Attitudes of women in Scotland to contraception: a qualitative study to explore the acceptability of long-acting methods.

BACKGROUND AND METHODOLOGY: Long-acting reversible contraception (LARC) (i.e. injections, implants and intrauterine methods) has the potential to reduce unintended pregnancies but in the UK these methods are under-used. To inform a campaign planned to increase awareness of LARC, eight focus discussion groups were held with 55 women in two cities in Scotland, UK. Trained interviewers sought spontaneous views of unintended pregnancy and contraception in general, and condoms and pills in particular, and attitudes towards health professionals giving contraceptive advice. Attitudes towards LARC were discussed both before and after women were given detailed information about the methods. RESULTS: Women recognised the importance of using contraception but admitted to taking risks. Pills and condoms were familiar and acceptable despite undesirable side effects. Women were poorly informed about LARC, had firm but incorrect beliefs about their safety and side effects, disliked any method which involved an invasive procedure and/or vaginal examination, and had rather a low opinion of advice given by health professionals. Accurate information was not wholly successful in dispelling negative views of LARC. DISCUSSION AND CONCLUSIONS: Many factors influence contraceptive choice. Attitudes towards methods are complex and may be difficult to change. Some barriers to LARC, including the need to see a health professional, cannot be overcome but giving more information about ease of use, reversibility, effects on weight and the positive experiences of other women, as well as describing these methods as lasting rather than long-acting, may help improve acceptability.

Effect of depot medroxyprogesterone acetate on bone density in a Scottish industrial city.

OBJECTIVE: To determine if long-term users of depot medroxyprogesterone acetate injectable contraception (DMPA) were more likely than their peers to have low bone density. DESIGN: Cross-sectional observational study. SETTING: The Domiciliary Family Planning Service, Glasgow, Scotland. SUBJECTS: Clients of the Domiciliary Service who had used DMPA for contraception for longer than 5 years (mean 12 years) were invited to participate and select their own control, a friend or relative who had never used this method of contraception. MAIN OUTCOME MEASURES: Bone density measured at the hip and lumbar spine by dual X-ray absorptiometry (DXA). RESULTS: DMPA users had a significantly lower bone density than controls, 12-13% less at both hip and lumbar spine. This difference remained even when controlling for parity, smoking, family history of kyphosis or hip fracture, and body mass index. CONCLUSIONS: DMPA significantly decreases bone density in a group of long-term users with significant social deprivation. The long-term significance of this remains uncertain.

Low literacy: a hidden problem in family planning clinics.

OBJECTIVES: Low literacy is highly prevalent among UK adults. This study assessed functional health literacy among family planning clinic clients and whether this was associated with sexual health knowledge and behaviours. It also assessed the readability of patient leaflets. METHODS: 505 female family planning clinic attendees aged 16-35 years were interviewed about their sexual behaviour and knowledge. Their reading age was assessed using a validated test (REALM). The readability of leaflets on contraception supplied to clinic users was measured. RESULTS: All respondents had a reading age of 12 years and above, 221 (43.8%) between 12 and 14 years and 284 (56.2%) greater than 14 years. Those in the lower literacy group were significantly more likely to have been aged under 16 years at time of first sexual intercourse, and significantly less likely to know the most fertile time of the menstrual cycle, to identify sexually transmitted infections and to know that sexual infections can be transmitted through oral and anal sex. The reading age of information leaflets in the clinics ranged from 11 to 17 years. Thus, clients with a reading level of 12-14 years would have difficulty in understanding some of the leaflets. CONCLUSIONS: Functional health literacy is related to sexual behaviour and knowledge. Written information should be prepared with this in mind and other routes of communication considered.

Risk of pregnancy and external validity in clinical trials of emergency contraception.

