Elsevier

Contraception

Volume 93, Issue 6, June 2016, Pages 556-564
Contraception

Original research article
“I don't know enough to feel comfortable using them:” Women's knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus,☆☆

https://doi.org/10.1016/j.contraception.2016.02.007Get rights and content

Abstract

Objective

To assess multiple dimensions of long-acting reversible contraception (LARC) knowledge and perceived multi-level barriers to LARC use among a sample of college women.

Study Design

We conducted an Internet-based study of 1982 female undergraduates at a large mid-western university. Our 55-item survey used a multi-level framework to measure young women's understanding of, experiences with intrauterine devices (IUD) and implants and their perceived barriers to LARC at individual, health systems and community levels. The survey included a 20-item knowledge scale. We estimated and compared LARC knowledge scores and barriers using descriptive, bivariate and linear regression statistics.

Results

Few college women had used (5%) or heard of (22%) LARC, and most self-reported “little” or “no” knowledge of IUDs (79%) and implants (88%). Women answered 50% of LARC knowledge items correctly (mean 10.4, range 0–20), and scores differed across sociodemographic groups (p values < .04). Factors associated with scores in multivariable models included race/ethnicity, program year, sorority participation, religious affiliation and service attendance, employment status, sexual orientation and contraceptive history. Perceived barriers to IUDs included the following: not wanting a foreign object in body (44%), not knowing enough about the method (42%), preferring a “controllable” method (42%), cost (27%), and not being in a long-term relationship (23%). Implant results were similar. “Not knowing enough” was women's primary reason for IUD (18%) and implant (22%) nonuse.

Conclusion

Lack of knowledge (both perceived and actual) was the most common barrier among many perceived individual-, systems- and community-level factors precluding these college women's LARC use. Findings can inform innovative, multi-level interventions to improve understanding, acceptability and uptake of LARC on campuses.

Implications

Lack of knowledge of IUDs and implants served as a primary barrier to highly effective contraceptive use among these college women. Comprehensive, patient-centered and multi-level educational public health strategies are needed to promote positive campus climates around LARC and improve family planning outcomes among this substantial reproductive-aged population.

Introduction

Leading health organizations have recognized long-acting reversible contraception (LARC) as a strategic priority to reduce rates of unintended pregnancy among young women in the United States and worldwide [1], [2], [3], [4]. Intrauterine devices (IUDs) and implants are highly efficacious, safe and cost-effective, and have higher satisfaction and continuation rates compared to other contraceptive methods [1], [2], [3], [4], [5], [6], [7], [8]. Nonetheless, use of LARC remains low in the United States. An estimated 6.4% and 0.8% of sexually active women use IUDs and implants, respectively [9]. Estimates are lower for adolescents and young adult women [10] and are similar for specific groups who are historically believed to have greater access to and knowledge of contraception, such as women in higher education programs [11]. In the most recent American College Health Association's National College Health Assessment (NCHA), 6.6% of sexually active females reported IUD use at last intercourse and 2.7% reported implant use [11].

College settings are an underutilized resource for improving young women's use of highly effective contraception. Women 18–24 years of age experience the highest rates of unintended pregnancy in the United States and comprise over half of the 18 million students attending US colleges; thus, campuses offer a unique opportunity to reach large, diverse numbers of women and reduce unintended pregnancy among this high-risk group [12], [13]. The NCHA, the most comprehensive, recurring survey of college students' health, collects little information on family planning outcomes or contraception method awareness, experiences and barriers to use [11]. An increasing body of research on IUDs, and to a lesser extent implants, from other contexts suggests that lack of knowledge and misconceptions are prevalent among young women generally, although these results have often been based on studies with clinical settings, small sample sizes, limited measurement approaches and inadequate attention to multiple dimensions of knowledge (e.g., mechanisms of action, efficacy, risks, benefits, use) [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]. Furthermore, research to date has not adequately considered young women's perspectives on the diverse factors operating across levels of their environment which influence LARC knowledge, attitudes and uptake, especially in college contexts and among this high-risk age demographic.

We sought to describe knowledge, perceptions and experiences regarding IUDs and implants among a sample of college women and identify women's perceptions of individual-, health systems- and community-level barriers to LARC use on campuses.

Section snippets

Study design and sample

This study was part of a larger multiphase, mixed-method project aimed at identifying and addressing multi-level barriers to LARC in college settings. We conducted an Internet-based survey of undergraduate females at a large mid-western US university in fall of 2013. All full-time enrolled female undergraduate students who were English speaking and aged ≥ 18 years (n = 13,693) were eligible and e-mailed a series of invitations to participate in a “survey on reproductive health” through the Office

Sample characteristics

Characteristics of the sample (n = 1982) are presented in Table 1. The mean age was 19 years, and women were dispersed evenly across years in their undergraduate programs. The majority were white (75%), insured (90%), employed (67%); had mothers with at least some college education (91%); and identified as heterosexual (87%). Significant proportions resided on campus (43%), were not in a relationship (46%), were not religiously affiliated (34%) and never attended religious services (36%). Most

Discussion

Among this large sample of undergraduate women, knowledge of IUDs and implants was exceedingly low, estimated by both self-report and our formal LARC knowledge scale. In fact, women's perceived knowledge was much lower than their measured knowledge and the most salient individual-level perceived barrier precluding IUD and implant use was “not knowing enough.” Moreover, misperceptions about side effects, pain, serious health problems and method eligibility were other common barriers. These

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    Disclosures: V.K.D. served as an expert witness for Bayer Pharmaceuticals in 2014.

    ☆☆

    Acknowledgements/Funding: This work was supported by NICHD Grant Nos. K12HD001438 (K.S.H.), T32HD007339 (E.E.), and R24HD041028 (K.S.H. and E.E.); the Society of Family Planning No. SFPRF7-T5 (A.C. and K.S.H.); and Robert Wood Johnson Foundation Clinical Scholars Program (M.M.), and received support from the Department of Obstetrics and Gynecology and Program on Women's Health Care Effectiveness Research at the University of Michigan (Director V.K.D.).

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