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 the London area.
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 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.² We used qualitative methods to allow women to define the issues relevant to their own use or non-use of emergency contraception. We are unaware of any such published work outside university settings.³

	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.

Each interview lasted about an hour, or until no new themes emerged. We tape recorded and fully transcribed the interviews, then conducted a thematic analysis of the transcripts.

	Results

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CF interviewed 41 women. We report here the findings from the 30 women who were sexually active. The table gives their personal details. We present the key themes identified by our analysis.

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 also reported episodes when they had not used emergency contraception after problems with other forms of contraception.

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 (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. 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.

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. 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. A few women dissociated themselves from emergency contraception entirely, reporting that they were not the kind of person who would ever need it.

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. 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.

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 three 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). 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.

	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.⁴ 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.⁵ Many women also felt ashamed about what had happened and about needing emergency 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. Younger and more disadvantaged women were also more likely to avoid emergency contraception because of associated anxiety and guilt. These women are less able to afford over the counter emergency contraception. Educational interventions targeted at these vulnerable groups should promote the attitudes and personal skills needed to obtain 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. Consultations with healthcare professionals that focus on the risks of unprotected intercourse can deter women from reattending for 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: See bmj.com

	Footnotes

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

Competing interests: None declared.

This is an abridged version; the full version is on bmj.com

	References

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2.	Anderson C, Bissell P, Sharma S, Sharma R. The Lambeth, Southwark and Lewisham community pharmacy emergency contraception service. London: Lambeth, Southwark, and Lewisham Health Action Zone, 2001.
3.	Harper C, Ellertson C. Knowledge and perception of emergency contraceptive pills among a college-age population: a qualitative approach. Fam Plann Perspect 1995; 27: 149-154[Medline].
4.	Rosenstock I. Historical origins of the health belief model. Health Educ Monographs 1974; 2: 1-8.
5.	Weinstein N. Why it won't happen to me: perceptions of risk factors and susceptibility. Health Psychol 1984; 3: 431-457[CrossRef][Web of Science][Medline].

(Accepted 24 September 2002)