OBJECTIVES: To compare women who enroll in emergency contraception (EC) trials to those who decline and to understand why eligible women decline to participate. METHODS: Data were collected from all women seeking EC (n = 5,787) at three clinics in the USA and UK during a period of nearly 1 year (from September 1997 to August 1998). The main outcome measures were pregnancy risk calculated by adjusted cycle day of ovulation. RESULTS: Enrolled and non-enrolled women had similar mean ages and similar mean cycle lengths. However, the enrolled and non-enrolled groups were different with respect to adjusted cycle day of unprotected sexual intercourse (UPSI), the regularity of their cycles, recent hormone use, breastfeeding, the number of other acts of UPSI they had engaged in during the same cycle, and their willingness to participate in the study. Expected pregnancy risk among enrolled patients was higher than among non-enrolled EC seekers (6.5% vs 5.0%, p<0.001, calculated using Dixon conception probabilities, and 5.4% vs 4.6%, p = 0.086, calculated using Trussell conception probabilities). Unwillingness to take part in the study was the most common reason women did not enrol in the trial. Otherwise-eligible women most often declined to enrol because they were concerned about the effectiveness of the trial regimen. CONCLUSIONS: Women in EC trials are likely to face higher pregnancy risk than the general population. Clinical trials might overestimate the number of pregnancies averted by treatment because the number of expected pregnancies in trial populations is not representative of the population of all EC seekers. This information could be useful in projecting the public health impact of expanded EC access.

Recording what happens in the under-16 consultation.

BACKGROUND: Clinical staff offering sexual health services to young people need to balance the rights of the young person to confidentiality and good quality advice with the need to protect their wider interests. The needs of young clients may be complex and raise ethical and medico-legal questions for the staff involved in their care. METHODS: In our large, integrated sexual health service, a 'recording form' was introduced to prompt staff to record data systematically pertinent to consultations in clients under 16 years of age, to understand what kind of presentations dominate in these consultations, and to establish how common child protection concerns are. RESULTS: From April to October 2004, more than 500 forms were completed in our service. The age range for female clients was 12-15 years, with the median age of first sexual intercourse 14 years. Most respondents were in consensual relationships with partners of around their own age, but 10% had been in relationships of less than a week's duration. Most had not told their parents of their sexual activity and did not intend to. Child protection issues did occur, although not commonly. CONCLUSIONS: Most clients initially present requesting emergency contraception or pregnancy testing, and the inference is that unprotected sexual intercourse is common in this group of clients before they seek our services. The data collected give a valuable overview of the type of issues dealt with in the clinical context and can help to target training and teaching, in addition to potentially highlighting child protection issues.

A comparative study of clinical management strategies for vaginal discharge in family planning and genitourinary medicine settings.

OBJECTIVE: To compare strategies for management of women with vaginal discharge in genitourinary medicine (GUM) and family planning (FP) settings. METHODS: The setting was a centre housing both FP and GUM departments within a primary care trust in Scotland. The study participants were 200 women presenting with vaginal discharge. A randomised, controlled, crossover design was employed. Strategies typical of FP and GUM were performed on every participant in a randomised sequence. Day 1 diagnoses were made by the FP strategy (history and examination) and the GUM strategy (nearpatient microscopy added). Day 7 results were obtained from final analysis of all specimens. Days 1 and 7 results were compared with the reference standard provided by all the test results. The main outcome measures were incorrect diagnoses on Days 1 and 7. RESULTS: On Day 1 the FP strategy resulted in significantly more incorrect diagnoses than the GUM strategy when compared with the reference standard (73 vs 32; p <0.001). On Day 7 the GUM strategy resulted in significantly more incorrect diagnoses than the FP strategy when compared with the reference standard (32 vs 17; p = 0.019). CONCLUSIONS: Vaginal discharge can be managed effectively in community settings such as FP and primary care. The addition of near-patient microscopy produces a more accurate immediate diagnosis. The addition of a high vaginal swab for culture produces a more accurate final diagnosis. The costs of on-site microscopy must be considered.

What do clients of a young people's sexual health service recall about their sex education programme at school?

OBJECTIVES: To assess young people's recall of school-based sexual health education. METHODS: Clients attending The Place, an open-access sexual health service for young people, were asked to recall whether they had received teaching on key areas of sex education outlined in the Scottish Executive's draft Sexual Health and Relationship Strategy and Greater Glasgow NHS Board's guidelines for sex education in schools.Their responses were analyzed by age, sex, and type of school attended. RESULTS: Although most could remember receiving some teaching about risks of sexual activity, there was little recall of teaching in positive areas of sexual health, such as having good relationships, rights and responsibilities, and being good parents. CONCLUSIONS: Further research is needed to establish why recall of taught sex education is low in this group of clients, and how to improve retention of important sexual education information.

Client perspectives on sexual health service provision.

