Department of Public Health and Caring Sciences
Section of Caring Sciences
Knowledge, Use and Perceptions of
Emergency Contraceptive Pills among
Undergraduate University Students in Thailand
Author:
Supervisor:
Ida Gröning Wallner
Pranee Lundberg
Johanna Bennhult Hansson
Supunee Thrakul
Benjamapoen Butsripoom
Examinator:
Marianne Carlsson
Thesis, 15 ECTS credits
Nursing Program 180 ECTC credits
2012
Abstract
Even if abortions are illegal in Thailand, except from some circumstances, it still occurs. Unwanted pregnancies and induced abortions are made among Thai youths. The aim of this study was to examine the knowledge, use and perceptions of Emergency contraceptive pills (ECPs) among undergraduate university students in Bangkok, Thailand, and also investigate differences between genders concerning these issues. An empirical descriptive cross- sectional study was performed. A quantitative method was used and Dorothea Orem’s Nursing Theory of Self- care deficit was provided as the theoretical framework. A questionnaire was distributed to 210 students at a university outside Bangkok. The result shows that 84% of the male and 88.9% of the female students knew that the purpose of using ECPs is to avoid unwanted pregnancies. About 36% of the males and 36% of the females had the misconception that ECPs aborts fertilized ovum. Around 21% of the male and 13.7% of the female students had the experience of using ECPs. One common perception among the students was that ECPs are the best method to prevent from unwanted pregnancies, 14.7% of the males and 27.7% of the females perceived that. This study results indicate that more knowledge about ECPs are required for these students.
Key words: Emergency Contraception Pills, Knowledge, Perception, Consumption, Thai
Sammanfattning
Även om det är olagligt med aborter i Thailand, förutom under vissa omständigheter, sker dessa. Oönskade graviditeter och inducerade aborter förekommer bland unga thailändare. Syftet med denna studie var att undersöka kunskap, användande och uppfattningar av akut p-piller bland universitetsstudenter i Bangkok, Thailand, och även undersöka skillnaderna mellan kön gällande dessa områden. En empirisk deskriptiv tvärsnittsstudie genomfördes och en kvantitativ metod användes. Dorotea Orems egenvårdteori användes som teoretiskt ramverk i studien. Ett frågeformulär delades ut till 210 studenter på ett universitet utanför Bangkok. Resultaten visade att majoriteten av studenterna visste att akut p-piller ska användas i syfte att undvika oönskade graviditeter, 84% av de manliga och 88.9% av de kvinnliga studenterna visste det. Ca 36% av männen och 36% av kvinnorna hade missuppfattningen att akut p-piller aborterar ett befruktat ägg. Ungefär 21% av de manliga och 13.7% av de kvinnliga studenterna sa att de hade erfarenhet av akut p-piller-användning. En vanlig uppfattning bland studenterna var att akut p-piller är den bästa metoden för att förebygga oönskade graviditeter, 14.7% av männen och 27.7% av kvinnorna hade den uppfattningen. Resultatet visar på att mer kunskap om akut p-piller behövs bland dessa studenter.
Nyckelord: Akut p-piller, kunskap, uppfattningar, konsumtion, thailändska
Contents
1. Introduction………...1
1.1 Pregnancies and abortion methods in the world………1
1.2 Emergency contraception pills………...1
1.3 Knowledge, use and perception of emergency contraception pills (ECPs) in developed countries………...…2
1.4 Knowledge, use and perception of ECPs in developing countries………...3
1.5 Source of information and availability of ECPs………....5
1.6 Abortion situations, usage and knowledge about contraceptive methods in Thailand………...5 2. Theoretical framework ………..7 3. Rational of research….………...7 4. Aim………...8 5. Research questions……….8 6. Method ...8 6.1 Design………....8 6.2 Setting ………...8 6.3 Sample ………...9
6.4 Data collection method ……….9
6.5 Procedure ………11
6.6 Data analysis ………...12
7. Ethical considerations ………..12
8. Results ………..13
8.1 Demographics characteristics………..13
8.2 Knowledge about ECPs………...14
8.3 Usage of ECPs……….22
8.4 Perceptions of ECPs………25
9. Discussion ………...27
9.1 Result discussion……….27
9.2 Theoretical framework discussion………..30
9.3 Method discussion………...32
9.4 Conclusion………..34
9.5 Acknowledgement………..34
Appendix
1. INTRODUCTION
1.1 Pregnancies and abortion methods in the world
According to World Health Organization approximately 200 million pregnancies occur every year in the world. Eighty-four millions of these pregnancies are unwanted and 46 millions of them end in an induced abortion. Unplanned pregnancy is a worldwide health problem and half of the abortions are performed under unsafe conditions (Berer, 2000). The abortions are performed by injecting a range of substances into the uterus, for example saline, distilled water, cumin mixed with water, alcohol and gasoline. Massage is another common method where a professional try to locate the fetal mass by extern palpation and then press, pull and jab with the fingers to dislodge it. This often continues until the women are bleeding. Vaginal suppository, oral tablets and surgery are also common abortion methods (Whittaker, 2002). Unsafe abortion methods are likely to give intrauterine bleedings, infections and cervical damages. Therefore, giving knowledge about contraceptive methods among women is important, even when it comes to safeguard women's reproductive health (Lo, 2002). Inadequate use of contraceptives and lack of knowledge regarding fertility have an important connection with the number of unwanted pregnancies (Berer, 2000).
1.2 Emergency contraception pills
To prevent pregnancy the use of different contraception methods is necessary, such as condoms, oral contraception pill or intrauterine methods. If a contraceptive method fails, an emergency contraceptive pill (ECP) can be taken by the woman after an intercourse. The use of ECP is a temporary post-coital anticonception method and should not replace common contraceptive methods (Haque & Soonthorndhada, 2009). The active substances in ECPs differ and may be, for example, Levonorgestrel, which inhibits the ovulation. This is a synthetic form of progesterone which is a naturally occurring female sex hormone, which is necessary for a pregnancy. ECPs may also contain Mifepristone which also inhibits Progesterone. It is not clearly known about the mechanism of action of ECPs, but the most probable is that the ovulation inhibits. It may be other mechanisms included, like prevent the fertilized egg from attaching to the uterus. The ECPs should be taken orally as soon as
administrated up to 72 hours after completion of intercourse, but cannot interrupt an ongoing pregnancy. ECPs can be used throughout the menstrual cycle (Farmaceutiska Specialiteter I Sverige [FASS], 2011).
1.3 Knowledge, use and perception of emergency contraception pills in developed countries
About 95 % of the young people in the USA had heard of ECPs and more than half of them could not distinguish therapy with ECPs which is used after unprotected intercourse, from the therapy taken for induced abortion when an unwanted pregnancy occurs. Positive perceptions of using ECPs are reported by 80% of the youth and 91% approve the use of ECPs in case of rape (Harper & Ellerston, 1995). In another study made in USA (Corbett, Mitchell, Smith Taylor & Kemppainen, 2006) shows that almost every one of the respondent students had heard of ECPs and 71% knew that ECPs prevents pregnancy. Around four out of five students knew that ECPs is available in the USA. Almost half of the students could not distinguish ECPs from the pill taken when you want an abortion.
