeries, the participants, and Connie Smith, codirector of Westside Contraceptive Services, for her comments on the paper.

Contributors: CF designed the study, carried out the field work, conducted the analysis, and wrote the paper; she will act as guarantor for the paper. RML and JO acted as advisers for the design and conduct of the research and the analysis. All authors made comments on the paper.

	Footnotes

Funding: Department of Health as part of the national primary care training fellowship.

Competing interests: None declared.

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(Accepted 24 September 2002)