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ORIGINAL RESEARCH |
From the California School of Professional Psychology, Alliant University, Alhambra, California; Pacific Institute for Women’s Health, Los Angeles, California; Azusa Pacific University, Azusa, California; Public Health Institute, Berkeley, California; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California; and Center for the Study of Women in Society, University of Oregon, Eugene, Oregon.
Address reprint requests to: Linda J. Beckman, PhD CSPP, Alliant University 1000 S. Fremont Avenue, Unit 5 Alhambra, CA 91803 E-mail: lbeckman{at}alliant.edu
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Abstract |
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Methods: Health care providers completed self-administered questionnaires before and 1 year after full implementation of the project. The 102 providers who completed both questionnaires were physicians (64%) and mid-level professionals from 13 San Diego County Kaiser Permanente medical offices working in departments such as obstetrics and gynecology, primary care, and emergency medicine.
Results: The frequency of prescription for emergency contraceptive pills increased significantly from baseline to follow-up. There was an increase of almost 20% in the percentage who prescribed emergency contraception at least once a year. Knowledge also improved significantly, and perceptions of barriers to prescribing emergency contraceptive pills within the health maintenance organization decreased significantly. In contrast, attitudes about emergency contraception showed little change.
Conclusion: This study suggests that providers who participate in in-service training and other aspects of a demonstration project show changes in perceptions, knowledge, and behavior. However, findings also suggest that significant gaps remain in knowledge about medications, side effects, and mode of action. It is likely that many providers in other health care settings also need additional information and training concerning protocols of emergency contraception provision and its modes of action and effects.
Emergency contraceptive pills consist of high doses of oral hormonal contraceptives taken within 72 hours of unprotected sexual intercourse. Recent studies show that a specific regimen of emergency contraception, the Yuzpe regimen, reduces pregnancy risk an average of 74%.1 Yet several barriers have limited use of emergency contraceptive pills in the United States. Initially, the lack of a product packaged for use as emergency contraception was thought to greatly limit distribution. Despite nationwide availability of a dedicated product since October 1998 and much media attention, we know of no empirical evidence that supports a significant increase in use rates. Other barriers to use include characteristics of the health care system and the knowledge, attitudes, and beliefs of providers. Few interventions have targeted reproductive health providers (for exceptions, see Hutchings et al,2 Wells et al,3 and Kishen and Presho4).
Although the proportion of practitioners who prescribe emergency contraceptive pills may be increasing somewhat and most women’s health care providers have prescribed them,5,6 prescribing frequency across all provider types is relatively low,5–7 with most providers prescribing less than five times a year.5 Yet surveys of providers indicate primarily positive attitudes towards emergency contraceptive pills.5,8 On the other hand, providers lack detailed knowledge of emergency contraception.6,9 For instance, taking cues from the misnomer "morning-after pill," many believe treatment must be initiated immediately after unprotected sex.6,7 Lack of knowledge regarding pill availability, timing of administration, and efficacy also is associated with low levels of prescription.7.
This article reports on changes in the attitudes, knowledge, and prescribing practices of health care providers after implementation of an intervention whose purpose was to introduce emergency contraceptive pills as a new service option within a large health maintenance organization. Although the program was implemented in 1996–98 before the availability of a packaged product in the United States, the results remain relevant for several reasons. First, Trussel et al10 found that access to emergency contraception is currently limited, even when women obtain referrals from an emergency contraceptive hot line. Second, research7 suggests that knowledge deficits of providers are among the most important barriers to access. Third, the program was implemented in a large health maintenance organization, one type of managed care plan. The percentage of Americans who receive health care through managed care plans has increased rapidly11,12 with recent estimates ranging as high as 71% in the private sector and 40% in the public sector.13 Finally, the project involved repackaging of oral contraceptives as emergency contraceptive pills, mimicking current national market conditions regarding product availability.
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Materials and Methods |
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shows the demographic characteristics of the 102 providers who completed baseline and postintervention questionnaires and 62 providers who completed only the baseline.
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In-service training for providers consisted of a formal lecture presentation, followed by detailed review of a comprehensive clinical manual that provided information about emergency contraceptive pills with specific recommendations for treatment and a bibliography. Each participant received a copy of the clinical manual, and manuals were sent to providers unable to attend a presentation.