Students in the study made by Corbett et al. (2006) meant that they did not have any religious or moral objections to ECPs, but almost every student who was very unlikely to use ECPs had religious or moral objections to the method. The authors had study the students’ behavior related to the use of ECPs. They found out that over half of the female students reported that they would use ECP in failure of chosen contraceptive method. The likelihood to use ECPs should increase if they already had a pill at home, even among the women which reported that they were very unlikely to use ECPs. Fewer than half of the male students said that they would be likely to recommend ECPs to their partner if needed (Corbet et al., 2006). In another study made in USA, women aged 18-24 with higher income, were most likely to have heard about ECPs. Women with health care funded from government and those living in rural areas were less likely to have awareness of ECPs (Baldwin, Solorio, Washington, Yu, Huang & Brown, 2008).
In Sweden, ECPs are quite well known among the young adults and the teenagers, but the specific knowledge about the way of using ECPs after the intercourse and the working mechanism are not widespread among them. Young women had more knowledge about ECPs and were more frequent users than women over 30 years old. About 54% of the women thought that ECPs is a fertilizatior preventer and 16% did not knew the mechanism of action.
Around one out of three thought that ECPs is an abortifacient (Aneblom, Larsson, Odlind & Tydén, 2003).
Falah-Hassani, Kosunen, Rahman and Rimpelä (2007) found in Finland that almost every girl aged 18 years old knew about ECPs and 29 % of them had ever used the pill. The use of ECPs increased with dating relationship. The girls who lived in cities used ECPs more often than the girls who lived in capital cities. Those who lived in sparsely populated areas used ECPs less often. Education career, school achievement and urbanization level was not associated with the use of ECPs. The girls who drank alcohol and smoked had a higher knowledge and use of ECPs than those who did not drink or smoke. Socio-economic background and religion were not associated with unawareness of ECPs. Girls aged 16-18 from rural village and capitals had better knowledge about ECPs (Falah- Hassini et al,. 2007).
1.4 Knowledge, use and perception of emergency contraception pills in developing countries
In developing countries, ECP is still quite unavailable (Lovvorn, Nerquave- Tetteh, Glover, Amankwah- Poku, Hays & Raymond, 2000). A study by Byamugisha, Mirembe, Fazelid and Gemzell-Danielsson (2006) among university students in Uganda, showed that they had lack of knowledge regarding ECPs as a therapy and how they act. Less than half of the students had ever heard of ECPs and one out of three students had the misconception that ECPs interrupt an ongoing pregnancy. Around 7% of the students had experience from using ECP. The knowledge of general features of ECPs was low in Cameroon and the level of misinformation was high among the students. Their knowledge differed depending on where they had got their information from. Informal sources such as family and friends gave inadequate and misleading information while information from medical and professional sources gave better knowledge about ECPs. The students’ perceptions of ECPs were in general positive, but 65 % thought that ECPs were unsafe to use. About 7% of the students had used ECP (Kongnyuy, Ngassa, Fomulu, Wiysonge, Kouam & Doh, 2007).
In Curacao, socio- cultural and economic factors are related to ineffective use of contraception and inadequate sexual education. In the study by Van Den Brink, Boersma, Meyboom-de Jong and de Bruijn (2011), 9 % of the respondents reported that they had ever used ECPs. It is taboo on discussing sexuality and that leads to poor sexual education and also to poor
education in how to use contraception. In China, teenager and less educated women used ECPs less often than young adults and higher educated women and they also had less knowledge on fertility control (Meng, Gemzell-Danielsson, Stephansson, Kang, Chen & Cheng, 2009). The study result shows the needs to give adequate information about contraceptive methods to women in reproductive age. In this study 6.5% of the pharmacists in Shanghai thought that ECPs could work as a substitute for regular birth control methods. In India, the ECPs were introduced in year 2000. Around 7% of Indian female college students reported that they were aware of emergency contraceptive methods and 73% of the students knew about the ECPs. Most students did not have any knowledge about the time frame in which the ECPs had to be taken. Of the students who were aware of the pill, one out of ten did not know about the side effects of ECPs. One out of three reported the ECPs could be used in the case of rape and almost half of them thought ECPs should be used by married couples. Even though the majority of the students thought that ECPs had no impact on fertility, some students had the perception that the usage of ECPs increases the risk of infertility (Puri et al., 2007).
A study about knowledge and awareness of ECPs in Nepal has been done among male and female college students. The results showed that 68% of the students had heard of ECPs. The awareness and knowledge about the pill had a clear association with for example age, sex, education level and place of residence. Male students who aged 15-19 years old and those who had low education level had slightly higher knowledge and awareness about ECPs when compared with female students and those with high education level. Other important factors related with higher knowledge and awareness regarding ECPs was if the students came from the suburb, if they lived alone or with friends and if they had received reproductive health education in school (Adhikari, 2009).
1.5 Source of information and availability of ECP
The Swedish teenagers identified the main source of information about ECPs from friends. The second main source of information came from media (Aneblom et al., 2003). In USA students said that television and friends or relatives were the primary source of information about ECPs. If they would like to seek good information about the pills, over 40% would go to their doctor (Corbet et al., 2006). The main source of information about contraceptive methods in Curacao came from school. Parents, especially the mother, were also an important
main source (Van Den Brink et al., 2011).
One of the most important parts in the pursuit of making ECPs more known and used is the over-the-counter sales. The access to this regimen has a crucial role in regarding the frequency of the usage of ECPs (Lo, 2002). The author believed that an easy availability of ECPs might encourage unprotected intercourse (Meng et al., 2006). The study by Meng et al. (2006) showed that ECP- users, who had received information about ECPs, were more presumptive to use contraception and they had more general knowledge of contraceptive methods.
To promote the sexual behavior and health among the youth, it is necessary to incorporate the cooperation from multiple sectors. One way is to give information about ECPs and sexual education to the whole family and not only to the teenagers. This should be given in addition to the education that is given in schools and in the national health programs (Saranrittichai, Sirtanyarat & Ayuwat, 2006). One way of encourage the women to use the ECPs is to counsel them about the method and to instruct them how to use ECPs after unprotected intercourse. Another alternative way is to give the women a packet of ECPs to keep at home and use when they need. Some concerned that if the women have ECPs at home, they will be more careless, and maybe stop using their regular contraceptive methods (Lovvorn et al., 2000).
1.6 Abortion situations, usage and knowledge about contraceptive methods in Thailand In case of rape, danger to a women health or seduction of a girl under 15 years old, it is legally to go thru an abortion. In any other circumstances, abortion is illegal in Thailand. Still, abortions in Thailand occur. This is an important health issue for Thai women. Unsafe methods performed by untrained personnel is common, especially for whom who have bad economics. Some Thai who are Buddhist have own conflicts regarding to have an induced abortion or not in the case of unplanned/unwanted pregnancy. They mean that it may affect their reincarnation and karmic status. Between 80 000- 300 000 abortions are performed illegal each year in Thailand (Whittaker, 2002). As many as 74% of them are made outside hospitals and are performed by uneducated personnel using unsafe methods. Usages of medical tools that are not sterile and unscientific courses of action are examples of unsafe abortion methods (Teerawattananon & Tangcharoensathien, 2004).
correlated with abortions. Complications from abortion can be heavy bleeding and infections which lead to hysterectomy, perforated uterus and septicemia. A common reason for induced abortion is socioeconomic problems. Deficiencies in family planning are another reason. If the woman is wealthy, she can undergo a safe abortion in clean areas (Whittaker, 2002). Thai adolescents are now days more sexually liberated and as a result of that, more unwanted pregnancies and induced abortions are increasing among the teenager. The needs of sexual education, such as contraceptive use, responsible sexual behavior and knowledge of safe sex, are higher than the sexual education that the public health program gives. Even if abortions are considered as a sin, young girls will choose to carry out an abortion if they get pregnant (Saranrittichai et al., 2006).
