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Knowledge and attitudes about the use of emergency contraception among college students in Tamil Nadu, India

Knowledge and attitudes about the use of emergency contraception among college students in Tamil... Background: In India, a large number of pregnancies are unplanned resulting in unsafe and illegal abortion. For every legal abortion, 10 to 11 illegal abortions are occurring which endangers the health and survival of the women. In recent years, there is an increase in unwanted and unintended pregnancy at the early age group. Usage of emergency contraception (EC) can decrease the unwanted pregnancy and provide a healthier life. Aim: The aim of study is to assess the knowledge and attitude regarding EC among college students in Thiruvarur District, Tamil Nadu, India. Methods: A cross-sectional study was conducted among the college students of Thiruvarur district, Tamil Nadu, India. A total of 758 students were selected by convenient sampling technique. Data was collected by administering a pretested semi-structured questionnaire. Results: Out of 758 students, 183(24%) heard about EC. The commonest source of information was the internet 91 (49.7%). The majority 116 (63.4%) knew that it does not prevent STDs. Of those who were aware, 42% were awareof42.6% areaware of thetimelimit to useEC. Theknowledge levelofabout theECwas moderate (60.1%), and it was significantly (p < 0.05) more among students > 25 years old, married participants, students in private institution, of lower socio-economic status, Muslim students and days’ scholars. The negative attitude towards EC was 59%. Nearly 38.8% believed that the EC will affect the next menstrual period, and 35.5% informed it will increase high risk behaviour among adults. The attitude level was significantly associated with the same factors associated with the awareness level with the factors Christian religion replacing Muslim and higher socioeconomic class replacing lower class participants. Conclusion: The knowledge level of the studied college students was moderate, and they mostly had negative attitude towards the EC. Reproductive health education should be given in educational institutions to promote awareness and to remove misconceptions about EC. Keywords: Emergency contraception, College students, Abortions, Unwanted pregnancy * Correspondence: premdavis93@gmail.com Health Centre, Central University of Tamil Nadu, Thiruvarur 610005, India Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 2 of 11 1 Introduction 2 Materials and methods In today’s time, the population growth has become This cross-sectional study was conducted among the one of the leading problems in the world. According college-going students of Thiruvarur District in Tamil to 2019 data, nearly about 7.7 billion people are living Nadu from February 2019 to April 2019. in the world [1]. India contributes to 1210 million population, and every year, it is adding 17.5 million 2.1 Sampling people newly. At present, this overpopulation is the major Considering the awareness regarding EC among college problem in the country, which leads to problems like students is 23.1% [13]. Taking alpha error as 5% and ab- poverty, illiteracy, decrease in the economic growth, solute margin of error as 3% [13], the sample size was starvation, malnutrition, depletion of natural resources calculated to be 758. All the colleges of the district (n = and unemployment [2]. 15) were contacted and informed about the nature of Worldwide, it is estimated that 44% of the pregnancy oc- the study. Due to its sensitiveness, finally one govern- curring were unintended between 2010 and 2014 [3]. In the ment university and two private colleges agreed to par- same interval, 55.7 million abortions occurred worldwide, of ticipate in the study after assuring that the name of which 25.1 million abortions were unsafe abortions, mostly colleges will not be disclosed at any point in time. happening in the developing countries [4]. In India, 78% of the pregnancies are unplanned. And it is estimated that 2.2 Data collection nearly 25% of them are unwanted. Every year nearly 11 mil- The questionnaire was pretested on 5% of the students lion abortions take place of which 6.7 million are induced prior to the actual data collection of the study population. and 4 million are spontaneous abortions. Under the preview This wasdone toassessthe ambiguity and comprehensibil- of MTP act, abortions are permitted in India since 1971 for ity of the questionnaire and subsequent modification was specific indications. However, approximately 10 to 11 illegal done for the ease of comprehension. The students who are abortions for each legal abortion are occurring. Nearly 20, included in the pretesting were excluded from the study. 000 women are dying annually due to abortion-related com- The content validation of the questionnaire was done by plications which are almost preventable [5]. Thus, unwanted experts in the research subject from the departmental re- and unintended pregnancies play a major role in the repro- search committee of the Institute. The participants were ductive health of young adults. chosen by convenient sampling methods. All the students The emergency contraception (EC) is a contracep- of the colleges were approached and were informed about tive method used to prevent unwanted pregnancy in the objectives of the study and assured that the information the first few days after the unprotected sexual inter- collected will be kept confidential. The students who gave course or contraceptive failure/accident. The EC is written consent were given a pre-tested (modified after pre- also known as post-coital pills or morning-after pills testing) self-administered anonymous questionnaire with a [5]. According to WHO, EC can prevent up to 95% condition that all the questions to be answered compulsor- of the pregnancies [6]. In many developed countries, ily. The students actively get the questionnaire and enthusi- there is an increased incidence of high-risk sexual be- astically gave their response with a net response rate 91%. haviour among the adolescents’ age group, and their The anonymity of the participants was also assured and awareness level of the EC were excellent with the ensured. percentage varying from 61 to 93% [7–9]. Surpris- ingly, in developing countries also there is an in- 2.3 Variables of the study creased trend of sexual activity at an early age. By the The semi-structured questionnaire consisted of three age of 18 years, 40–80% of females become sexually parts. The first part consisted of the basic demographic active [10]. But their awareness level regarding the details like age, gender, marital status, course, year, insti- EC is low compared with the developed countries. tution type, place of matriculation and socio-economic Limited access to information and services often status based on modified BG Prasad scale [14], religion cause major reproductive health problems to young and residence. The second part consists of 17 knowledge women due to unwanted pregnancy or unsafe/illegal questions with multiple choices regarding EC, and some abortions [11]. India is also facing similar problems questions have multiple responses. Each correct answer like other counties. Though Tamil Nadu is one of the was scored “1”. Based on the total scores, the level of best states in providing health care service in India awareness was divided into poor, moderate and high [12], only one previous study was conducted among awareness. The cumulative score below 8 was considered college students and it was in private colleges in the as poor awareness, the score of 9 to 17 was considered state. This study was planned to assess the awareness as moderate awareness and score of 18–25 was consid- and attitude of college students in Tamil Nadu re- ered as high awareness. The third part consists of the at- garding EC. titude of the participants regarding EC. It consists of Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 3 of 11 nine statements with responses of “Agree”, “Neutral”, Table 1 Socio-demographic characteristics of the college student’s sample in Thiruvarur District, Tamil Nadu, India (n = “Disagree” These responses were scored on a three-point 758) Likert scale: a score of “2” was assigned for a favourable Characteristics N % response, “1” for neutral response and “0” for the un- favourable/negative response. Scores ranged from 0 to Age 18 and the cumulative score ranging between 0 and 12 Less than 25 493 65 was considered as negative attitude, and score of 13 to 25 and above 265 35 18 was considered as positive attitude towards the EC. Gender Female 419 55.3 2.4 Statistical analysis Male 339 44.7 All the data were entered in Excel and analysed through SPSS version 20 software. Chi-square test was used to Marital status