Knowledge and Attitude Toward Emergency Contraceptive Pills Among First-Year Undergraduate Students in Southern Thailand

DOI: https://doi.org/10.21203/rs.3.rs-1051995/v1

Abstract

Background: The objective of this study was to investigation of the knowledge and attitude towards emergency contraceptive pills (ECPs) among first-year undergraduate students in a university in Thailand.

Methods: This cross-sectional survey study was performed using the developed questionnaires that was validated by four experts. The questionnaires were distributed to all the first-year students in the university via an online platform. The characteristic data were descriptively analyzed and the knowledge data were analyzed using Chi-square test, Mann-Whitney U test and one-way ANOVA.

Results: A total of 335 students who responded to the questionnaires and met the eligible criteria for the study was analyzed. The mean knowledge score of all respondents was 7.76±0.15 out of 15. The most correct-answered questions were the questions relating to efficacy and safety of ECPs in pregnant women (78.5% and 72.2% corrected, respectively). On the contrary, the least correct-answered questions were about the ECP regimens and using ECPs instead of combined oral contraception (COC) (30.4% and 34.9%, respectively). In addition, the results indicated that experience in using ECPs and in ECP education were significant factors in high scores of knowledge. Moreover, most respondents trusted and would like to receive the information on ECPs from health professionals in hospitals, academic institutions, or pharmacies.

Discussion: The average knowledge of ECPs of first-year students in a university in Thailand was at a moderate level. More knowledge about the regimens of the drug and using ECPs instead of COC should be advised to students, particularly at the university or pharmacies, and should be done by healthcare staff.

Introduction

Emergency Contraceptive Pills (ECPs) are defined as the medicines that can be used to prevent pregnancy after sexual intercourse [1].There are three regimens of ECP that are recommended by the World Health Organization (WHO) including ulipristal acetate, levonorgestrel, and combined oral contraceptives (COCs) consisting of ethinyl estradiol plus levonorgestrel. However, in Thailand, the only ECP regimen that is registered by Thai Food and Drug Administration (FDA) is levonorgestrelalone.

According to the information from International Consortium for Emergency Contraception, several countries allow direct access to ECPs with or without via pharmacists. Thailand is one of the countries whereECPs must be dispensed by pharmacists without a doctor’s prescription[2]. Although Thai people have to obtain ECPs from pharmacist, many of the studies conductedin Thailand have reported low to moderate levels of knowledge relating toECPs especially in adolescents and young adults[3-6].Inappropriate usage of ECPs could result in multiple adverse effects such as ectopic pregnancy, vaginal bleeding, and pregnancy complications [7].

Focusing on adolescents and young adults, the first-year undergraduate period should be considered the mostchanging in their lives. In Thailand, before going to universities, students usually live with their parents; however, when becoming freshmen in the universities, most of them have to leave their homes and stay in university dormitories. This situation, without or away from parental control, leads to high risk of sexual intercourse [8]. Having knowledge and a positive attitude toward ECPs is one of the methods to preventpremature pregnancy. Therefore, this study aimed to investigate the knowledge and attitude to ECPs among first-year undergraduate students in a university in Thailand. Additionally, the personal factors relating to knowledge and attitude were analyzed.

Materials And Methods

This cross-sectional descriptive study was conducted at auniversity inNakhon Si Thammarat, Southof Thailand, between 1 December 2019 and 31 January 2020. An online questionnaire was developed and validated by four experts in the university. The questionnaire consists of 3 sections: general characteristics (i.e. gender, religion, salary from parents, experience in using ECPs and in ECPs education), knowledge of ECPs, andattitude to ECPs (i.e. suitable setting for ECPs education, suitable person for ECPs education, and reason for using ECPs).

The online questionnaire was distributed to all first-year undergraduate students in the university. The inclusion criteria included students who have finished high schools or colleges in Thailand, who were able to read and write in Thai, and who have registered for the first-time to the university. Students who did not complete all questions in the survey were excluded. The sample size of this study was calculated using Krejcie and Morgan formula, resulting in325 students as the minimum number of respondents.

General characteristics of respondents were descriptively analyzed as frequency and percentage. The scores of knowledge were analyzed as mean and standard deviation (SD). Attitude to ECPs was described as sequential preference. Mann-Whitney U test and one-way ANOVAwere used for analysis of difference for continuous variables. The methodology of this study was approved by the Human Research Ethics Committee of Walailak University (WUEC-20-341-01). All data were received from only participants with written informed consent.