Haque and Soonhorndhada (2009) say that previous studies showed that Thai youth are not consistent in their use of contraceptive methods. There was also lack of knowledge regarding fertility awareness among young people. This may be a result of insufficient sexual education (Teerawattananon & Tangcharoensathien, 2004).
In another study made in Thailand, by Aimnoi et al (2004) the result showed that 74% of the students had some knowledge about ECPs. The percentage of females (69.9%) with knowledge about ECPs was lower than the percentage of males (80.8%). 71% of the students were unaware of the side effects of the ECPs. The area where more than one out of three students had the lowest knowledge, were in which time interval the two ECPs should be taken (if using the two-dosage medication). Regarding the source of information, the students said that friends were the most common source of information about ECPs. The study showed that the students wished to get more information from qualified medical staff about ECPs.
2. THEORETICAL FRAMEWORK
Orem's Nursing Theory of Self-care deficit was used to provide theoretical framework of this study. Orem describes self-care as goal-directed activities that a person on hers own initiative performs for herself and for the dependent and helpless people, such as patients. These activities are performed in order to promote normal function, development, health and welfare for the person herself or for someone else (Kristoffersen, 2007).
The ability to perform these self-care actions for maintaining functional health and life may depend on the individual`s ability of self reflection, on social and cultural environment and on health status and knowledge. Orem is also talking about theory of nursing system, which describes how the nurse should think about nursing interventions around a patient with care deficit (Kistoffersen, 2007). The nurse should, in case of limitations in a person’s self-care, analyze the needs and contribute with actions which are necessary for encouragement and supplement of the self-care (NE, 2012). Limited abilities can occur when a person has lack of knowledge about his or her individual health situation and its treatment, for example the usage of ECPs. Orem believes that self-care actions can be finding knowledge or support and to find the necessary guidelines. She also highlights the social context as important and believes that the environment around the individual is significant in the goal of self-care (Kristoffersen, 2007).
The self-care theory of Orem was used to discuss the students' knowledge about ECPs and how it may affect their ability of self-care, regarding usage of ECPs and prevention from unwanted pregnancies.
3. RATIONAL OF RESEARCH
Currently there are few studies made in Thailand regarding knowledge, use and perceptions of practices of ECPs. Therefore, the authors considered that more studies highlighting the shortcomings related to the use of ECPs should be carried out. Knowledge about such shortcomings could, if taken in action, improve the sexual education in schools, encourage the use of contraceptive methods and develop specialized information to different demographic groups. This might improve the prevention of unwanted pregnancies and unsafe abortions. It should also be useful for the participating university for improving the sexual education, increasing the fertility awareness and clarifying the use of ECPs. The information about today’s knowledge, use and perceptions about ECPs among university students, can also be used in preventive public health work, when developing strategies for preventing unwanted pregnancies and unsafe abortions in Thailand and other developing countries. Sweden, like many other western countries, has turned into a multicultural society in which people have different attitudes, perceptions and knowledge about contraceptive methods. Therefore, this study could be relevant for the improvement of sexual education also in Sweden and similar countries.
4. AIM
The aim of this study was to examine the knowledge, use and perceptions of ECPs among undergraduate university students at a university in Bangkok, Thailand. The aim was also to investigate differences between genders concerning knowledge, use and perceptions of ECPs.
5. RESEARCH QUESTIONS
• What do the university students know about ECPs?
• How is the usage of ECPs among the university students? • How do the university students perceive ECPs?
• Are there any differences between genders concerning knowledge, use and perceptions of ECPs?
6. METHOD
6.1 Design
An empirical descriptive cross-sectional study was performed. A quantitative method was used.
6.2 Setting
The data was collected at Rangsit University, a private University in Pathum Than Province near Bangkok, Thailand, where is located 30 km from Bangkok. This university was chosen since it was one of few universities in Bangkok area, which not yet had had their final examinations, due to the flooding catastrophe in Thailand last year, 2011. Regarding to this, the university students were still having classes in school and therefore had the opportunity to participate in the study.
6.3 Sample
The most suitable selection method in view of our aim was to use a convenience sample method (Polit & Beck, 2004). The inclusion criteria were male and female students, who were studying the national or international program, at Rangsit University. Only the students, who
were present at the time for distribution of the questionnaire, were included in the study. The preferable number of participating students was 200; desired distribution was 100 male and 100 female students. The numbers of participators were chosen with consideration of the circumstance that some participants in the study might want to withdraw their attendance. 6.4 Data collection method
A questionnaire in Thai and English was used. It was developed by Mrs. Trieu Thi Ngoc Thu, head of the Department of Midwifery, Faculty of Nursing and Medical Technology,
University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam, together with Dr.
Pranee Lundberg at the department of Public Health and Caring Sciences, Uppsala University, Sweden. The questionnaire was adjusted to be suitable for the study in Thailand, by the two co- supervisors Asst. Prof. Supunee Thrakul and Lect. Dr. Benjamapoen Butsripoon, Faculty of Nursing, Mahidol University, Bangkok, Thailand (see Appendix 2). The questionnaire, written in English, was translated into Thai by Asst. Prof. Thrakul, and she was also responsible for selecting the chosen University. Dr. Lundberg had tested the English version of the questionnaire with two Thai university students in Thailand who did not participated in the study. This took place three months before the study was conducted. This was to ensure the reliability and validity of the questionnaire (Polit & Beck, 2004).
The questionnaire consisted of three parts; demographic characteristic data, knowledge about ECPs, experience of using ECPs and perceptions of using ECPs. The question sheets which were distributed were coded with numbers from 1-210 and contained closed questions with response alternatives. Ten extra questionnaires were distributed in case of that some students wanted to withdrawn their attendance. This increased the chance to get the desirable 200 participants for the data analyzes.
The first part of the questionnaire gave information about the participants demographic characteristics; Gender, Age, Religion, Education level, Residence and Economic support. The participants did answer every question in the questionnaire by marking “X” in the answer box. Some questions could be answered with the response alternative “Other”, which gave the respondents the opportunity to write alternatives of their own.
The second part of the questionnaire gave information about the participants’ knowledge about emergency contraceptive pills. This part contained statements about the purpose of
using ECPs, mechanism of actions, when and how ECPs should be used, side effects and information sources for ECPs. The statements had three response alternatives; “True”, “False” and “Don't know”. Some of the questions contained several answer alternatives and was answered by marking “X” in the answering box and could also be answered by writing an own alternative.
The third part gave information about the participants use of ECPs, which included; if they ever had used ECPs, what kind of ECPs they used, who bought the pill and from where, information of usage of ECPs, perceived side effects and if they advised other women to use ECPs. The questions were answered by choosing a suitable answer alternative by marking “X” in the answering box or write an own answer alternative.
Part four of the questionnaire gave information about the perceptions of the usage of ECPs among the participants. This part contained statements which concern; if the use of ECPs is the best method of prevent from pregnancy, if the accurate use of ECPs is a 100% effective method, if the use of ECPs is a better contraceptive method than the use of ordinary contraceptive pills, if they will recommend friends to use ECPs, if they think that sexual intercourse and sexually transmitted diseases among adolescents will increase when ECPs are available, if the participant together with their partner will use ECPs as a contraceptive method in the future. The questions were answered by marking an “X” in the answering box and the responds alternatives were “Yes”, “No” and “Don not know.