test the association. And the p value of < 0.05 was con- Married 101 14.4 sidered significant. Unmarried 649 85.6 Course 3 Results Arts 299 39.4 A total of 758 students participated in the study and filled Science 235 31.0 the questionnaire. The mean age of the participants was 22.9 ± 4.3 years. The majority were females 419 (55.3%), Professional 170 22.4 less than 25 years old 493 (65%), unmarried 649 (85.6%) Research scholars 55 7.2 and belonging to upper socio-economic status 331 Year (43.7%). The study was conducted among the students of I 303 40.0 various disciplines/colleges pursuing undergraduate, post II 372 49.1 graduate and doctorate degrees. And for better under- III 83 10.9 standing, all the courses were grouped in 4 main branches based on its nature. The branches include the background Institution type of arts, science, professional courses and research scholars. Government 409 54.0 The majority of the study participants are the students of Private 349 46.0 arts course 299 (39.4%), second year of their course 372 Place of matriculation (49.1%), from the government institutions 409 (54%) and Rural school 356 47.0 402 (53%) did schooling in urban areas; 526 (69.4%) were Urban school 402 53.0 Hindu by religion and 426 (52.6%) were hostellers as shown in Table 1 Socioeconomic status (modified BG Prasad scale) Out of 758 participants, 183 (24.1%) had heard about Rs 6574 and above 331 43.7 the EC. Among them, males comprised 39.9% and fe- Rs 3287 to 6573 99 13.1 males comprised 60.1%. The main source of information Rs 1972 to 3286 148 19.5 about EC among participants was internet 49.7%, text- Rs 986 to 1971 125 16.5 books 37.7%, television 35%, doctors 30.6%, friends 29%, Rs 985 and below 55 7.2 hospital 26.8, newspaper 21.3%, family 12.6% and radio 5.5% as shown in Fig. 1. Religion Out of 183 (24.1%) who had knowledge about the EC, Christian 130 17.2 42.1% had knowledge that combined oral contraceptive Hindu 526 69.4 pills (OCPs) can be used as an EC followed by 23% pro- Muslim 102 13.4 gesterone only pills. About 31.7% of the participants were Residence aware that intra uterine contraceptive device (IUCD) can Day scholar 332 43.8 be used as EC, and 20.2% were aware about the maximum time limit to IUCD as EC as within 5 days. Hosteler 426 56.2 Most of the participants have knowledge regarding Professional courses: Students who are pursing undergraduate and postgraduate degree in management and engineering were grouped in the brand of ECPs, 31.1% opted for I-pill followed professional courses. Students who are pursuing PhD in any branch are under by 27.9% for Mala-N, 12.6% Ezy pill and 7.1% for research scholar category Ovral while 37.7% were unaware about this. Com- mon places preferred by the participants to purchase A considerable proportion of the participants who EC were local pharmacy shops 64.5%, government were aware of EC had knowledge regarding the indica- hospitals 61.7% followed by private hospitals 35.5%. tions of EC, 56.8% after unprotected sex, 50.8% as a birth Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 4 of 11 Fig. 1 The source of information about the emergency contraception (multiple response question) control measure, 48.1% following failure of contracep- associated with the awareness level about the EC among tion, 42.6% following forced sex/sexual assault and the participants as shown in Table 3. 42.1% following rape. Only 8.2% of the participants lack Out of 183 participants, 55.2% disagreed that the EC is knowledge about the indication. promoting promiscuity (immoral). Only 29% of the partic- The majority of the participants 63.4% were aware that ipants had misconception that EC is a method of abortion. the EC will not protect against HIV/AIDS and other Most of them 71% disagreed for EC as a sinful act. Nearly sexually transmitted diseases. 66.2% of the participants 38.8% were neutral for the question, whether EC may reported that consultation is necessary before taking EC. affect the baby and half of the participants disagreed that Nearly half 48.1% of the participants reported that preg- the use of EC leads to infertility. Some 38.8% of the study nancy test is required before taking EC. participants agreed that the usage of EC will affect the About 42.6% opted that the OCPs can be taken within next menstrual period. Most of the participants 60.1% 72 h of the unprotected sex followed by 13.7% within 24 agreed that they will advise EC to others and 35.5% agreed hours. The majority of the participants 77.6% were that the use of EC will increase the high-risk behaviour aware of the failure rate/effectiveness of the OCPs that among the youths. The majority 82.5% gave positive re- failure can happen in spite of taking EC, and only a few sponse that the knowledge of EC should be given in the (12, 6.6%) had a misconception that it is always effective. educational institutions as shown in Table 4. Most of the study participants 63.4% were unaware of Out of 183 participants who heard of EC, nearly 59% had the exact recommended doses of OCPs, and 63.9% were negative attitude towards the use of EC as shown in Fig. 3. unaware of the recommended time interval between the On assessing the association between the socio- doses of OCPs as shown in Table 2. demographic variables with the attitude levels of the The majority of the participants were aware about the participants, significant associations were seen with the side effects of EC; the common side effects of EC as participants who are 25 years and above (p < 0.001), stated by the participants were menstrual irregularities married participants (p = 0.010), professional group (p 60.7%, abdominal pain 40.4%, vomiting 38.3% and nau- < 0.001), from private institutions (p < 0.001), class IV sea 31.1%, fever 11.5% while 30.6% of the participants socioeconomic status (p = 0.011), Christian community were unaware of the side effects of the EC. participants (p = 0.009) and hostellers (p < 0.001). The awareness levels of the students were poor aware- However, variables like gender (p = 0.210), year of the ness 23%, moderate awareness 60.1% and high awareness study (p = 0.286) and place of matriculation (p =0.362) 16.9% as shown in Fig. 2 were not associated with the attitude level about the EC On assessing the association between the sociodemo- among the study participants as shown in Table 5. graphic variables with the awareness level of the study With regards to association between the knowledge participants, there is a strong association seen with the score and the attitude score of the participants towards participants of more than or equal to 25 years of age (p the EC, there is a significant association noted, the nega- < 0.001), married participants (p = 0.027), private college tive attitude is associated with poor and moderate students (p = 0.002), class IV socioeconomic status (p < awareness regarding the EC (p < 0.001) (Table 6) 0.001), Muslim community participants (p = 0.001) and days' scholars (p = 0.001). However, variables like gender 4 Discussion (p = 0.946), course (p = 0.080), year of the study (p = This study aimed to assess the knowledge and attitude 0.704), and place of matriculation (p = 0.459) were not on EC among the college students and to find the Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 5 of 11 Table 2 Knowledge regarding the EC among the college Table 2 Knowledge regarding the EC among the college students who had heard about the EC (n = 183) students who had heard about the EC (n = 183) (Continued) Characteristics N % Characteristics N % Medications used as EC Time at which OCPs to be taken OCPs 77 42.1 Within 24 h after sex 25 13.7 Progesterone only pills 42 23.0 Within 72 h after sex 78 42.6 Antibiotics like amoxicillin, erythromycin 3 1.6 Within 5 days after sex 7 3.8 Do not know 61 33.3 Before sex 14 7.7 Trade names Do not know 59 32.2 I Pill 57 31.1 Effectiveness in pregnant women Ezy Pill 23 12.6 Yes 23 12.6 Mala-N 51 27.9 No 115 62.8 Ovral 13 7.1 Do not know 45 24.6 Do not know 69 37.7 Effectiveness in preventing pregnancy Place of availability Always effective 12 6.6 Government hospital 113 61.7 Failures can happen 142 77.6 Private hospital 65 35.5 Do not know 29 15.8 Pharmacy 118 64.5 EC are same as abortion pills Supermarket 8 4.4 Yes 17 9.3 Any shops 5 2.7 No 125 68.3 Do not know 9 4.9 Do not know 41 22.4 Price (INR) Recommended number of doses Less than 100 61 33.3 One dose 26 14.2 100 to 200 37 20.2 Two doses 39 21.3 200 to 300 3 1.6 Three doses 2 1.1 Do not know 82 44.8 Do not know 116 63.4 Indications for EC Recommended time between the doses Unprotected sex 104 56.8 12 h apart 9 4.9 Forced sex/sexual assault 78 42.6 24 h apart 21 11.5 Rape 77 42.1 48 h apart 34 18.6 Birth control measure 93 50.8 To be taken with the pill 2 1.1 Failure of contraception 88 48.1 Do not know 117 63.9 To induce abortion 33 18 Frequency