A pre-implementation survey was conducted in fall 1996. A member of the project team distributed survey packets to providers in their offices. A survey packet was left on the desk of providers not in their offices during survey distribution. Two weeks after the initial distribution of surveys, a second packet with a reminder letter was distributed to nonrespondents. A total of 288 providers were surveyed; 164 providers responded, yielding a response rate of 57%. Participation was greatest among providers in the Department of Obstetrics and Gynecology (94% response rate) and lowest in the Emergency Department (38% response rate).
A second survey was given to providers using the same procedures 1 year after full implementation of the project (November 1997 to January 1998). A total of 62% (n = 102) of those providers who completed the baseline survey also completed the postintervention questionnaires. Only these 102 providers, 72 of whom attended a training session, are included in the data analysis.
The questionnaires, developed specifically for this study, used items from a measure used in a prior study.6 Baseline and follow-up questionnaires were identical except that more demographic information was collected at baseline, and attendance at the training session was assessed at follow-up. Providers’ prescribing practices were measured with three items: frequency of prescribing, whether they limit the number of times they would prescribe emergency contraceptive pills to a given patient, and if they routinely require a pregnancy test prior to prescribing. Attitudes about emergency contraceptive pills were measured using 17 items rated on a 4-point Likert scale ranging from (1) "Strongly disagree" to (4) "Strongly agree." Knowledge of emergency contraceptive pills was measured using eight multiple-choice items regarding timing of administration, which medications could be used, efficacy, teratogenicity, side effects, mode of action, and contraindications. Perception of barriers to prescribing emergency contraceptive pills within Kaiser Permanente in San Diego County was measured using 11 items rated on the 4-point Likert scale described above. The item scores for attitudes, knowledge, and barriers were separately summed to create three overall scores.
Paired baseline and follow-up scores were examined using parametric and nonparametric statistics. To control for the large number of statistical tests computed for individual item comparisons, the Bonferroni procedure was used to adjust the alpha level for each set of individual items.
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Results |
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The frequency with which providers prescribed emergency contraception increased significantly from baseline to follow-up (
2 [98] = 25.60, P < .001, Friedman analysis of variance by ranks). The percentage of providers who prescribed emergency contraception at least once a year increased from 30% to 49%. Whereas at baseline 7% of providers (who prescribed emergency contraceptive pills) reported prescribing them at least once a month, at follow-up 26% reported this behavior.
Knowledge about emergency contraceptive pills improved significantly among providers from baseline to follow-up surveys (t [91] = 7.06, P < .001). Providers could answer on average about 1.25 more questions (on the eight-item knowledge scale) correctly at follow-up (4.29 versus 3.00) than at baseline. The percentage of participants who had correct knowledge increased significantly for four of the eight knowledge items (McNemar change tests; Table 2). At follow-up, providers were more knowledgeable about timing, mode of action, and efficacy of emergency contraceptive pills. Despite significant increases in knowledge, providers still had limited information. For instance, only 13% were aware of all the oral contraceptives recommended for emergency contraception, and only 27% correctly indicated the most common side effects of emergency contraceptive pills. Basic facts, such as the 72-hour window first-dose ingestion, were correctly indicated by about two-thirds of the sample.
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). There were no significant differences in changes in prescribing practices, attitudes, knowledge, and barriers by provider specialty (physician or mid-level professional), department, gender, or age.
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Discussion |
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Providers showed increased knowledge about emergency contraception after implementation, but they still had limited knowledge about medications, side effects, and modes of action. Findings suggest that many providers in this medical setting and probably other settings need additional information and training concerning emergency contraception and protocols for its provision.
This study had several limitations. Because there was no control group, it is possible that changes were due to other influences during the intervention time frame. Emergency contraception received increased media attention in 1997; a media campaign occurred in San Diego in fall 1997. Providers also may have been influenced by ensuing national events such as the February 1997 Federal Drug Administration statement that oral contraceptives were safe for use as emergency contraception. It is possible that the informational materials made available to women members of Kaiser-Permanente and increased media attention increased demand. Changes in providers’ knowledge, however, suggest that increased prescribing practices reflect more than increasing local demand.