6.5 Procedure
The demand for permission to carry out the study was submitted to the Dean of the chosen university by Asst. Prof. Thrakul. Ethical considerations were applied at Faculty of Medicine Ramathibodi Hospital, Mahidol University for approval and an information letter including the aim of the study and the rights of the participants was given to the principal (Appendix 1). Asst. Prof. Thrakul was responsible for the access and the number of participants.
The authors were together with Asst. Prof. Thrakul visiting Rangsit University during one day in March, 2012. Before the distribution of the questionnaire, information was given orally to the participants. To ensure that the information was understood by the students, Asst. Prof. Thrakul acted as an interpreter for the authors and translated English into Thai. The questionnaire contained information about; the aim of the study and voluntary and anonymous
participation. It was distributed to the students in the classroom and it took about 10-15 minutes to answer. After finishing the questionnaires, the authors together with Asst. Prof. Thrakul collected the questionnaires from the students. A pen was given to all of the students, to ensure that the students could participate in the study. When completed the questionnaires, the students were offered to keep the pen.
Two hundred and ten questionnaires were distributed, 14 of them were excluded due to incorrectly completed questions. One hundred and six correctly completed questionnaires were analyzed. One hundred and seven female and 69 male students were included. The respondent rate was 93.3%.
One hundred and five questionnaires in Thai and 105 in English were distributed. The English questionnaire version was due to the circumstances that the University had an international profile where some courses were held in English. To be able to analyze the completed questionnaires written in Thai, three Thai nursing students at Mahidol University, were asked to translate the questions were the students had written their own answers. Before the data were transmitted into SPSS, the questionnaires were renumbered from 1 to 196. This facilitated the transmission.
6.6 Data analysis
Statistical Package for the Social Sciences (SPSS) was used when analyzed the data from the questionnaire. To be able to analyze the comparison between male and female and to get the p- value and chi2- value, a chi2- test was used. To be able to summarize the total right answer in the part about knowledge in the questionnaires, the questions and the statements were coded into different points: rights answer gave one point, wrong answer gave zero point and “don´t know” gave zero point. A total score of knowledge for each student were counted. This was to get the mean total score for both male and female students. The minimum score was zero points and the maximum score was 35. The final results from SPSS output were transmitted to Word Documents where it was presented in text and tables. Both percentages and number were shown.
The three research questions in this study were answered by the responses from the questions in the questionnaire as follows; Research question number one; “What do the university students know about ECPs?” was answered by the responses from part two, questions 1 to 6.
Research question number two; “How do the university students use ECPs?” was answered by the responses from part three, questions 1 to 8.
Research question number three; “How do the university students perceive ECPs?” was answered by the responses from part four, questions 1 to 7.
7. ETHICAL CONSIDERATIONS
Application for ethical approval of the study has been submitted to the Ethical Committee of the Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, by Asst. Prof. Thrakul. To ensure the students understanding of the study, both written and oral information was given to the participants. Participation was voluntary and anonymous, and the data was analyzed confidently. Participants could at any time choose to withdraw their participation (Codex, 2011). Since the questionnaire was coded with numbers, the participants could withdraw their participation even after the collection of the questionnaires. In order to follow the World Medical Association Declaration of Helsinki [WMA] (2004), an additional page in Thai were added to the questionnaire, so that the students could read about their rights, and if they wanted they could sign their name on the questionnaire, for approval of their participation in the study.
8. RESULTS
8.1 Demographic characteristics
The sample consisted of 196 undergraduate students, 69 (35.2%) of them were males and 127 (64.8%) were females. The majority of them were between 18 to 22 years old (n= 139, 73.5%). The mean age was 21.7 years old (SD= 3.1). Most of the students was Buddhists (n=166, 84.7%). The most common living situation for them was "live alone" and the second was "with parents". Most of the students got economic support from their parents. See Table 1.
Table 1. Demographic characteristics.
Demographic characteristics University students (n=196)
n % Gender Male Female 69 127 35.2 64.8 Age 18-22 years 23-27 years ≥ 28 years 139 44 6 73.5 23.3 3.2 Religion Buddhist Christian Islam Other 166 11 6 13 84.7 5.6 3.1 6.6 Living situation With parents With relatives With friends Alone Other 58 8 52 65 13 29.6 4.1 2.6 33.2 6.6 Economic support From parents From relatives Scholarship Other 157 4 18 16 80.5 2.1 9.2 8.2
8.2 Knowledge about ECPs
Around 87.2% (n=171) of the students knew that the purpose of using ECPs is to avoid unwanted pregnancies. There were no significant differences between male and female students in the knowledge about ECPs. More than one out of three students (36%, n=70) had the misconception that ECPs aborts a fertilized ovum, and 34.7% (n=67) did not know about it. See Table 2.
Table 2: Knowledge of ECPs: The purpose of using ECPs and the working mechanism of
ECPs.
Statement Total Male Female p-value
n % n % n %
The purpose of using ECPs is to avoid unwanted pregnancy?(T) Right answer Wrong answer Don’t know 171 3 22 87.2 1.5 13.0 58 2 9 84.0 3.1 14.0 113 1 13 88.9 0.7 10.2 1.740 0.419
In what way do ECPs work? 1.It inhibits ovulation (T)
Right answer Wrong answer Don’t know 68 51 74 35.2 26.4 38.3 24 17 26 35.8 25.3 38.8 44 34 48 34.9 26.9 38.0 0.059 0.971 2. It prevents fertilization (T) Right answer Wrong answer Don’t know 117 38 40 60.0 19.4 20.5 39 17 13 56.2 24.6 18.8 78 21 27 61.9 16.6 21.4 1.815 0.404 3. It kills spermatozoa (F) Right answer Wrong answer Don’t know 83 51 61 42.5 26.1 31.2 32 19 18 46.3 27.5 26.0 51 32 43 40.4 25.3 34.1 1.364 0.506
4. It aborts fertilized ovum (F) Right answer Wrong answer Don´t know 56 70 67 29.0 36.2 34.7 20 25 23 29.4 36.7 33.8 36 45 44 20.8 36.0 35.2 0.037 0.982 5. I delays ovulation (F) Right answer Wrong answer Don’t know 50 66 80 25.5 33.6 40.8 21 20 28 30.4 28.9 40.5 29 46 42 22.8 36.2 33.0 1.709 0.426
6. It makes uterine cavity unsuitable for ovum (T) Right answer Wrong answer Don’t know 90 31 73 46.3 15.9 37.6 28 13 26 41.7 19.4 38.8 62 18 47 48.8 14.1 37.0 1.255 0.534 7. It prevents implantation (T) Right answer Wrong answer Don’t know 114 18 64 58.1 9.1 32.6 40 7 22 57.9 10.1 31.8 74 11 42 58.2 8.6 33.0 0.127 0.938
*p-value ≤ 0.05 for significant differences. (T)= True statement (F)= False statement.
Regarding when ECPs should be used, more than a half of the students knew that an ECP should be taken after an unprotected intercourse as a result of a rape (68.8%, n= 135), which was a significant result (p = 0.033), where the female students answered more correct than the male students. The students´ total knowledge about ECPs was scored between zero and 31
points out of maximum 35 points. The mean (SD) total score for the male students were 13.9 points (n= 69, SD= 7.09) and for the female students 13.8 points (n= 125, SD= 7.24). The highest total score among the males was 26 points and 31 points among the females. See table 7.
About 34.3% (n=67) of the students have known that ECPs should be taken when only one progestin oral contraceptive pill was missed in a given cycle while 47.6% (n=93) did not know. There was also a significant difference between genders (p = 0.047). The female students have answered more correct than the male students. See Table 3.