in a month Do not know 15 8.2 Once 36 19.7 Requirement of doctor consultation before taking EC Twice 11 6 Yes 121 66.2 Thrice 4 2.2 No 31 16.9 Daily 4 2.2 Do not know 31 16.9 weekly 4 2.2 EC prevent STD Do not know 124 67.7 Yes 43 23.5 Can IUCD used for EC No 116 63.4 Yes 58 31.7 Do not know 24 13.1 No 39 21.3 Requirement of pregnancy test before taking EC Do not know 86 47 Yes 88 48.1 Timing of insertion of IUCDs No 44 24 Within 5 days 37 20.2 Do not know 51 27.9 Within 7 days 4 2.2 Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 6 of 11 Table 2 Knowledge regarding the EC among the college study conducted at Ethiopia by Grima et al. also students who had heard about the EC (n = 183) (Continued) showed that oral contraceptive pills can be used as Characteristics N % EC [17]. This shows that most of the students know the medications to be used as EC. In our study, Within 1 month 1 0.5 31.7% of the students knew that the IUCD can also At the time of sexual intercourse 18 9.8 be used as EC and 20% of them knew that it should Do not know 123 67.2 be inserted within 5 days of unprotected sexual inter- Multiple responses course. This shows that the study participants have knowledge regarding the IUCD, their use as EC and their maximum time limit of insertion to prevent association between the socio-demographic variables pregnancy. A study conducted by Tilahun et al. in with the knowledge and attitude score. Only 24.1% of Ethiopia also showed that IUCD can be used as an the participants heard about the EC which is similar to EC,and in thesamestudy,only 3.5%of the study another study conducted in college students in Pudu- participants reported that the IUCD should be cherry which showed that 23.1% were aware of the EC inserted within 5 days of unprotected sexual inter- [13]. More females 60.1% heard about EC when com- course [18]. pared with males 39.9%. The reason could be that the I-pill was the most commonly known brand of OCPs wide availability of information about EC in the internet, among students of the present study. Similarly, the study newspaper, radio etc., and also the EC methods are at Mangalore also shows that the same brand is known widely used by females. Similar to this study, a study among the study participants [16]. Nearly 64.5% of the conducted in the USA showed significantly greater pro- students informed that EC can be purchased from local portion of the female students had heard about the EC pharmacy shops followed by government (61.7%) and than the males [15]. private (35.5%) hospitals. A study conducted in female Nearly half of the study participants opted for the university students at South Africa also showed that the internet as the common source of information which public health facilities are the common source of getting might be due to the easy accessibility of the high- EC [19]. speed internet through the smartphone’sinthe recent The unprotected sex, birth control measure and times followed by textbook which shows most of the following the failure of the contraception were par- students had a knowledge about the EC in their ticipants’ responses for the indication of the EC, in- school days. A similar study at Mangalore, India, dicating that the participants were aware of the showed that television was the most common source situations in which EC should be used. This may be of information [16]. In this study, the majority of the due to the widespread knowledge of EC among stu- participants had correct knowledge that combined dents. A significant number of the students (63.4%) oral contraceptive pills can be used as EC. A similar reported that it will not prevent the sexually trans- mitted diseases, and almost half of them were aware to have a pregnancy test before taking EC. But the study conducted at Gujarat, India, among under- graduate medical students showed that nearly 75% of the participants reported that the EC will prevent sexually transmitted diseases, and a significant num- ber of the students mentioned that there is no need to do pregnancy test before taking EC [20]. About 42.6% of the study participants opted that the OCPs can be taken up to 72 h followed by 13.7% opted for within 24 h after the unprotected sexual intercourse. A similar study conducted by Shiferaw et al. among the female university students in Ethiopia showed that 36.1% of the students, opted that it should be taken within 24 h followed by 28.3% reporting the timing as within 72 h after the unprotected sex [21]. In our study, a significant number of participants opted that failure can happen after taking an EC, and they were aware Fig. 2 Distribution of the college students according to the level of that it is not the same as that of the abortion pills. awareness (n = 183) However, thestudy didnot investigatethe failurerate Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 7 of 11 Table 3 Association between the socio-demographic variables and the awareness level of college students regarding the emergency contraception (n = 183) Characteristics Awareness level X (p value) Poor (%) (1–8) Moderate (%) (9–17) High (%) (18–25) Total N (%) Age Less than 25 36 (29.8) 72 (59.5) 13 (10.7) 121 (100) 15.3 25 and above 6 (9.7) 38 (61.3) 18 (29) 62 (100) (< 0.001) Gender Female 26 (23.6) 66 (60) 18 (16.4) 110 (100) 0.1 (0.946) Male 16 (21.9) 44 (60.3) 13 (17.8) 73 (100) Marital status Married 4 (10.3) 24 (61.5) 11 (28.2) 39 (100) 7.2 (0.027) Unmarried 38 (26.4) 86 (59.7) 20 (13.9) 144 (100) Course Arts 18 (31.6) 27 (47.4) 12 (21.1) 57 (100) Science 15 (21.1) 50 (70.4) 6 (8.5) 71 (100) 11.3 (0.080) Professional 4 (14.3) 18 (64.3) 6 (21.4) 28 (100) Research Scholars 5 (18.5) 15 (55.6) 7 (25.9) 27 (100) Year I 15 (26.8) 33 (58.9) 8 (14.3) 56 (100) II 20 (19.6) 62 (60.8) 20 (19.6) 102 (100) 2.2 (0.704) III 7 (28) 15 (60) 3 (12) 25 (100) Institution type Government 33 (29.2) 68 (60.2) 12 (10.6) 113 (100) 11.9 (0.002) Private 9 (12.9) 42 (60) 19 (27.1) 70 (100) Place of matriculation Rural school 17 (20.5) 49 (59) 17 (20.5) 83 (100) 1.5 (0.459) Urban school 25 (25) 61 (61) 14 (14) 100 (100) Socioeconomic status Rs 6574 and above 33 (29.5) 71 (63.4) 8 (7.1) 112 (100) Rs 3287 to 6573 1 (4) 13 (52) 11 (44) 25 (100) 34.7 Rs 1972 to 3286 4 (14.3) 18 (64.3) 6 (21.4) 28 (100) (<0.001) Rs 986 to 1971 2 (15.4) 8 (61.5) 3 (23.1) 13 (100) Rs 985 and below 2 (40) 0 (0) 3 (60) 5 (100) Religion Christian 4 (12.1) 23 (69.7) 6 (18.2) 33 (100) Hindu 34 (26.6) 79 (61.7) 15 (11.7) 128 (100) 17.9 (0.001) Muslim 4 (18.2) 8 (36.4) 10 (45.5) 22 (100) Residence Day scholar 8 (13.8) 32 (55.2) 18 (31) 58 (100) Hosteler 34 (27.2) 78 (62.4) 13 (10.4) 125 (100) 13.4 (0.001) p < 0.05 is considered significant of each EC among the participants. A similar study In our study, about 60% opted for the menstrual irri- conducted at Gujarat, India also showed that a signifi- gularity as the most commom side effect followed by ab- cant number of the students knew that the EC, and the dominal pain (40.4%), vomiting (38.3%) and nausea abortion pills are different [20]. (31.1%). A similar study conducted at Ahmedabad, India, Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 8 of 11 Table 4 Attitude of college students towards the emergency contraception (n-183) Characteristics Attitude Agree (%) Neutral (%) Disagree (%) EC promoting promiscuity (immoral) 23 (12.6) 59 (32.2) 101 (55.2) EC is a method for inducing abortion 53 (29) 32 (17.5) 98 (53.6) EC a sinful act 18 (9.8) 35 (19.1) 130 (71) EC use will lead to infertility 34 (18.6) 58 (31.7) 91 (49.7) EC may affect the baby if it does not work 48 (26.3) 71 (38.8) 64 (35) EC will affect the next menstrual period 71 (38.8) 61 (33.3) 51 (27.9) Will you advice EC for others 110 (60.1) 41 (22.4) 32 (17.5) The use of EC will encourage high risk behaviour among youths 65 (35.5) 59 (32.2) 59 (32.2) The information and knowledge regarding the EC have to be given in educational institutions 151 (82.5) 25 (13.7) 7 (3.8) by Shelat et al. [22] among college students showed the the marital status and knowledge level [23]. A study most common side effect is nausea and vomiting in Nigeria byAwolkeetal. showed asignificant asso- followed by menstrual irregularities. ciation between the socio-economic status and the In our study on assessing the association between the knowledge level [24]. A study at Tigray, Ethiopia by sociodemographic variables with the awareness level, Gebrehiwot et al. [25] showed association with the there is a significant association seen with participants > private college students with the knowledge level. A 25 years of age, married participants, private college stu- study at Lucknow, India, by Mishra et al. [26]showed dents, class IV and class V socioeconomic status, significant association with the religion, and the study Muslim community participants and days’ scholars. by Hoque et al. [19] in South Africa showed