Development of integrated genitourinary medicine (GUM) and family planning (FP) services must take into account the views and requirements of service users. As we strive to modernize sexual health services, various changes are being introduced, such as a policy of no microscopy for selected patients attending GUM clinics. In order to determine the views of our clients prior to implementation of change, we performed a qualitative study in our UK centre, which houses both FP and GUM. One hundred women presenting to FP and 100 to GUM were interviewed. In addition, we collected details of their characteristics to identify any significant differences in users attending each clinic. A summary of their views and characteristics is presented. Although near-patient testing results in a longer time spent in clinic, 99% of participants expressed a preference for immediate microscopy results and treatment. GUM and FP clients exhibited many similar characteristics.

Effect of hormonal emergency contraception on bleeding patterns.

Spotting following the use of emergency contraception is not unusual, nor is anxiety in women waiting to see if the treatment has worked. It is not known whether such spotting should bring worry or relief. We, therefore, wished to see if there was any correlation between bleeding pattern and treatment outcome. Using data from a large multicenter efficacy trial, we examined bleeding patterns post-emergency contraception. The earlier in the cycle the pills were taken, the more likely the next bleed was to be early and the less likely it was to be on time. There was no observable difference in spotting rates between women who got pregnant and those who did not. The occurrence of spotting did not influence whether the next period was lighter or heavier.

Modifying the Yuzpe regimen of emergency contraception: a multicenter randomized controlled trial.

OBJECTIVE: Emergency contraceptives can prevent unintended pregnancy after unprotected intercourse. The best-studied regimen ("Yuzpe") consists of ordinary combined oral contraceptives containing levonorgestrel and ethinyl estradiol. Women traditionally take one dose within 72 hours after unprotected intercourse, and a second dose 12 hours later. Historically, half experience nausea and a fifth vomit. The purpose of this study was to determine whether 1). women could use combined oral contraceptives other than those containing levonorgestrel and 2). eliminating the second dose improves comfort and convenience. METHODS: Women presenting within 72 hours after unprotected intercourse were randomized to receive 1). standard two-dose Yuzpe, 2). a variant of Yuzpe substituting norethindrone for levonorgestrel, or 3). only the first dose of Yuzpe, followed 12 hours later by a placebo. RESULTS: Perfect-use failure rates were low in all groups and did not differ in a statistically significant way (standard Yuzpe 2.0% [n = 589], norethindrone-ethinyl estradiol 2.7% [n = 547], single dose of Yuzpe 2.9% [n = 546]). Typical-use failure rates were slightly higher but similarly did not differ significantly. Side effects were similar across groups, except that women taking the single dose reported half the vomiting. Taking the pills with food did not seem to reduce nausea or vomiting, and the pills were not more effective when started sooner after unprotected intercourse. CONCLUSION: Oral contraceptives containing norethindrone-ethinyl estradiol work approximately as well for emergency contraception as levonorgestrel-ethinyl estradiol formulations and should be offered when first-line therapies are not available.

Assessment of compliance with a weekly contraceptive patch (Ortho Evra/Evra) among North American women.

OBJECTIVE: To determine compliance with the contraceptive patch (Ortho Evra/Evra) overall and by age among women in North America and to compare rates of perfect use with those of an established oral contraceptive. DESIGN: Data were pooled for three contraceptive studies in which women participated for up to 13 cycles; the subset of centers in North America was used in this analysis. SETTING: 76 North American centers. PATIENT(S): Healthy women 18-45 years of age. INTERVENTION(S): In all studies, the patch regimen was three consecutive 7-day patches (21 days) followed by 1 patch-free week per cycle. MAIN OUTCOME MEASURE(S): Perfect use for the patch or oral contraceptive, defined as 21 consecutive days of drug-taking followed by a 7-day drug-free period; for contraceptive patch users, no patch could be worn for more than 7 days. Oral contraceptives were used according to package labeling. RESULTS: For all contraceptive patch users in North America (n = 1,785), perfect use was consistent across age groups. The percentage of cycles with perfect use of the patch ranged within age groups from 88.1% to 91.0%. In the comparative study conducted only in North America, perfect use was also consistent across age groups for the patch (n = 812), but rates of perfect use for the oral contraceptive (n = 605) differed significantly by age. CONCLUSION(S): Age did not affect compliance with the patch among all North American women studied. In a comparative study of women at North American centers, compliance with the weekly contraceptive patch was significantly better than with an established oral contraceptive. The contraceptive patch is uniformly easy to use across all ages.