Concerning the knowledge about the way that ECPs should be used, 57.6% (n=113) of the students had the misconception that ECPs must be initiated within 7 days after unprotected sex, while 59.4% (n=116) had correct knowledge that ECPs should be used as early as possible after unprotected sex. There were no significant differences between genders about the way that ECPs should be used. See Table 4.
The knowledge of the side effects of ECPs was presented in Table 5. Most of the students answered that they did not know about the side-effects of ECPs. There were no differences between genders in the knowledge of the side effects of ECPs.
Considering to the source of information about knowledge of ECPs, the most common source that the students got information was from Internet (47.9%, n=94). Other sources of information were school (40.8%, n=94) and newspaper/magazine (36.2%, n=71). There were significant differences between genders regarding the source of information from boyfriend/girlfriend (p=0.017) and partner (p=0.033). A higher percentage of the males than the females students answered that they got information from boyfriend/girlfriend (27.5%,
n=19 respectively 14.9%, n=19) and partner (26%, n=18 respectively 12.5%, n=16). See
Table 3: Knowledge about ECPs: When ECPs should be used. Statement
Total Male Female p-value
When should women use ECPs? n % n % n %
1.After unprotected intercourse(T)
Right answer Wrong answer Don’t know 96 74 26 48.9 37.7 13.2 36 27 6 52.1 39.1 8.6 60 47 20 47.2 37.0 15.7 1.951 0.377
2.Before unprotected intercourse(F) Right answer Wrong answer Don’t know 65 102 28 33.3 52.3 14.3 24 36 8 35.2 52.9 11.7 41 66 20 32.2 51.9 15.7 0.618 0.734
3. Unprotected intercourse occurred as a result of rape (T) Right answer Wrong answer Don’t know 135 23 38 68.8 11.7 19.3 47 13 9 68.1 18.8 13.0 88 10 29 69.2 7.8 22.8 6.802 0.033*
4. Condom leak or slip after intercourse (T) Right answer Wrong answer Don’t know 114 33 47 58.7 17.0 24.2 47 12 10 68.1 17.3 14.4 67 21 37 53.6 16.8 29.6 5.792 0.055
5. One combined oral contraceptive pill was missed (F) Right answer Wrong answer Don’t know 40 82 72 20.6 42.2 37.1 20 25 23 29.4 36.7 33.8 20 57 49 16.0 45.6 39.2 4.982 0.083
6. Missed injection due date and had unprotected intercourse (T) Right answer Wrong answer Don’t know 72 31 93 36.7 15.8 47.4 25 15 29 36.2 21.7 42.0 47 16 64 37.0 12.5 50.3 3.028 0.220
7. Only one progestin oral
contraceptive pill was missed in a given cycle (T) Right answer Wrong answer Don’t know 67 35 93 34.3 17.9 47.6 18 18 32 26.4 26.4 47.0 49 17 61 38.5 13.3 48.0 6.124 0.047*
8. ECP cannot be used by breastfeeding mothers (T) Right answer Wrong answer Don’t know 87 43 66 44.3 21.9 33.6 33 14 22 47.8 20.2 31.8 54 29 44 42.5 22.8 34.6 0.517 0.772
Table 4: Knowledge about ECPs: The way that ECPs should be used. Statement
Total Male Female p-value
How should women use ECPs? n % n % n %
1. ECP must be initiated within 72 hours after unprotected sex (T)
Right answer Wrong answer Don’t know 68 69 59 34.6 35.2 30.1 24 22 23 34.7 31.8 33.3 44 47 36 34.6 37.0 28.3 0.703 0.704
2. ECP must be initiated within 7days after unprotected sex (F)
Right answer Wrong answer Don’t know 113 18 65 57.6 9.1 33.1 36 6 27 52.1 8.6 39.1 77 12 38 60.6 9.4 29.9 1.725 0.422
3. ECP must be initiated within 120 hours after unprotected sex (T)
Right answer Wrong answer Don’t know 72 63 60 36.9 32.3 30.7 22 21 25 32.3 30.8 36.7 50 42 35 39.3 33.0 27.5 1.876 0.391
4. ECP should be used as early as possible after unprotected sex (T)
Right answer Wrong answer Don’t know 116 23 56 59.4 11.7 28.7 47 4 18 68.1 5.7 26.0 69 19 38 54.7 15.0 30.1 4.851 0.088
5. ECP can be used 2 times every months after unprotected sex (T)
Right answer Wrong answer Don’t know 40 76 80 20.4 38.7 40.8 18 23 28 26.0 33.3 40.5 22 53 52 17.3 41.7 40.9 2.498 0.287
6. ECPs can be used many times every month after unprotected sex (F)
Right answer Wrong answer Don’t know 84 29 82 43.0 14.8 42.0 26 11 32 37.6 15.9 46.3 58 18 50 46.0 14.2 39.6 1.279 0.528
7. ECP can be used at anytime during the menstrual cycle (F)
Right answer Wrong answer Don’t know 66 48 79 34.1 24.8 40.9 22 16 29 32.8 23.8 43.2 44 32 50 34.9 25.3 39.6 0.235 0.889
8. ECP (2 tablets/dosages): take the first tablet within 72 hours after unprotected sex and the second tablet 12 hours later (T) Right answer Wrong answer Don’t know 62 54 80 31.6 27.5 40.8 19 20 30 27.5 28.9 43.4 43 34 50 33.8 26.7 39.3 0.829 0.661
9. ECP (one tablet/ dosages): take the tablet within 120 hours after unprotected sex (T) Right answer Wrong answer Don’t know 42 50 103 21.5 25.6 52.8 16 17 36 23.1 24.6 52.1 26 33 67 20.6 26.1 53.1 0.185 0.911
Table 5: Knowledge about ECPs: Side effects related to usage of ECPs.
Statement
Total Male Female p-value
What are the side effects related to the use of ECP? n % n % n % 1.Breast tenderness (T) Right answer Wrong answer Don’t know 73 23 100 37.2 11.7 51.0 28 5 36 40.5 7.2 52.1 45 18 64 35.4 14.1 50.3 2.174 0.337
2. Nausea and vomiting (T)
Right answer Wrong answer Don’t know 67 28 101 34.1 14.2 51.5 28 5 36 40.5 7.2 52.1 39 23 65 30.7 18.1 51.1 4.977 0.083 3. Insomnia (T) Right answer Wrong answer Don’t know 53 40 102 27.1 20.5 52.3 23 9 37 33.3 13.0 53.6 30 31 65 23.8 24.6 51.5 4.428 0.109 4. Headache (T) Right answer Wrong answer Don’t know 67 37 92 34.1 18.8 46.9 20 13 36 28.9 18.8 52.1 47 24 56 37.0 18.8 44.0 1.464 0.481
5. Cramping and bleeding (T)
Right answer Wrong answer Don’t know 71 22 100 36.4 11.2 51.2 22 9 38 31.8 13.0 55.0 49 15 62 38.8 11.9 49.2 0.947 0.623 6. Spotting (T) Right answer Wrong answer Don’t know 50 29 117 25.6 14.8 60.0 16 9 44 23.1 13.0 63.7 34 20 73 26.9 15.8 57.9 0.742 0.690 7. Fatigue (T) Right answer Wrong answer Don’t know 38 41 116 19.4 21.0 59.4 14 12 43 20.2 17.3 62.3 24 29 73 19.0 23.0 57.9 0.850 0.654 8. Heavy bleeding (T) Right answer Wrong answer Don’t know 64 30 101 32.8 15.3 51.7 18 14 37 26.0 20.2 53.6 46 16 64 36.5 12.6 50.7 3.214 0.200 9. Dizziness (T) Right answer Wrong answer Don’t know 76 27 92 38.9 13.8 47.1 25 7 37 36.2 10.1 53.6 51 20 55 40.4 15.8 43.6 2.202 0.332 10. Weakness (T) Right answer Wrong answer Don’t know 87 41 65 45.0 21.2 33.6 27 11 30 39.7 16.1 44.1 60 30 35 48.0 24.0 28.0 5.338 0.069
Table 6: Knowledge about ECPs: Information sources.