signifi- However, other variables like gender, course, year of the cant association with the day’s scholar with the know- study and place of matriculation did not show any asso- ledge level similar to our study. The Mangalore study ciation. Similarly, a study by Tilahun et al. in Ethiopia by Joseph et al. [16] showed a significant association also showed significant association with the age, course of with the gender which is against our study results the study and knowledge level [18]. The Ethiopian study and no association with the place of matriculation by Nibabe et al. showed a significant association with and the knowledge level which is similar to our study. The studies in Mangalore and Turkey showed an as- sociation between the course and the knowledge level which is not seen in our study [16, 27]. Similar to ourstudy,a Nigerian studybyArinze-Oniyaetal. also showed no association with the year of the study and the knowledge level [28]. Regarding the attitude about the EC, 55.2% disagreed that the EC promots promiscuity. A similar study by Shiferaw et al. in South West Ethiopia also showed that EC is not promoting promiscuity [21]. But the Mangalore [16]and Raipur study [29] showed a neutral response towards promiscuity associated with the use of EC. Only 29% of our participants agreed that EC is a method of abortion. But theEthiopian studybyShiferawetal. showed half of the participants did not know whether the EC leads to abortion or not [21]. Meanwhile, the majority (71%) disagreed that EC is a sinful act and does not lead to infertility in a woman. In contrary, participants in the study by Shiferaw et al. showed that the EC will lead to infertility [21]. A large percentage of the participants 38.8% believed that the use of EC will affect the next menstrual period. Similar to this, Shiferaw et al. also showed the EC will affect the next Fig. 3 Distribution of college students according to the attitude menstrual period [21]. Butthe studybyTajure et al. shows levels toward emergency contraception (n = 183) the majority of the participants (50.2%) mentioned that Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 9 of 11 Table 5 Association between sociodemographic variable and attitude of college students regarding emergency contraception (n = 183) Characteristics Attitude level X (p value) Negative attitude (0–12) Positive attitude (13–18) Total N (%) Age Less than 25 86 (71.1) 35 (28.9) 121 (100) 21.5 (< 0.001) 25 and above 22 (35.5) 40 (64.5) 62 (100) Gender Female 69 (62.7) 41 (37.3) 110 (100) 1.6 (0.210) Male 39 (53.4) 34 (46.6) 73 (100) Marital status Married 16 (41) 23 (59) 39 (100) 6.6 (0.010) Unmarried 92 (63.9) 52 (36.1) 144 (100) Course Arts 44 (77.2) 13 (22.8) 57 (100) Science 45 (63.4) 26 (36.6) 71 (100) 24.1 (< 0.001) Professional 7 (25) 21 (75) 28 (100) Research scholars 12 (44.4) 15 (55.6) 27 (100) Year I 37 (66.1) 19 (33.9) 56 (100) 2.5 (0.286) II 55 (53.9) 47 (46.1) 102 (100) III 16 (64) 9 (36) 25 (100) Institution type Government 82 (72.6) 31 (27.4) 113 (100) 22.4 (< 0.001) Private 26 (37.1) 44 (62.9) 70 (100) Place of matriculation Rural school 52 (62.7) 31 (37.3) 83 (100) 0.8 (0.362) Urban school 56 (56) 44 (44) 100 (100) Socioeconomic status Rs 6574 and above 76 (67.9) 36 (32.1) 112 (100) Rs 3287 to 6573 12 (48) 13 (52) 25 (100) 13.1 (0.011) Rs 1972 to 3286 12 (42.9) 16 (57.1) 28 (100) Rs 986 to 1971 4 (30.8) 9 (69.2) 13 (100) Rs 985 and below 4 (80) 1 (20) 5 (100) Religion Christian 12 (36.4) 21 (63.6) 33(100) 9.4 (0.009) Hindu 80 (62.5) 48 (37.5) 128(100) Muslim 16 (72.7) 6 (27.3) 22(100) Residence Day scholar 19 (32.8) 39 (67.2) 58(100) 24.2 (< 0.001) Hosteler 89 (71.2) 36 (28.8) 125(100) p < 0.05 is taken as significant it will not have any effect on next menstrual period participants believed that EC will increase high-risk be- [30]. Sixty percent will recommend EC to others which haviour among youths. Other studies in Nigeria [31] is similar to studies conducted at Ahmadabad [22]and and Trinidad [32] also showed similar results. Most of Mangalore [16]. In our study, only 35.5% of the the students (82.5%) agreed to have the knowledge of EC in Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 10 of 11 Table 6 Association between the knowledge score and attitude score towards emergency contraception among college students (n = 183) Characteristics Awareness level Total X (p value) Poor awareness (%) Moderate awareness (%) High awareness (%) Attitude level Negative attitude 36 (33.3) 62 (57.4) 10 (9.3) 108 (100) 21.9 (< 0.001) Positive attitude 6 (8) 48 (64) 21 (28) 75 (100) Total 42 110 31 183 educational institutions. Similarly, the South African study Acknowledgements The authors wish to thank all the study participants for their contribution in by Hoque et al. also showed that 70.3% of participants this research. agreed to have the knowledge of EC in study programmes [19]. Authors’ contributions PD coordinated and supervised the data collection process, carried out the On assessing the attitude level, there is significant statistical analysis, drafted and critically reviewed the manuscript and association seen with the participants who are 25 years prepared the manuscript for submission. MS designed the data collection and above, married participants, professional group, forms and coordinated and supervised data collection. JK coordinated and supervised data collection. LB and NK performed statistical analysis and private institutions, class IV socioeconomic status, revised the manuscript. All authors read and approved the final manuscript. Christian participants and days’ scholar. A study in Adama, Ethiopia, also showed a significant association Funding This research did not receive any specific grant from funding agencies in the between the age of the participants, marital status and public, commercial or not-for-profit sectors. religion with the attitude level [18]. Another study at Uttar Pradesh, India, also showed association with the Availability of data and materials course of study and religion with the awareness level The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. of the participants [26]. In our study, the participants with a positive attitude aresignificantlyand most Ethics approval and consent to participate likely to have moderate awareness regarding EC. Stud- The approval of the study protocol was obtained from the Internal Human Ethics Sub-Committee of the Central University of Tamil Nadu, Thiruvarur, ies by Gajera et al. [20] and Bugssa et al. [33]also India, vide the reference no CUTN/IHESC/2019-001 dated: 07/02/2019. After showed significant association between the knowledge getting permission from the college administration, the objectives and pro- and attitude level of the participants. ceeding of the study were explained to the study participants and assured that the information collected will be kept confidential. The participants who gave written consent were only given pre-tested self-administered anonym- ous questionnaire. 4.1 Limitations of the study Consent for publication As convenience sampling was used in the study, so the Written informed consents from study participants were obtained for sample may not represent the target population. Though publication. the anonymity was ensured, the accuracy of the response provided by participants cannot be guaranteed since the Competing interests The authors declare that they have no competing interests EC is a sensitive issue. Author details Health Centre, Central University of Tamil Nadu, Thiruvarur 610005, India. 2 3 Hospital, National Institute of Technology, Tiruchirappalli, India. Department 5 Conclusions of Life Sciences, Central University of Tamil Nadu, Thiruvarur, India. The accurate knowledge about EC was low. The majority Department of Epidemiology & Public Health, Central University of Tamil Nadu, Thiruvarur, India. of the participants had moderate awareness and a negative attitude about it. So, there is a need to improve the know- Received: 9 July 2019 Accepted: 15 November 2019 ledge and the attitude level of the participants about EC. Strategies to promote EC should be developed through References IEC materials, and information about EC should be given 1. United Nations, Department of Economic and Social Affairs, Population within the curricula of the educational institutions. Many Division (2019). World Population Prospects 2019: Highlights (ST/ESA/SER.A/ awareness programs should be conducted regarding EC 423). https://population.un.org/wpp/Publications/Files/WPP2019_Highlights. pdf among college-going students. For the prevention of the 2. Government of India (2012). Census 2011, Provisional Population Report, unwanted, unintended pregnancy and abortion, EC should Office of the Registrar General and Census Commissioner India, Ministry of be promoted along with the family planning methods in Home Affairs, March 31st, 2011. 3. Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and sub- the health care settings. If these factors are addressed regional trends in unintended pregnancy and its outcomes from 1990 to through appropriate health education methods, the mor- 2014: estimates from a Bayesian hierarchical model. Lancet Glob Health. bidity and the economic burden could be averted. 2018;6(4):e380–9. Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 11 of 11 4. GanatraB,Gerdts C,Rossier C, JohnsonBRJr, Tunçalp Ö,AssifiA,etal. 26. Mishra M, Tripathi SS, Verma MK. Knowledge and attitude towards Global, regional, and sub-regional classification of abortions by safety, emergency contraception in females of urban area of Lucknow, Uttar 2010-14: estimates from a Bayesian hierarchical model. Lancet. 2017; Pradesh, India. Int J Reprod Contracept Obstet Gynecol. 2017;6:210–4. 390(10110):2372–81. 27. Yapici G, Oner S, Sasmaz T, Bugdayci R, Kurt AO. Awareness of emergency 5. Arora P, Bajpai RC, Srivastava R. Emergency contraception: a study to assess contraception among university students in Mersin, Turkey. J Obstet knowledge, attitude and practices among female college students in Delhi. Gynaecol Res. 2010;36(5):1087–92. Natl J Community Med. 2013;4(2):282–5. 28. Arinze-Onyia SU, Aguwa EN, Nwobodo E. Health education alone and health education plus advance provision of emergency contraceptive pills 6. World Health Organization. Emergency contraception. Fact sheet, 2018, on knowledge and attitudes among university female students in Enugu, February. https://www.who.int/news-room/fact-sheets/detail/emergency- Nigeria. Niger J Clin Pract. 2014;17(1):100–5. contraception 29. Singh V, Thakur P, Nayak PK, Agrawal S. Knowledge attitude and practice 7. Ottesen S, Narring F, Renteria SC, Michaud PA. Emergency contraception (KAP) of emergency contraceptive pills among women of reproductive age among teenagers in Switzerland: a cross-sectional survey on the sexuality of group attending AIIMS OPD Raipur (C.G.). Int J Adv Med. 2014;1:105–12. 16- to 20-year-olds. J Adolesc Health. 2002;31(1):101–10. 30. Tajure N, Pharm B. Knowledge, attitude and practice of emergency 8. Walker DM, Torres P, Gutierrez JP, Flemming K, Bertozzi SM. Emergency contraception among graduating female students of Jimma university, contraception use is correlated with increased condom use among southwest Ethiopia. Ethiop J Health Sci. 2010;20(2):91–7. adolescents: results from Mexico. J Adolesc Health. 2004;35(4):329–34. 31. Ojule JD, Oriji VK, Georgewill KN. Awareness and practice of emergency 9. Langille DB, Delaney ME. Knowledge and use of emergency post-coital contraception among students of University of Port Harcourt, South-South contraception by female students at a higher school in Nova Scotia. Can J Nigeria. Niger Health J. 2008;8:6–9. Public Health. 2000;91(1):29–32. 32. Parey B, Addison L, Mark JK, Maurice B, Tripathi V, Wahid S, et al. 10. World Health Organisation (2011). The sexual and reproductive health of younger Knowledge, attitude and practice of emergency contraceptive pills among adolescents: research issues in developing countries. https://apps.who.int/iris/ tertiary level students in Trinidad: a cross-sectional survey. West Indian Med bitstream/handle/10665/44590/9789241501552_eng.pdf;jsessionid=5F9224210B6 J. 2010;59(6):650–5. F7E27A14685158EDF21EF?sequence=1 33. Bugssa G, Kahsay T, Asres A, Dimtsu B, Tsige Y. Factors associated with 11. Munakampe MN, Zulu JM, Michelo C. Contraception and abortion knowledge, knowledge, attitude and practice towards emergency contraception among attitudes and practices among adolescents from low and middle-income female clients of Ethiopian immigration and nationality affairs office. J countries: a systematic review [published correction appears in BMC Health Community Med Health Educ. 2014;4:305. Serv Res. 2019 Jul 2;19(1):441]. BMC Health Serv Res. 2018;18(1):909. 12. National Institution for Transforming India (NITI Aayog). Healthy states progressive India. Report on the rank of the states and union territories. Publisher’sNote 2019. http://social.niti.gov.in/uploads/sample/health_index_report Springer Nature remains neutral with regard to jurisdictional claims in 13. Dorairajan G, Chinnakali P, Mohan B. Knowledge, attitude & factors affecting published maps and institutional affiliations. potential use of emergency contraception in college students in Puducherry, south India. Indian J Med Res. 2015;141(1):122–4. 14. Pandey VK, Aggarwal P, Kakkar R. Modified BG Prasad’s Socio-economic Classification-2018: The need of an update in the present scenario. Indian J Comm Health. 2018;30(1):82–4. 15. Yen S, Parmar DD, Lin EL, Ammerman S. Emergency contraception pill awareness and knowledge in uninsured adolescents: high rates of misconceptions concerning indications for use, side effects, and access. J Pediatr Adolesc Gynecol. 2015;28(5):337–42. 16. Joseph N, Shetty B, Hasreen F, Ishwarya R, Baniya M, Sachdeva S, et al. Awareness and attitudes toward emergency contraceptives among college students in South India. J Obstet Gynecol India. 2016;66(Suppl 1):363–9. 17. Girma T, Ejeta E, Dechasa A, Abdulkadir K. Knowledge, attitude and practices of emergency contraception among female students in preparatory school of East Shoa, Adama, Ethiopia. Gynecol Obstet (Sunnyvale). 2015;5:310. 18. Tilahun D, Assefa T, Belachew T. Knowledge, attitude and practice of emergency contraceptives among Adama university female students. Ethiop J Health Sci. 2010;20(3):195–202. 19. Hoque ME, Ghuman S. Knowledge, practices, and attitudes of emergency contraception among female university students in KwaZulu-Natal, South Africa. PLoS ONE. 2012;7(9):e46346. 20. Gajera AN, Barvaliya MJ, Shukla A, Tripathi CB. Knowledge and attitude towards emergency contraception among undergraduate medical students. Int J Basic Clin Pharmacol. 2017;6:955–61. 21. Shiferaw BZ, Gashaw BT, Tesso FY. Factors associated with utilization of emergency contraception among female students in Mizan-Tepi University, South West Ethiopia. BMC Res Notes. 2015;8:817. 22. Shelat PR, Hihoriya NH, Kumbar S. Knowledge and attitude towards the use of emergency contraceptive pills among college students. Int J Basic Clin Pharmacol. 2012;1(2):77–84. 23. Nibabe WT, Mgutshini T. Emergency contraception amongst female college students: knowledge, attitude and practice. Afr J Prim Health Care Fam Med. 2014;6(1):E1–7. 24. Awoleke JO, Adanikin AI, Awoleke A, Odanye M. Awareness and practice of emergency contraception at a private university in Nigeria. BMC Res Notes. 2015;8:215. 25. Gebrehiwot H, Gebrekidan B, Berhe H, Kidanu K. Assessment of knowledge, attitude, and practice towards emergency contraceptives among female college students at Mekelle Town, Tigray Region, Ethiopia: a cross sectional study. Int J Pharm Sci Res. 2013;4(3):1027–38. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Knowledge and attitudes about the use of emergency contraception among college students in Tamil Nadu, India

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Abstract

Background: In India, a large number of pregnancies are unplanned resulting in unsafe and illegal abortion. For every legal abortion, 10 to 11 illegal abortions are occurring which endangers the health and survival of the women. In recent years, there is an increase in unwanted and unintended pregnancy at the early age group. Usage of emergency contraception (EC) can decrease the unwanted pregnancy and provide a healthier life. Aim: The aim of study is to assess the knowledge and attitude regarding EC among college students in Thiruvarur District, Tamil Nadu, India. Methods: A cross-sectional study was conducted among the college students of Thiruvarur district, Tamil Nadu, India. A total of 758 students were selected by convenient sampling technique. Data was collected by administering a pretested semi-structured questionnaire. Results: Out of 758 students, 183(24%) heard about EC. The commonest source of information was the internet 91 (49.7%). The majority 116 (63.4%) knew that it does not prevent STDs. Of those who were aware, 42% were awareof42.6% areaware of thetimelimit to useEC. Theknowledge levelofabout theECwas moderate (60.1%), and it was significantly (p < 0.05) more among students > 25 years old, married participants, students in private institution, of lower socio-economic status, Muslim students and days’ scholars. The negative attitude towards EC was 59%. Nearly 38.8% believed that the EC will affect the next menstrual period, and 35.5% informed it will increase high risk behaviour among adults. The attitude level was significantly associated with the same factors associated with the awareness level with the factors Christian religion replacing Muslim and higher socioeconomic class replacing lower class participants. Conclusion: The knowledge level of the studied college students was moderate, and they mostly had negative attitude towards the EC. Reproductive health education should be given in educational institutions to promote awareness and to remove misconceptions about EC. Keywords: Emergency contraception, College students, Abortions, Unwanted pregnancy * Correspondence: premdavis93@gmail.com Health Centre, Central University of Tamil Nadu, Thiruvarur 610005, India Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 2 of 11 1 Introduction 2 Materials and methods In today’s time, the population growth has become This cross-sectional study was conducted among the one of the leading problems in the world. According college-going students of Thiruvarur District in Tamil to 2019 data, nearly about 7.7 billion people are living Nadu from February 2019 to April 2019. in the world [1]. India contributes to 1210 million population, and every year, it is adding 17.5 million 2.1 Sampling people newly. At present, this overpopulation is the major Considering the awareness regarding EC among college problem in the country, which leads to problems like students is 23.1% [13]. Taking alpha error as 5% and ab- poverty, illiteracy, decrease in the economic growth, solute margin of error as 3% [13], the sample size was starvation, malnutrition, depletion of natural resources calculated to be 758. All the colleges of the district (n = and unemployment [2]. 15) were contacted and informed about the nature of Worldwide, it is estimated that 44% of the pregnancy oc- the study. Due to its sensitiveness, finally one govern- curring were unintended between 2010 and 2014 [3]. In the ment university and two private colleges agreed to par- same interval, 55.7 million abortions occurred worldwide, of ticipate in the study after assuring that the name of which 25.1 million abortions were unsafe abortions, mostly colleges will not be disclosed at any point in time. happening in the developing countries [4]. In India, 78% of the pregnancies are unplanned. And it is estimated that 2.2 Data collection nearly 25% of them are unwanted. Every year nearly 11 mil- The questionnaire was pretested on 5% of the students lion abortions take place of which 6.7 million are induced prior to the actual data collection of the study population. and 4 million are spontaneous abortions. Under the preview This wasdone toassessthe ambiguity and comprehensibil- of MTP act, abortions are permitted in India since 1971 for ity of the questionnaire and subsequent modification was specific indications. However, approximately 10 to 11 illegal done for the ease of comprehension. The students who are abortions for each legal abortion are occurring. Nearly 20, included in the pretesting were excluded from the study. 000 women are dying annually due to abortion-related com- The content validation of the questionnaire was done by plications which are almost preventable [5]. Thus, unwanted experts in the research subject from the departmental re- and unintended pregnancies play a major role in the repro- search committee of the Institute. The participants were ductive health of young adults. chosen by convenient sampling methods. All the students The emergency contraception (EC) is a contracep- of the colleges were approached and were informed about tive method used to prevent unwanted pregnancy in the objectives of the study and assured that the information the first few days after the unprotected sexual inter- collected will be kept confidential. The students who gave course or contraceptive failure/accident. The EC is written consent were given a pre-tested (modified after pre- also known as post-coital pills or morning-after pills testing) self-administered anonymous questionnaire with a [5]. According to WHO, EC can prevent up to 95% condition that all the questions to be answered compulsor- of the pregnancies [6]. In many developed countries, ily. The students actively get the questionnaire and enthusi- there is an increased incidence of high-risk sexual be- astically gave their response with a net response rate 91%. haviour among the adolescents’ age group, and their The anonymity of the participants was also assured and awareness level of the EC were excellent with the ensured. percentage varying from 61 to 93% [7–9]. Surpris- ingly, in developing countries also there is an in- 2.3 Variables of the study creased trend of sexual activity at an early age. By the The semi-structured questionnaire consisted of three age of 18 years, 40–80% of females become sexually parts. The first part consisted of the basic demographic active [10]. But their awareness level regarding the details like age, gender, marital status, course, year, insti- EC is low compared with the developed countries. tution type, place of matriculation and socio-economic Limited access to information and services often status based on modified BG Prasad scale [14], religion cause major reproductive health problems to young and residence. The second part consists of 17 knowledge women due to unwanted pregnancy or unsafe/illegal questions with multiple choices regarding EC, and some abortions [11]. India is also facing similar problems questions have multiple responses. Each correct answer like other counties. Though Tamil Nadu is one of the was scored “1”. Based on the total scores, the level of best states in providing health care service in India awareness was divided into poor, moderate and high [12], only one previous study was conducted among awareness. The cumulative score below 8 was considered college students and it was in private colleges in the as poor awareness, the score of 9 to 17 was considered state. This study was planned to assess the awareness as moderate awareness and score of 18–25 was consid- and attitude of college students in Tamil Nadu re- ered as high awareness. The third part consists of the at- garding EC. titude of the participants regarding EC. It consists of Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 3 of 11 nine statements with responses of “Agree”, “Neutral”, Table 1 Socio-demographic characteristics of the college student’s sample in Thiruvarur District, Tamil Nadu, India (n = “Disagree” These responses were scored on a three-point 758) Likert scale: a score of “2” was assigned for a favourable Characteristics N % response, “1” for neutral response and “0” for the un- favourable/negative response. Scores ranged from 0 to Age 18 and the cumulative score ranging between 0 and 12 Less than 25 493 65 was considered as negative attitude, and score of 13 to 25 and above 265 35 18 was considered as positive attitude towards the EC. Gender Female 419 55.3 2.4 Statistical analysis Male 339 44.7 All the data were entered in Excel and analysed through SPSS version 20 software. Chi-square test was used to Marital status test the association. And the p value of < 0.05 was con- Married 101 14.4 sidered significant. Unmarried 649 85.6 Course 3 Results Arts 299 39.4 A total of 758 students participated in the study and filled Science 235 31.0 the questionnaire. The mean age of the participants was 22.9 ± 4.3 years. The majority were females 419 (55.3%), Professional 170 22.4 less than 25 years old 493 (65%), unmarried 649 (85.6%) Research scholars 55 7.2 and belonging to upper socio-economic status 331 Year (43.7%). The study was conducted among the students of I 303 40.0 various disciplines/colleges pursuing undergraduate, post II 372 49.1 graduate and doctorate degrees. And for better under- III 83 10.9 standing, all the courses were grouped in 4 main branches based on its nature. The branches include the background Institution type of arts, science, professional courses and research scholars. Government 409 54.0 The majority of the study participants are the students of Private 349 46.0 arts course 299 (39.4%), second year of their course 372 Place of matriculation (49.1%), from the government institutions 409 (54%) and Rural school 356 47.0 402 (53%) did schooling in urban areas; 526 (69.4%) were Urban school 402 53.0 Hindu by religion and 426 (52.6%) were hostellers as shown in Table 1 Socioeconomic status (modified BG Prasad scale) Out of 758 participants, 183 (24.1%) had heard about Rs 6574 and above 331 43.7 the EC. Among them, males comprised 39.9% and fe- Rs 3287 to 6573 99 13.1 males comprised 60.1%. The main source of information Rs 1972 to 3286 148 19.5 about EC among participants was internet 49.7%, text- Rs 986 to 1971 125 16.5 books 37.7%, television 35%, doctors 30.6%, friends 29%, Rs 985 and below 55 7.2 hospital 26.8, newspaper 21.3%, family 12.6% and radio 5.5% as shown in Fig. 1. Religion Out of 183 (24.1%) who had knowledge about the EC, Christian 130 17.2 42.1% had knowledge that combined oral contraceptive Hindu 526 69.4 pills (OCPs) can be used as an EC followed by 23% pro- Muslim 102 13.4 gesterone