Results

There were a total of 435 students who responded to the survey; however, 100 students were excluded because they did not first-time register to the university. Therefore, 335 students were analyzed in this study. Of them, 275 students (82.1%) were female, and 289 students (86.3%) were Buddhist (Table 1). Majority of respondents had a monthly salary of 4000-6000 Thai Baht (53.4%), followed by less than 4000 (30.4%) and more than 6000 (16.1%), respectively. Most students had never taken ECPs (89.0%) but had been educated about ECPs (74.6%). The sources of ECPs education were academy, self-education and health professionals, respectively.

The average score and SD of knowledge about ECPs was 7.76±0.15 out of 15, which was at moderate level of knowledge. Table 2 describes all questions and percentages of correct-answered respondents. The question that most students answered correctly was efficacy of ECPs to prevent pregnancy (78.5% corrected), followed by safety of ECPs in pregnant women (72.2% corrected) and efficacy of ECPs to prevent sexually transmitted diseases (66.3% corrected), respectively. The questions that fewest students answered correctly included comparison of ECPs and usual contraceptive pills (30.4% corrected), appropriate time to take ECPs (within 72-hour post-intercourse) (34.9% corrected), and effect of ECPs to cause abortion (36.7% corrected).

With regard to the association between student characteristics and scores, the results showed that experience in using ECPs and previous education in ECPs were significantly associated with higher scores. (p-value 0.001 and <0.001, respectively; Mann-Whitney U test). The respondents with both factors had an average score of 10.31±3.21, while the respondents with none of the factors had an average score of 6.38±3.78. The mean score of respondents with either factor was 7.60±3.74.

Table 3 and 4 describe the preferences of respondents to suitable location for ECPs education and suitable person for ECPs education, respectively. For location, most students preferred ECPs education at hospitals, academic institutions, and pharmacies rather than online media or webpages. For person, most students preferred receiving knowledge from health professionals, parents, and teachers rather than their friends or their lovers.

For reasons of using ECPs, the first preferred reason was the efficacy to prevent unintended pregnancy (mean score 3.17 out of 5). Convenience of getting ECPs and simple instructions were also important reasons that made respondents use ECPs (mean score 3.17 and 3.08 out of 5, respectively). Safety and price were the least two factors of using ECPs among all respondents with mean scores 2.75 and 2.54 out of 5, respectively. Moreover, 86.0% of students said that they are going to use ECPs in case of unprotected sex.

Discussion

The results from this survey study indicated that first-year undergraduate students in a university ofSouthern Thailand, had a moderate level of knowledge about emergency contraceptive pills (ECPs) with an average score of 7.76 out of 15 (51.73%). The most preference of students for place of ECPs education was hospitals, and for the proper person to educate on ECPs was health professionals. In addition, the most important reason to use ECPs was the efficacy to prevent unintended pregnancy.

Knowledge and attitude toward ECPs were an interesting topic to study globally, especially among adolescents and young adults. For example, there were several studies in the United States [9, 10], India [11], Korea [12], Cameroon [13], Nigeria [13], as well as in Thailand [3, 4]. The results from almost all studies indicated that college students and undergraduate students had a poor to moderate level of knowledge about ECPs although most of them had a high attitude toward the drug.

Focusing on Thailand, a study by Aimnoi, et al. revealed that the majority (58.2%)of undergraduate students in Bangkok were at low level of knowledge while 32.1% was at moderate level [3]. In addition, 67.9% of students knew the indication of the drug, but 39.3% of them provided wrong answers on drug regimens. Most students (71.1%) were also unaware of the side effects. A similar study was performed in 210 university students outside Bangkok, and it showed similar results [4]. Over 80% of students knew the indication of ECPs; however, approximately 36% of students had misconception about side effects of the drug. Those results were in concordance to this study; almost 80% of all respondents knew that ECPs had efficacy to prevent unintended pregnancy whilst only approximately 30% knew the side effects of abortion and correct regimens of the drug.

Although many previous studies focused on young adults, to the best of our knowledge, none of them particularly conducted on first-year undergraduate students. Indeed, college or high school students might be younger than first-year undergraduate students, and probably need more attention. This study, however, would like to emphasize the first-year undergraduate students due to the reason forenvironmental change. In Thailand, most college and high school students stay with their parents or guardians such as uncles, aunts, or grandparents, so the possibility of sexual intercourse is fairly low. Those students usually move to dormitories when becoming first-year undergraduate students, and then have a much higher chance of sexual relationship[14, 15]. Nonetheless, the results in this study showed no difference from previous studies that were performed in college students andwhole undergraduate students.

With regard to the place for ECPs education, most respondents preferred hospitals, academic institutions, and pharmacies.Moreover, they preferred getting knowledge from health professionals rather than teachers or parents. These resultsindicated that students were confident if the knowledge was impartedfrom reliable places and persons. In agreement with the studyby Aimnoi et al., the preferred source of information on ECPswas from qualified medical staff although students actually received the information from their friends or the internet [3].Althoughthe accuracy of ECPs knowledge is essential, some studies suggest that contraceptive knowledge should be conveniently accessible such as from home or school[16].