Statements
Total Male Female p-value
n % n % n %
Where I can acquire knowledge about ECPs School Friends Partner Boyfriend/ girlfriend Physician Nurse/ midwife Radio Television Newspaper/ magazine Internet Book Other 80 57 34 38 46 47 31 50 71 94 61 11 40.8 29.0 17.3 19.3 23.4 23.9 15.8 25.5 36.2 47.9 31.1 5.6 25 21 18 19 18 18 9 15 25 31 21 6 36.2 30.4 26.0 27.5 26.0 26.0 13.0 21.7 36.2 44.9 30.4 8.6 55 36 16 19 28 29 22 35 46 63 40 5 43.3 28.3 12.5 14.9 22.0 22.8 17.3 27.5 36.2 49.6 31.4 3.9 0.926 0.095 5.673 4.524 0.406 0.259 0.615 0.797 0.000 0.392 0.023 1.911 0.336 0.758 0.017* 0.033* 0.524 0.611 0.433 0.372 0.999 0.531 0.878 0.167
Table 7: Knowledge of ECPs: Total score among the students.
Total score Total students Male (n) Female (n)
0 3 2 1 1 8 1 7 2 6 2 4 3 3 2 1 4 4 0 4 5 7 3 4 6 4 1 3 7 5 1 4 8 9 3 6 9 7 5 2 10 9 5 4 11 5 2 3 12 7 2 5 13 9 2 7 14 10 4 6 15 12 5 7 16 9 3 6 17 12 3 9 18 9 2 7 19 10 3 7 20 11 5 6 21 8 3 5 22 3 0 3 23 4 0 4 24 8 6 2 25 5 1 4 26 4 3 1 27 0 0 0 28 1 0 1 29 0 0 0 30 1 0 1 31 1 0 1 32-35 0 0 0
8.3 Usage of ECPs
About 16.5% (n=32) of the students had experiences of using ECPs, which were 15 (21.1%) male students and 17 (13.7%) female students. Most of the students (83.4%, n=161) had never used ECPs. See Table 7. Of those who answered that they never had used ECPs, one out of five (25.1%, n=47) answered that they don’t need to use them (e.g. not sexual active). See Figure 1.
Concerning who buys the ECPs, 62.5% (n=20) of the students reported that they bought it by themselves, 28.1% (n=9) reported that boyfriend bought it, and 9.3% (n=3) answered that other bought it. There were significant differences between genders in this issue, more male than female students (80%, n=12 respectively 47%, n=8) reported that they bought it by themselves. Twenty percentage (n=3) of the males respectively 0% (n=0) of the females reported that other bought it. More female than male students stated that “Boyfriend” bought it (0%, n=0 respectively 52.9%, n=9). See Table 8.
0
5
10
15
20
25
30
35
40
45
50
Not
heard/
known
about
ECPs.
Affraid
of side
effects.
Don´t
know
how to
use
ECPs.
Have
not
been in
need of
using
ECPs.
Other
Total(n)
M ale(n)
Female(n)
The place where the students bought ECPs was presented in Table 7. The majority of the students reported that they bought ECPs from the drugstore (78.1%, n=25), while 15.6% (n=5) bought it from the private clinic. About 40.7% (n=13) of the students reported that the pharmacist taught them how to use ECPs. The students also reported that other taught them how to use it (12.5%, n=4). Twenty- six percentage (n=4) of the male students and no female students reported about this.
Regarding the side-effects of using ECPs, the students reported irregular menstruation (46.8%, n=15), dizziness (28.1%, n=9), nausea (25%, n=8) and headache (25%, n=8). There was a significant difference between gender about headache as side-effect (p=0.008). More male than female students stated that they got experience of headache as a side effect (46.6%,
n=7 respectively 5.8%, n=1). About 43.7% (n=14) of the students reported that they have
Table 8: Usage of ECPs
Statements
Total Male Female p-value
n % n % n %
Have you/ your partner ever used ECPs? no yes 161 32 83.4 16.5 54 15 78.2 21.7 107 17 86.2 13.7 2.066 0.151
Who buys the ECPs? Myself Boyfriend Friend Sister/relative Other 20 9 2 1 3 62.5 28.1 6.2 3.1 9.3 12 0 1 0 3 80.0 0.0 6.0 0.0 20.0 8 9 1 1 0 47.0 52.9 5.8 5.8 0.0 6.066 14.045 2.076 3.054 6.134 0.048* 0.354 0.217
Where did you/ your partner buy the ECPs? Drugstore Hospital/clinic Private clinic Other 25 2 5 2 78.1 6.2 15.6 6.2 13 0 2 2 86.6 0.0 13.3 13.3 12 2 3 0 70.5 11.7 17.6 0.0 3.373 4.107 2.188 4.688 0.185 0.128 0.335 0.096 Who taught you/your partner how to use
ECPs? Friends Boyfriend Drug literature Sister/ relative Physician/Nurse/Midwife Pharmacist Other 7 4 8 4 6 13 4 21.8 12.5 25.0 12.5 18.7 40.6 12.5 4 2 3 3 4 6 4 26.6 13.3 20.0 20.0 26.6 40.0 26.6 3 2 5 1 2 7 0 17.6 11.7 29.4 5.8 11.7 41.1 0.0 2.478 2.086 2.475 3.641 3.326 2.071 7.683 0.290 0.352 0.290 0.162 0.190 0.355
Have you/ your partner ever got any of the following side effects from using ECPs? Nausea Vomiting Weakness Dizziness Headaches Brest engorgement Irregular menstruation Abdominal pain Got pregnant Other 8 4 4 9 8 3 15 6 0 4 25.0 12.5 12.5 28.1 25.0 9.3 46.8 18.75 0.0 12.5 5 3 2 5 7 2 6 2 0 2 33.3 20.0 13.3 33.3 46.6 13.3 40.0 13.3 0.0 13.3 3 1 2 4 1 1 9 4 0 2 17.6 5.8 11.7 23.5 5.8 5.8 52.9 23.5 0.0 11.7 3.200 3.641 2.086 2.477 9.731 2.631 2.647 2.656 2.066 2.086 0.202 0.162 0.352 0.290 0.008* 0.268 0.266 0.265 0.151 0.352 Have you/ your partner advised other women
or friends to use ECPs?
Yes 14 43.7 7 46.6 7 41.1 2.172 0.338
8.4 Perceptions of ECPs
The perception of ECPs was shown in Table 8. Around 54% (n= 105) of the students answered that they thought that ECP is the best method to prevent from pregnancies. Most of the students did not think that it is 100% effective if you have taken ECPs accurately. 25.0% (n=17) of the males respectively 18.5% (n=23) had the perception that it is better to take ECPs than ordinary contraceptive pills because of the advantage of not taking it daily. Of all the students, 40.1% (n=77) would recommend ECPs to their friends.