only pills. About 31.7% of the participants were Residence aware that intra uterine contraceptive device (IUCD) can Day scholar 332 43.8 be used as EC, and 20.2% were aware about the maximum time limit to IUCD as EC as within 5 days. Hosteler 426 56.2 Most of the participants have knowledge regarding Professional courses: Students who are pursing undergraduate and postgraduate degree in management and engineering were grouped in the brand of ECPs, 31.1% opted for I-pill followed professional courses. Students who are pursuing PhD in any branch are under by 27.9% for Mala-N, 12.6% Ezy pill and 7.1% for research scholar category Ovral while 37.7% were unaware about this. Com- mon places preferred by the participants to purchase A considerable proportion of the participants who EC were local pharmacy shops 64.5%, government were aware of EC had knowledge regarding the indica- hospitals 61.7% followed by private hospitals 35.5%. tions of EC, 56.8% after unprotected sex, 50.8% as a birth Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 4 of 11 Fig. 1 The source of information about the emergency contraception (multiple response question) control measure, 48.1% following failure of contracep- associated with the awareness level about the EC among tion, 42.6% following forced sex/sexual assault and the participants as shown in Table 3. 42.1% following rape. Only 8.2% of the participants lack Out of 183 participants, 55.2% disagreed that the EC is knowledge about the indication. promoting promiscuity (immoral). Only 29% of the partic- The majority of the participants 63.4% were aware that ipants had misconception that EC is a method of abortion. the EC will not protect against HIV/AIDS and other Most of them 71% disagreed for EC as a sinful act. Nearly sexually transmitted diseases. 66.2% of the participants 38.8% were neutral for the question, whether EC may reported that consultation is necessary before taking EC. affect the baby and half of the participants disagreed that Nearly half 48.1% of the participants reported that preg- the use of EC leads to infertility. Some 38.8% of the study nancy test is required before taking EC. participants agreed that the usage of EC will affect the About 42.6% opted that the OCPs can be taken within next menstrual period. Most of the participants 60.1% 72 h of the unprotected sex followed by 13.7% within 24 agreed that they will advise EC to others and 35.5% agreed hours. The majority of the participants 77.6% were that the use of EC will increase the high-risk behaviour aware of the failure rate/effectiveness of the OCPs that among the youths. The majority 82.5% gave positive re- failure can happen in spite of taking EC, and only a few sponse that the knowledge of EC should be given in the (12, 6.6%) had a misconception that it is always effective. educational institutions as shown in Table 4. Most of the study participants 63.4% were unaware of Out of 183 participants who heard of EC, nearly 59% had the exact recommended doses of OCPs, and 63.9% were negative attitude towards the use of EC as shown in Fig. 3. unaware of the recommended time interval between the On assessing the association between the socio- doses of OCPs as shown in Table 2. demographic variables with the attitude levels of the The majority of the participants were aware about the participants, significant associations were seen with the side effects of EC; the common side effects of EC as participants who are 25 years and above (p < 0.001), stated by the participants were menstrual irregularities married participants (p = 0.010), professional group (p 60.7%, abdominal pain 40.4%, vomiting 38.3% and nau- < 0.001), from private institutions (p < 0.001), class IV sea 31.1%, fever 11.5% while 30.6% of the participants socioeconomic status (p = 0.011), Christian community were unaware of the side effects of the EC. participants (p = 0.009) and hostellers (p < 0.001). The awareness levels of the students were poor aware- However, variables like gender (p = 0.210), year of the ness 23%, moderate awareness 60.1% and high awareness study (p = 0.286) and place of matriculation (p =0.362) 16.9% as shown in Fig. 2 were not associated with the attitude level about the EC On assessing the association between the sociodemo- among the study participants as shown in Table 5. graphic variables with the awareness level of the study With regards to association between the knowledge participants, there is a strong association seen with the score and the attitude score of the participants towards participants of more than or equal to 25 years of age (p the EC, there is a significant association noted, the nega- < 0.001), married participants (p = 0.027), private college tive attitude is associated with poor and moderate students (p = 0.002), class IV socioeconomic status (p < awareness regarding the EC (p < 0.001) (Table 6) 0.001), Muslim community participants (p = 0.001) and days' scholars (p = 0.001). However, variables like gender 4 Discussion (p = 0.946), course (p = 0.080), year of the study (p = This study aimed to assess the knowledge and attitude 0.704), and place of matriculation (p = 0.459) were not on EC among the college students and to find the Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 5 of 11 Table 2 Knowledge regarding the EC among the college Table 2 Knowledge regarding the EC among the college students who had heard about the EC (n = 183) students who had heard about the EC (n = 183) (Continued) Characteristics N % Characteristics N % Medications used as EC Time at which OCPs to be taken OCPs 77 42.1 Within 24 h after sex 25 13.7 Progesterone only pills 42 23.0 Within 72 h after sex 78 42.6 Antibiotics like amoxicillin, erythromycin 3 1.6 Within 5 days after sex 7 3.8 Do not know 61 33.3 Before sex 14 7.7 Trade names Do not know 59 32.2 I Pill 57 31.1 Effectiveness in pregnant women Ezy Pill 23 12.6 Yes 23 12.6 Mala-N 51 27.9 No 115 62.8 Ovral 13 7.1 Do not know 45 24.6 Do not know 69 37.7 Effectiveness in preventing pregnancy Place of availability Always effective 12 6.6 Government hospital 113 61.7 Failures can happen 142 77.6 Private hospital 65 35.5 Do not know 29 15.8 Pharmacy 118 64.5 EC are same as abortion pills Supermarket 8 4.4 Yes 17 9.3 Any shops 5 2.7 No 125 68.3 Do not know 9 4.9 Do not know 41 22.4 Price (INR) Recommended number of doses Less than 100 61 33.3 One dose 26 14.2 100 to 200 37 20.2 Two doses 39 21.3 200 to 300 3 1.6 Three doses 2 1.1 Do not know 82 44.8 Do not know 116 63.4 Indications for EC Recommended time between the doses Unprotected sex 104 56.8 12 h apart 9 4.9 Forced sex/sexual assault 78 42.6 24 h apart 21 11.5 Rape 77 42.1 48 h apart 34 18.6 Birth control measure 93 50.8 To be taken with the pill 2 1.1 Failure of contraception 88 48.1 Do not know 117 63.9 To induce abortion 33 18 Frequency in a month Do not know 15 8.2 Once 36 19.7 Requirement of doctor consultation before taking EC Twice 11 6 Yes 121 66.2 Thrice 4 2.2 No 31 16.9 Daily 4 2.2 Do not know 31 16.9 weekly 4 2.2 EC prevent STD Do not know 124 67.7 Yes 43 23.5 Can IUCD used for EC No 116 63.4 Yes 58 31.7 Do not know 24 13.1 No 39 21.3 Requirement of pregnancy test before taking EC Do not know 86 47 Yes 88 48.1 Timing of insertion of IUCDs No 44 24 Within 5 days 37 20.2 Do not know 51 27.9 Within 7 days 4 2.2 Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 6 of 11 Table 2 Knowledge regarding the EC among the college study conducted at Ethiopia by Grima et al. also students who had heard about the EC (n = 183) (Continued) showed that oral contraceptive pills can be used as Characteristics N % EC [17]. This shows that most of the students know the medications to be used as EC. In our study, Within 1 month 1 0.5 31.7% of the students knew that the IUCD can also At the time of sexual intercourse 18 9.8 be used as EC and 20% of them knew that it should Do not know 123 67.2 be inserted within 5 days of unprotected sexual inter- Multiple responses course. This shows that the study participants have knowledge regarding the IUCD, their use as EC and their maximum time limit of insertion to prevent association between the socio-demographic variables pregnancy. A study conducted by Tilahun et al. in with the knowledge and attitude score. Only 24.1% of Ethiopia also showed that IUCD can be used as an the participants heard about the EC which is similar to EC,and in thesamestudy,only 3.5%of the study another study conducted in college students in Pudu- participants reported that the IUCD should be cherry which showed that 23.1% were aware of the EC inserted within 5 days of unprotected sexual inter- [13]. More females 60.1% heard about EC when com- course [18]. pared with males 39.9%. The reason could be that the I-pill was the most commonly known brand of OCPs wide availability of information about EC in the internet, among students