Several limitations of this study needed to be discussed. Firstly, because this study used online questionnaires, respondents were unable to contact the researchers if they were unclear about questions. For instance, there were some male respondents who answered “have ever used ECPs”; it was unsure that how they understood the word “use”. Secondly, only a few personal characteristics of respondents were collected in this study.Neither the course of study nor the accommodation type of respondents were asked due to the recommendation from the ethical committee. Students in health science courses such as medicine, pharmacy, and nursing might have more knowledge than non-health science students. Moreover, students who stay in private accommodations might have more chance to have sex, and then might have different knowledge than those who stay in university dormitories.These factors should be considered and collected in future research.

Conclusion

This cross-sectional survey study was performed in first-year undergraduate students ofa universityfrom Southern Thailand. The results showed that the respondents had moderate knowledge of emergency contraceptive pills. The knowledge relating to indication and efficacy of the drug were at highest level, while side effects and using regimens of the drug were at lowest level. Moreover, the preferred source of ECPs information was from health professionals, and the preferred locations were hospital, academic institution and pharmacies.

Declarations

Ethics approvaland consent to participate

This study has been approved by the Ethics Committee on Human Research, Walailak University, Nakhon Si Thammarat province (WUEC-20-341-01). All participants in the study had to give consent documents to the researchers before answering the questionnaire.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

All fundings involving this study were from Walailak University. The funding body, however, had no involvement in the design of the study, data collection, analysis, and interpretation of data.

Authors' contributions

S.Y. and S.U.conducted the concept of the study and organized all process of study. S.U. wrote the main manuscript text and prepared all tables. All authors reviewed the manuscript.

Acknowledgments

The authors would like to thank pharmacy students: PakwanDaengnapapornkul, BunthitaSinsangbun, and Rawiporn O-infor assisting in distribution and collection of the questionnaires.

References

[1] World Health Organization. Emergency contraception, https://www.who.int/news-room/fact-sheets/detail/emergency-contraception;2018 [access 28 April 2021].

[2] International Consortium for Emergency Contraception. EC Status and Availability: Countries with non-prescription access to EC, https://www.cecinfo.org/country-by-country-information/status-availability-database/countries-with-non-prescription-access-to-ec;2021 [access 30 April 2021].

[3] Aimnoi K, Taeborisutikul W, Chuenbunngam W, Ngaechareankul S, Lermankul W. Knowledge of emergency contraceptive pills among undergraduate students in Bangkok. Thai J Pharm Sci2004;28:31-41.

[4] Bennhult Hansson J, Gröning Wallner I. Knowledge, use and perception of emergency contraceptive pills among undergraduate university students in Thailand [Dissertation], http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-174859;2012 [access 28 April 2021].

[5] Ratanajamit C, Chongsuvivatwong V. Survey of knowledge and practice on oral contraceptive and emergency contraceptive pills of drugstore personnel in Hat Yai, Thailand. Pharmacoepidemiol Drug Saf 2001;10:149-56. https://doi.org/10.1002/pds.573.

[6] Sripichyakan K, Tangmunkongvorakul A. Comparison of knowledge, attitudes, experience, and opinions between teachers and guardians regarding the emergency contraceptive pill in Chiang Mai, Thailand. Nurs Health Sci2006;8:27-35.https://doi.org/10.1111/j.1442-2018.2006.00264.x.

[7] Leelakanok N, Methaneethorn J. A systematic review and meta-analysis of the adverse effects of levonorgestrel emergency oral contraceptive. Clin Drug Investig2020;40:395-420.https://doi.org/10.1007/s40261-020-00901-x.

[8] Uecker JE. Social context and sexual intercourse among first-year students at selective colleges and universities in the United States. Soc Sci Res2015;52:59-71.https://doi.org/10.1016/j.ssresearch.2015.01.005.

[9] Harper CC, Ellertson CE. The emergency contraceptive pill: a survey of knowledge and attitudes among students at Princeton University. Am J Obstet Gynecol1995;173:1438-45.https://doi.org/10.1016/0002-9378(95)90630-4.

[10] Miller LM. College student knowledge and attitudes toward emergency contraception. Contraception2011;83:68-73.https://doi.org/10.1016/j.contraception.2010.06.005.

[11] Shelat PR, Hihoriya NH, Kumbar S. Knowledge and attitude towards the use of emergency contraceptive pills among college students. Int J Basic Clin Pharmacol2012;1:77-84.https://doi.org/10.5455/2319-2003.ijbcp001912.