The response rate was modest. As might be expected, those affiliated with departments with the most interest, namely obstetrics-gynecology, were most likely to complete the baseline. Those who did not complete the surveys most likely had less interest in emergency contraception and would be less likely to prescribe it. The increases in knowledge and prescribing practices of providers may apply only to those most motivated.
This demonstration project supports the feasibility of providing emergency contraceptive pills as a service for women members of a large health maintenance organization. More widespread provision has the potential to significantly reduce health care costs because the alternatives of having an abortion or carrying a pregnancy to term are significantly more costly. Finally, the project is a rare example of a large-scale effort in the United States that promoted international family planning by providing support for introduction of emergency contraception and through sharing of provider educational materials in several developing nations.
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Footnotes |
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Received October 12, 2000. Received in revised form January 13, 2001. Accepted February 22, 2001.
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References |
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2. Hutchings J, Winkler JL, Fuller TS, Gardner JS, Wells ES, Downing D, et al. When the morning after is Sunday: Pharmacist prescribing of emergency contraceptive pills. J Am Med Wom Assoc 1998; 53(Suppl 2):230–2.
3. Wells ES, Hutchings J, Gardner JS, Winkler JL, Fuller TS, Downing D, et al. Using pharmacies in Washington State to expand access to emergency contraception. Fam Plann Perspect 1998;30:288–90.[Medline]
4. Kishen M, Presho M. Emergency contraception—A prescription for change. Br J Fam Plann 1996;22:25–7.
5. Delbanco SF, Stewart FH, Koenig JD, Parker ML, Hoff T, McIntosh M. Are we making progress with emergency contraception? Recent findings on American adults and health professionals. J Am Med Wom Assoc 1998;53(Suppl 2):242–6.
6. Gold M, Schein A, Coupey SM. Emergency contraception: A national survey of adolescent health experts. Fam Plann Perspect 1997;29:15–24.[Medline]
7. Sills MR, Chamberlain JM, Teach SJ. The associations among pediatricians’ knowledge, attitudes, and practices regarding emergency contraception. Pediatrics 2000;104:954–6.
8. Kaiser Family Foundation. Kaiser Family Foundation surveys of Americans and health care providers on emergency contraception. Menlo Park, CA: Kaiser Family Foundation, 1997.
9. Ellertson C, Shochet T, Blanchard K, Trussell J. Emergency contraception: A review of the programmatic and social science literature. Contraception 2000;61:145–86.[Medline]
10. Trussell J, Duran V, Shochet T, Moore K. Access to emergency contraception. Obstet Gynecol 2000;95:267–70.
11. Jenson GA, Morrisey MA, Gaffney S, Liston DK. The new dominance of managed care: Insurance trends in the 1990s. Health Affairs 1997;16:125–36.[Medline]
12. U.S. Health Care Financing Administration. Medicaid managed care enrollment report: Summary statistics as of June 1998. Available via the Internet at http://www.hcfa.gov/medicaid/omc1998.htm. Accessed 2000 Aug 18.
13. Gold RB, Richards CL. Managed care and unintended pregnancy.Womens Health Issues 1998;8:134–47.[Medline]
14. Pettiti DB, Harvey SM, Preskill D, Beckman LJ, Postlethwaite D, Switsky H, et al. Emergency contraception: Preliminary report of a demonstration and evaluation project. J Am Wom Med Assoc 1998;53(Suppl 2):250–4.
15. Chronbach LJ. Coefficient alpha and the internal structure of tests.Psychometrica 1951;16:297–334.
16. DeVellis RF. Scale development: Theory and applications. Newbury Park, CA: Sage, 1991.
This article has been cited by other articles:
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  Committee on Adolescence Emergency Contraception Pediatrics, October 1, 2005; 116(4): 1026 - 1035. [Abstract] [Full Text] [PDF]
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 E. Espey, T. Ogburn, D. Howard, C. Qualls, and J. Ogburn Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico Obstet. Gynecol., November 1, 2003; 102(5): 918 - 921. [Abstract] [Full Text] [PDF]
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R. A. Jackson, E. B. Schwarz, L. Freedman, and P. Darney Advance Supply of Emergency Contraception: Effect on Use and Usual Contraception--A Randomized Trial Obstet. Gynecol., July 1, 2003; 102(1): 8 - 16. [Abstract] [Full Text] [PDF]
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