When ECPs are available, 50.2% (n=96) of the students thought that sexual intercourse among adolescents will increase. 45.0% (n=86) of the students thought that the prevalence of sexual transmitted diseases will increase. About 38% (n=73) thought that they and their partner will use ECPs to prevent pregnancy in the future. There were no significant differences between genders regarding perception of ECPs. See Table 9.
Table 9: Perceptions of ECPs
Statement
Total Male Female p-value
n % n % n %
1. ECPs are the best method to prevent pregnancy. no yes don´t know 45 105 44 23.1 54.1 22.6 41 10 17 60.2 14.7 25.0 64 35 27 50.7 27.7 21.4 4.238 0.120 2. It is 100% effective if you have taken ECPs accurately. no yes don´t know 76 60 56 39.5 31.2 29.1 32 16 20 47.0 23.5 29.4 44 44 36 35.4 35.4 29.0 3.497 0.174
3. It is better to take ECPs than ordinary contraceptive pills because of the advantage of not taking it daily.
no yes don´t know 85 40 67 44.2 20.8 34.8 28 17 23 41.1 25.0 33.8 57 23 44 45.9 18.54 35.4 1.140 0.566
4. I will recommend ECPs to my friends. no yes don´t know 58 77 57 30.2 40.1 29.6 23 25 20 33.8 36.7 29.4 35 52 37 28.2 41.9 29.8 0.751 0.687
5. I think sexual intercourse among adolescents will increase when ECPs are available. no yes don´t know 41 96 54 21.4 50.2 28.2 14 33 20 20.8 49.2 29.8 27 63 34 21.7 50.8 27.4 0.127 0.938
6. I think the prevalence of sexually transmitted diseases will increase when ECPs are available. no yes don´t know 45 86 60 23.5 45.0 31.4 15 31 21 22.3 46.2 31.3 30 55 39 24.1 44.3 31.4 0.096 0.953
7. I think me and my partner will use ECPs to prevent pregnancy in the future no yes don’t know 40 73 77 21.0 38.4 40.5 14 28 24 21.2 42.4 36.3 26 45 53 20.9 36.2 42.7 0.855 0.652
9. DISCUSSION
The results of this study show that there is lack of specific knowledge regarding ECPs among undergraduate university students in Bangkok. The mean total score in knowledge about ECPs was less than half of the 35 possible points. The male students had slightly higher mean total score than the female students. Eighty-four percentages of the male and 88.9% of the female students knew that the purpose of using ECPs is to avoid unwanted pregnancies. Many students had the misconception that ECPs aborts fertilized ovum, 36.7% of the males and 36.0% of the females thought that. Twenty-one point seven percentages of the male and 13.7% of the female in this study had the experience of using ECPs. One common perception among the students was that ECPs are the best method to prevent from unwanted pregnancies, 14.7% of the males and 27.7% of the females perceived that. This study results indicate that more knowledge about ECPs are required for these students.
9.1 Result discussion
Knowledge
The result of this presented study shows that a majority of the male and female students knew about ECPs as a contraceptive method. This is in agreement with previous studies made in both developed and developing countries like USA, Sweden, India and Nepal (Corbett et al., 2006; Harper & Ellerston, 1995; Aneblom et al., 2003; Puri et al., 2007; Adhikari, 2009). In the study made in Thailand by Aimnoi et al. (2004), around 74% of the students had some knowledge about ECPs.
The male students had slightly higher mean total score about knowledge than the female students. This can also be seen in the study made in Nepal, where the results showed that the male students had slightly higher knowledge than the females (Adhikari, 2009). Aimnoi et al (2004) also showed that the percentage of females with knowledge about ECPs was lower than the percentage of males. However, it is hard to define what is enough knowledge regarding ECP. In the questionnaire that has been used in this study, the authors think that there are a lot of difficult questions concerning the mechanism of action regarding the ECPs. Some students had the misconception that ECPs aborts a fertilized ovum. Whittaker (2002) meant that some Thai who are Buddhist have own conflicts regarding if it is right to have an induced abortion or not. The Buddhists mean that it may affect their karmic status. The
authors believes that an assumption can be made that some Thai do not see ECPs as an alternative in case of failed contraception, because some of them may think that ECPs is a pill taken when an abortion is induced. This assumption is made from the fact that most of the students in this presented study were Buddhists. This, together with the fact that a majority of the students thought wrongly that ECPs is an abortifacient, may lead to that Thai Buddhist woman will not take ECPs after unprotected intercourse. This misinformation about the mechanism of action regarding ECPs might be able to lead to unwanted pregnancies among these students. The results of this study are supported by several researchers (Harpers & Ellerston, 1995; Corbett et al., 2006; Aneblom et al., 2003, Byamugisha et al. 2006) who found that the students have misconception about ECPs. The authors believes that these findings may shows that it is unclear what the differences are between ECPs and pills for induced abortion, and that this lack of knowledge are almost the same in both western countries as in developing countries.
In over half of the statements regarding knowledge about ECPs, most students have stated wrong answer or said they did not know. The authors think that this shows lack of knowledge about ECPs among these students in general. This is in line with the presented results from the study made in Sweden, where specific knowledge and in what way ECPs works not were widely spread (Aneblom et al., 2003). In Uganda, the university students had lack of knowledge regarding ECPs, especially how they act, and less than half of them had ever heard of ECPs (Byamugisha, 2006). In the study made among Indian female college students, it also showed a lack of knowledge about ECPs (Puri et al., 2007). The authors consider that general knowledge regarding ECPs should be highlighted and spread among the students. Knowledge about this area is important for god sexual health.
The majority of the students knew that ECPs prevents fertilization. A higher percentage of the males than the females knew that ECPs should be used after an unprotected intercourse. There was a significant difference between the male and the female students in the knowledge regarding that ECPs should be taken in case of rape. Similar finding can be seen in the results from studies made by Puri et al. (2007) and Harper and Ellerston (1995).
Around one out of three students knew that ECPs must be taken within 72 hours after unprotected sex. This number differ from the results in the study made among Indian students, where most of them did not have knowledge about in which time frame ECPs had to be taken (Puri et al., 2007).
The students did not know about the side effects related to ECPs, however, they knew that weakness can occur when taking ECPs. This may show that the side effects of ECPs are not widely known. This is supported by Aimnoi et al. (2004) who found that most of the Thai students were unaware of the side effects.
Internet was the most frequently reported source of information and the second most reported was school. Similar findings have been done in Curacao, where school was the main source of information (Van Den Brink, 2011). Those students in Nepal, who had got sexual education in school, showed high knowledge and awareness regarding ECPs (Adhikari, 2009). The results from different countries showed that good sexual education in school is a very important part in the learning about sexuality. Teerawattananon and Tangcharoensathien (2004) meant that there was lack of knowledge regarding fertility awareness among young Thai, which may be a result of insufficient sexual education. This supports the statement that school has an important role in educating the students.
There were significant differences between gender regarding the information sources “partner” and “boyfriend/girlfriend”. Mainly the female students stated that newspapers and magazines gave information about ECPs, and another source of information was “friends”. These results differ from other research results (Aimnoi et al, 2004; Aneblom et al., 2003; Corbet et al., 2006) which showed that “friends” are an important source of information. Aneblom et al. (2003) also reported that “media” gave information about ECPs. This shows that media is an important part in spreading knowledge about ECPs, same in both developed and developing countries. In the study made in Cameroon, it can be read that family and friends could give inadequate and misleading information about ECPs, and medical professionals gave better knowledge (Kongnyuy et al., 2007).