[12] Kang H-S. Emergency contraceptive pills: Knowledge, attitude, and intention of high school girls in Korea. Korean J Women Health Nurs2009;15:336-43.https://doi.org/10.4069/kjwhn.2009.15.4.336.

[13] Kongnyuy EJ, Ngassa P, Fomulu N, Wiysonge CS, Kouam L, Doh AS. A survey of knowledge, attitudes and practice of emergency contraception among university students in Cameroon. BMC Emerg Med2007;7:1-7.https://doi.org/10.1186/1471-227X-7-7.

[14] Savisit W. Sexual attitudes in first year undergraduate students at Mahasarakham Rajabhat University. Mahasarakham Hospital Journal. 2016;13:47-56.

[15] Promma N, Suparp J, Chamroonsawasdi K, Theachaboonsermsak P, Tansaku S. Factors predict intentions to have premarital sexual amongst freshman college male students. Naresuan Phayao Journal. 2013;6:157-67.

[16] Basic Requirements: Contraceptive Knowledge and Access. In: Institute of Medicine (US) Committee on Unintended Pregnancy, Brown SS, Eisenberg L, editors. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families,Washington (DC): National Academies Press (US); 1995.

Tables

Table 1  Characteristics of students responded to the questionnaire (n=335)

Characteristics

Number (%)

Gender

Male

Female

 

60 (17.9)

275 (82.1)

Religion

Buddhism

Islam

Christianity

No religion

 

289 (86.3)

38 (11.3)

2 (0.6)

6 (1.8)

Monthly salary

<4000 Baht

4000 – 6000 Baht

>6000 Baht

 

102 (30.4)

179 (53.4)

54 (16.1)

Having experience of using ECPs

Yes

No

 

37 (11.0)

298 (89.0)

Having experience of ECPs education

Yes

No

 

250 (74.6)

85 (25.4)

Table 2 Percentages of respondents who correctly answered the questions of knowledge about emergency contraceptive pills (ECPs) (n=335)

Question

Number (%)

Can ECPs treat pimples?

131 (39.1)

Can ECPs prevent sexually transmitted diseases?

222 (66.3)

Can ECPs be used as usual contraception (e.g. combined oral contraceptive pills; COCs)?

156 (46.6)

Is the most effective time for taking ECPs before sexual intercourse?

216 (64.5)

Should the second tablet of ECPs be taken 12 hours after the first tablet?

169 (50.4)

Should ECPs be taken within 72 hours after sexual intercourse?

117 (34.9)

Can ECPs completely (100%) prevent pregnancy?

263 (78.5)

Are ECPs more effective to prevent pregnancy than COCs?

102 (30.4)

Is the most effective time for taking ECPs within 12 hours after sexual intercourse?

207 (61.8)

Are nausea and vomiting side effects of ECPs?

217 (64.8)

Is vaginal bleeding a side effect of ECPs?

136 (40.6)

Is ectopic pregnancy a side effect of ECPs?

141 (42.1)

Is ECPs safe in pregnant women?

242 (72.2)

Can ECPs be taken more than 4 tablets a month?

160 (47.8)

Can ECPs cause abortion?

123 (36.7)

Table 3 Differences inaverage preference scores of suitable locations for education of emergency contraceptive pills (max score=5)

 

Academic institution

Mean=3.20

Pharmacy store

Mean=3.09

Online media

Mean=2.78

Webpage

Mean=2.69

Hospital

Mean=3.25

0.05

(p=0.66)

0.16

(p=0.14)

0.47

(p<0.001)

0.56

(p<0.001)

Academic institution

Mean=3.20

 

0.11

(p=0.29)

0.42

(p<0.001)

0.51

(p<0.001)

Pharmacy store

Mean=3.09

 

 

0.31

(p=0.01)

0.40

(p<0.001)

Online media

Mean=2.78

 

 

 

0.09

(p=0.42)

Note: One-way ANOVA with post-hoc analysis of Tukey was performed. Sample size was 335

Table 4  Differences in average preference scores of suitable persons for education of emergency contraceptive pills (max score=5)

 

Parents

Mean=3.26

Teachers

Mean=3.04

Friends

Mean=2.78

Lovers

Mean=2.69

Health professionals

Mean=3.56

0.30

(p=0.01)

0.52

(p<0.001)

0.78

(p<0.001)

0.87

(p<0.001)

Parents

Mean=3.26

 

0.22

(p=0.04)

0.48

(p<0.001)

0.57

(p<0.001)

Teachers

Mean=3.04

 

 

0.26

(p<0.001)

0.35

(p<0.001)

Friends

Mean=2.78

 

 

 

0.09

(p=0.13)

Note: One-way ANOVA with post-hoc analysis of Tukey was performed. Sample size was 335