In Honduras, Knowledge of Emergency Contraception Increases, but Use Does Not
Following public outreach activities promoting emergency contraception, awareness of the method among Honduran adults visiting family planning clinics in two cities quadrupled and concerns about it decreased, but willingness to use the method declined.1 The proportion of clients who had heard of emergency contraception rose from 5% to 20% between the 2001 preintervention survey and the 2003 postintervention survey, and the proportion who expressed concerns about the method fell from 26% to 20%; over the same period, however, willingness to use the method dropped from 80% to 71%.
This study examined knowledge about, attitudes toward and use of emergency contraception among urban family planning clients following the addition of the method to the National Family Planning Norms in 1999 and countrywide outreach activities that began in 2001. The surveys were conducted at a clinic in Tegucigalpa and another in San Pedro Sula; the clinics are run by a nongovernmental organization, and serve primarily lower-middle-class residents. More than 1,400 respondents were interviewed for the baseline survey and nearly 1,300 at follow-up. Respondents were asked about their demographic characteristics, pregnancy history, sexual behavior and contraceptive use, as well as their knowledge and attitudes about and use of emergency contraception. Chi-square tests determined significant differences between the surveys, and multivariate logistic regression models assessed associations between various characteristics and the emergency contraception measures.
The age distribution of respondents in the two surveys was similar: About 8% were aged 15–19, 43% were in their 20s, 31% were in their 30s and 19% were 40 or older. The proportion of respondents who were female was significantly higher at baseline than at follow-up (85% vs. 81%), as was the proportion of all respondents who had less than a high school education (56% vs. 50%). In each survey, more than eight in 10 respondents were sexually active, and the same proportion had been pregnant or had impregnated a partner; however, the proportion who were currently using a contraceptive declined between surveys (84% vs. 72%). Three-fourths of follow-up clients were married or in common-law unions. There were significant differences between surveys regarding emergency contraception: The level of awareness of the method rose from 5% to 20% of respondents, and the proportion with concerns about the method declined from 26% to 20%, but the proportion willing to use it fell from 80% to 71%. Only 6–8% of respondents in either survey had used the method in the past year.
Awareness of the method increased among all demographic groups, and did not vary by sexual experience, pregnancy history or contraceptive use. Nevertheless, there were differences among various groups. For example, levels of awareness at follow-up were much lower in San Pedro Sula than in Tegucigalpa (9% vs. 28%), and were higher among those aged 15–19 or 20–24 than among those 40 or older (28–30% vs. 12%). Furthermore, awareness levels in the postintervention survey were dramatically different depending on respondents' education: 11% among those with less than a high school education, 17% among those who had finished high school and 42% among those with higher education. Willingness to use emergency contraception fell from 90% to 68% among respondents in San Pedro Sula, and remained steady at 72–73% in Tegucigalpa. Notably, willingness declined for most of the other categories, although not among the youngest age-group or those with the most education. When asked whether the availability of a dedicated product would increase Honduran women's willingness to use the method, 90–93% of respondents in both surveys said that it would.
Multivariate regression analysis found that the likelihood of being aware of emergency contraception was higher among follow-up clients than among baseline clients (odds ratio, 4.9), among those with a high school or higher education compared with those having less education (1.7 and 5.1, respectively) and among those currently using a contraceptive than among nonusers (1.5). Respondents living in San Pedro Sula were less likely than those in Tegucigalpa to be aware of the method (0.4), and respondents aged 40 or older were less likely than those who were younger to be aware of it (0.5). The odds of being willing to use the method were lower among those aged 30 or older than among those aged 15–29 (0.2–0.5), among females than among males (0.8) and among those assessed at follow-up than among those assessed at baseline (0.5).
The multivariate analysis also found that respondents in San Pedro Sula were less likely to report concerns than were those in Tegucigalpa (odds ratio, 0.8), and that respondents at follow-up were less likely to do so than those at baseline (0.6). However, clients with at least a high school education were more likely to have concerns than those with less education (2.1–3.1), and those who were using a contraceptive were more likely to have concerns than were nonusers (1.5). The most common concerns were that the method caused side effects, acted as an abortifacient, failed often or was ineffective, might harm the fetus if it did fail or might cause future fertility problems.
According to the researchers, the study has several limitations. First, a media campaign by the Catholic Church and Honduran antiabortion groups coincided with the follow-up surveys and may have countered any effect the intervention had on levels of concerns and willingness to use emergency contraception. Second, clients were asked only whether they had used the method in the past year, and the question on willingness may not have differentiated between those who approved of the method and those who felt they would not need to use it. Finally, clients' marital status was not determined at baseline, and so its effect on awareness and use could not be determined.
The researchers suggest that outreach efforts should target young people, both because respondents younger than 25 showed the highest awareness of and willingness to use the method, and because they are at high risk of unwanted pregnancy. They also recommend that efforts be directed at Hondurans with less than a high school education. In addition, they say family planning counseling should be promoted and strengthened among clinic workers, physicians and pharmacists, as these workers could be a valuable source of accurate information. The researchers emphasize that "future educational efforts should be aimed at increasing specific knowledge about emergency contraception, its proper use, and its effectiveness" to counter misinformation, and that proponents of emergency contraception "must develop timely and strategic counterresponses" in this often contested arena of reproductive health.—J. Thomas
1. García SG et al., Emergency contraception in Honduras: knowledge, attitudes, and practice among urban family planning clients, Studies in Family Planning, 2006, 37(3):187–196.