Usages
Around 13% of the females stated that they had ever used ECPs. That is a lower percentage of users in comparison with the Finnish female students in the study made by Falah-Hassani et al. (2007). In Uganda, Curacao and Cameroon, the percentage of ECPs users was lower than the percentage of the Thai students in this presented study (Byamugisha et al., 2006; Kongnyuy et al., 2007; Van Den Brink et al., 2011). Some students who had ever used ECPs reported that they bought the ECPs at the drugstore and less than half of the students said that they were thought by the pharmacist how to use the ECPs. Meng et al. (2009) found that some
pharmacist in Shanghai thought wrongly that ECPs could work as a substitute for regular birth control methods. Regarding that information, the authors think it is important that not only students but also health personnel who work in this area should get correctly information about ECPs. The main reported reason for not have used ECPs were “Have not been in need of using ECPs”. The authors believe that the lack of knowledge regarding ECPs might have something to do with the fact that some of the students in this presented study do not need to use ECPs. Thereby the students may not search for information about ECP by themselves, which naturally leads to less knowledge in this area.
Perception
The majority of the students in this presented study had the perception that ECPs are the best method to prevent pregnancy, this is supported by several studies (Harper & Ellerston, 1995; Kngnyuy, 2007). The authors think it is debatable if the students´ statements have been based on that they think that ECPs are the best method to prevent pregnancy if chosen contraceptive method fails, or if they advocate ECPs instead of e.g. condom or intrauterine method. Almost half of the students had their perception that ECPs is better to take than ordinary contraceptive pills which are taken daily, because of the advantage of not taking it daily. A higher percentage of the male students than the female students had this perception. A higher number of the female students are afraid of side effects related to the use of ECPs, than the male students. The result shows that the female students think about side effects and might feel uncomfortable with using ECPs. It may be more disadvantages with using ECPs for women than for men, e.g. regarding side effects. Some of the students in this presented study thought that they together with their partner will use ECPs in the future for prevent pregnancy, and some students would recommend ECPs to their friends. This agrees with Corbett et al. (2006), who found that fewer than half of the American male students would recommend ECP to their partner if needed.
9.2 Theoretical framework discussion
The self-care theory of Orem was used to discuss the students' knowledge about ECPs and how it may affect their ability of self-care, regarding prevention from unwanted pregnancies. This study shows that the students had lack of knowledge regarding ECPs. The authors assume that these students probably had a good capacity for searching knowledge in case they need it, due to that they were studying at university. From this, assumptions can be made that
the students have the ability to perform good self-care and thereby maintain good health. However, it is debatable whether the students, which in this study achieved few correct answers in the part of knowledge of ECPs, have less ability to perform self-care if they would use ECPs, than those students who achieved more correct answers.
Lack of knowledge may lead to wrong way of understanding and using ECPs. This may be seen in the results of this study, where more than 36% of the students thought wrongly that ECPs abort a fertilized ovum, and many of them reported that they did not know the right answer to that question. If the student is against abortion and has the perception and misconception about ECPs in this issue, the ECPs will not be an alternative in the case of failed contraception method during sexual intercourse, and an unwanted pregnancy will occur. In this example, lack of knowledge, may affect the ability of self-care and thereby the health of the person it selves. Internet was the most frequently reported source of information of ECPs among the students. They also stated that they can acquire knowledge about the pills from their friends. Orem believes that the environment around the individual is important in the goal of self-care and she highlights the social context (Kristoffersen, 2007). From Orem's thoughts of self care, it can be assumed that Internet and social relationships around the students can affect the way of achieving independent self-care in usage of ECPs. The authors believe that the opinions and perceptions that may exist in a group of people will influence the individuals' act and practice according to his or hers own choice.
Orem believes that the nurse should, in case of limitations in a person’s self-care, contribute with actions for encouragement and supplement the person's self-care (NE, 2012). The authors believe that one part in the nursing profession is to fill in the gaps that exist in a patient's knowledge regarding self-care, health, illness and treatments. A nurse should e.g. be able to advice males and females regarding contraceptive methods. Therefore this study could be a guideline in a process where the youth’s knowledge about sex and relationships will be developed, for example in schools/universities, youth clinics, hospital and other places for sex education and counseling.
9.3 Method discussion
In this study, a quantitative method with using a questionnaire was chosen and a convenience sample was selected. When a quantitative method is selected, a questionnaire can be used as an instrument for data collections (Polit & Beck, 2004).This method was suitable to reach the study’s' aim.
One limitation of this study was that a convenience sample was used. The sample was similar to each other, both in age, education level and socioeconomic background. The desirable sample of the same number of male and female students was not fulfilled. This made the distribution of the sample not so widely spread, which makes the results of the study less generalized to a larger population.
Instrument
A questionnaire was used for collecting the data. This data collection method is suitable to use, when a large number of participants is desirable to be include in the study (Polit & Beck, 2004). The closed questions in the questionnaire gave, when handled out to the students, homogenous answer, which made it possible with statistical analyses of the data.
The questionnaire was created in English by the Head of Midwifery Department of a university in HO Chi Minh City and the main supervisor, and after that, translated into Thai by the co- supervisor. During this translation, there may be a possibility that the questions were interpreted and translated in a disadvantage way, and thereby got another contents of meaning than the original questions.
In the third part about the students' use of ECPs, question number four “Who buys the ECPs?” included unconsidered answer alternatives, only suitable for female heterosexual students. For example, when a male student answered that he and his partner used ECPs, he might wanted to answer that his girlfriend bought the ECPs, which unfortunately not was an answer alternative. For answer like aforementioned, the male had to choose the answer alternative “Other” and by himself specifying with e.g. writing that his girlfriend bought the pills.
When analyzing the data, two modifications of the questionnaires were made. In the part of demographic characteristics, the question which regarded economic support, many students stated ”Other”. The students had in some cases specified their answer, by writing
”scholarship”, which then was added as an answer alternative when the data was recorded. In the third part of the questionnaire which included the usage of ECPs, one answer alternative was added when coding the data. The added answer alternative was in question number two: ”What is the reason that you/your partner have not used ECPs?”. Many students had stated ”Other” and specifying that they, for different reasons, did not need to use ECPs. Thereby ”Do not need to use ECPs” was added as an alternative in the answers. However, the absence of these two answer alternatives, which seemed to be common, might effected the students' choice of answer.
When registered the data, there was some missing data due to that not all questions were answered and not filled in correctly. Unfortunately, in some cases, whole part four “Perception of using ECPs”, was totally ignored by the students. This might had to do with misunderstood instructions in the third part of the questionnaire.
Future research
Further research is needed about youth people's knowledge about ECPs in Thailand and similar countries. It should be performed for confirming the results in this study, and give deeper understanding and explanations about youth people's knowledge, use and perceptions about ECPs. It would be interesting to carry out a research study in rural areas outside Bangkok, where it may be differences about sexual beliefs and behaviors among the young people. This study was performed at a private university among both national and international students. These students may came from wealthy families, some with international background, which may in some way affected their knowledge, use and perceptions about ECPs.
A randomized and big sample size should be chosen in the future research for a more general result. Even a qualitative method with interviews would be of interest for obtaining deeper understanding and explanations about youth people own thoughts about their knowledge, use and perception about ECPs.
Contributions of the study
Few studies about knowledge and use of ECPs among young adults/students/adolescents in Thailand were found and no study about perceptions of ECPs among this group was available. This study contributes to show how university students in Thailand perceive ECPs and how