of the present study. Similarly, the study newspaper, radio etc., and also the EC methods are at Mangalore also shows that the same brand is known widely used by females. Similar to this study, a study among the study participants [16]. Nearly 64.5% of the conducted in the USA showed significantly greater pro- students informed that EC can be purchased from local portion of the female students had heard about the EC pharmacy shops followed by government (61.7%) and than the males [15]. private (35.5%) hospitals. A study conducted in female Nearly half of the study participants opted for the university students at South Africa also showed that the internet as the common source of information which public health facilities are the common source of getting might be due to the easy accessibility of the high- EC [19]. speed internet through the smartphone’sinthe recent The unprotected sex, birth control measure and times followed by textbook which shows most of the following the failure of the contraception were par- students had a knowledge about the EC in their ticipants’ responses for the indication of the EC, in- school days. A similar study at Mangalore, India, dicating that the participants were aware of the showed that television was the most common source situations in which EC should be used. This may be of information [16]. In this study, the majority of the due to the widespread knowledge of EC among stu- participants had correct knowledge that combined dents. A significant number of the students (63.4%) oral contraceptive pills can be used as EC. A similar reported that it will not prevent the sexually trans- mitted diseases, and almost half of them were aware to have a pregnancy test before taking EC. But the study conducted at Gujarat, India, among under- graduate medical students showed that nearly 75% of the participants reported that the EC will prevent sexually transmitted diseases, and a significant num- ber of the students mentioned that there is no need to do pregnancy test before taking EC [20]. About 42.6% of the study participants opted that the OCPs can be taken up to 72 h followed by 13.7% opted for within 24 h after the unprotected sexual intercourse. A similar study conducted by Shiferaw et al. among the female university students in Ethiopia showed that 36.1% of the students, opted that it should be taken within 24 h followed by 28.3% reporting the timing as within 72 h after the unprotected sex [21]. In our study, a significant number of participants opted that failure can happen after taking an EC, and they were aware Fig. 2 Distribution of the college students according to the level of that it is not the same as that of the abortion pills. awareness (n = 183) However, thestudy didnot investigatethe failurerate Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 7 of 11 Table 3 Association between the socio-demographic variables and the awareness level of college students regarding the emergency contraception (n = 183) Characteristics Awareness level X (p value) Poor (%) (1–8) Moderate (%) (9–17) High (%) (18–25) Total N (%) Age Less than 25 36 (29.8) 72 (59.5) 13 (10.7) 121 (100) 15.3 25 and above 6 (9.7) 38 (61.3) 18 (29) 62 (100) (< 0.001) Gender Female 26 (23.6) 66 (60) 18 (16.4) 110 (100) 0.1 (0.946) Male 16 (21.9) 44 (60.3) 13 (17.8) 73 (100) Marital status Married 4 (10.3) 24 (61.5) 11 (28.2) 39 (100) 7.2 (0.027) Unmarried 38 (26.4) 86 (59.7) 20 (13.9) 144 (100) Course Arts 18 (31.6) 27 (47.4) 12 (21.1) 57 (100) Science 15 (21.1) 50 (70.4) 6 (8.5) 71 (100) 11.3 (0.080) Professional 4 (14.3) 18 (64.3) 6 (21.4) 28 (100) Research Scholars 5 (18.5) 15 (55.6) 7 (25.9) 27 (100) Year I 15 (26.8) 33 (58.9) 8 (14.3) 56 (100) II 20 (19.6) 62 (60.8) 20 (19.6) 102 (100) 2.2 (0.704) III 7 (28) 15 (60) 3 (12) 25 (100) Institution type Government 33 (29.2) 68 (60.2) 12 (10.6) 113 (100) 11.9 (0.002) Private 9 (12.9) 42 (60) 19 (27.1) 70 (100) Place of matriculation Rural school 17 (20.5) 49 (59) 17 (20.5) 83 (100) 1.5 (0.459) Urban school 25 (25) 61 (61) 14 (14) 100 (100) Socioeconomic status Rs 6574 and above 33 (29.5) 71 (63.4) 8 (7.1) 112 (100) Rs 3287 to 6573 1 (4) 13 (52) 11 (44) 25 (100) 34.7 Rs 1972 to 3286 4 (14.3) 18 (64.3) 6 (21.4) 28 (100) (<0.001) Rs 986 to 1971 2 (15.4) 8 (61.5) 3 (23.1) 13 (100) Rs 985 and below 2 (40) 0 (0) 3 (60) 5 (100) Religion Christian 4 (12.1) 23 (69.7) 6 (18.2) 33 (100) Hindu 34 (26.6) 79 (61.7) 15 (11.7) 128 (100) 17.9 (0.001) Muslim 4 (18.2) 8 (36.4) 10 (45.5) 22 (100) Residence Day scholar 8 (13.8) 32 (55.2) 18 (31) 58 (100) Hosteler 34 (27.2) 78 (62.4) 13 (10.4) 125 (100) 13.4 (0.001) p < 0.05 is considered significant of each EC among the participants. A similar study In our study, about 60% opted for the menstrual irri- conducted at Gujarat, India also showed that a signifi- gularity as the most commom side effect followed by ab- cant number of the students knew that the EC, and the dominal pain (40.4%), vomiting (38.3%) and nausea abortion pills are different [20]. (31.1%). A similar study conducted at Ahmedabad, India, Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 8 of 11 Table 4 Attitude of college students towards the emergency contraception (n-183) Characteristics Attitude Agree (%) Neutral (%) Disagree (%) EC promoting promiscuity (immoral) 23 (12.6) 59 (32.2) 101 (55.2) EC is a method for inducing abortion 53 (29) 32 (17.5) 98 (53.6) EC a sinful act 18 (9.8) 35 (19.1) 130 (71) EC use will lead to infertility 34 (18.6) 58 (31.7) 91 (49.7) EC may affect the baby if it does not work 48 (26.3) 71 (38.8) 64 (35) EC will affect the next menstrual period 71 (38.8) 61 (33.3) 51 (27.9) Will you advice EC for others 110 (60.1) 41 (22.4) 32 (17.5) The use of EC will encourage high risk behaviour among youths 65 (35.5) 59 (32.2) 59 (32.2) The information and knowledge regarding the EC have to be given in educational institutions 151 (82.5) 25 (13.7) 7 (3.8) by Shelat et al. [22] among college students showed the the marital status and knowledge level [23]. A study most common side effect is nausea and vomiting in Nigeria byAwolkeetal. showed asignificant asso- followed by menstrual irregularities. ciation between the socio-economic status and the In our study on assessing the association between the knowledge level [24]. A study at Tigray, Ethiopia by sociodemographic variables with the awareness level, Gebrehiwot et al. [25] showed association with the there is a significant association seen with participants > private college students with the knowledge level. A 25 years of age, married participants, private college stu- study at Lucknow, India, by Mishra et al. [26]showed dents, class IV and class V socioeconomic status, significant association with the religion, and the study Muslim community participants and days’ scholars. by Hoque et al. [19] in South Africa showed signifi- However, other variables like gender, course, year of the cant association with the day’s scholar with the know- study and place of matriculation did not show any asso- ledge level similar to our study. The Mangalore study ciation. Similarly, a study by Tilahun et al. in Ethiopia by Joseph et al. [16] showed a significant association also showed significant association with the age, course of with the gender which is against our study results the study and knowledge level [18]. The Ethiopian study and no association with the place of matriculation by Nibabe et al. showed a significant association with and the knowledge level which is similar to our study. The studies in Mangalore and Turkey showed an as- sociation between the course and the knowledge level which is not seen in our study [16, 27]. Similar to ourstudy,a Nigerian studybyArinze-Oniyaetal. also showed no association with the year of the study and the knowledge level [28]. Regarding the attitude about the EC, 55.2% disagreed that the EC promots promiscuity. A similar study by Shiferaw et al. in South West Ethiopia also showed that EC is not promoting promiscuity [21]. But the Mangalore [16]and Raipur study [29] showed a neutral response towards promiscuity associated with the use of EC. Only 29% of our participants agreed that EC is a method of abortion. But theEthiopian studybyShiferawetal. showed half of the participants did not know whether the EC leads to abortion or not [21]. Meanwhile, the majority (71%) disagreed that EC is a sinful act and does not lead to infertility in a woman. In contrary, participants in the study by Shiferaw et al. showed that the EC will lead to infertility [21]. A large percentage of the participants 38.8% believed that the use of EC will affect the next menstrual period. Similar to this, Shiferaw et al. also showed the EC will affect the next Fig. 3 Distribution of college students according to the attitude menstrual period [21]. Butthe studybyTajure et al. shows levels toward emergency contraception (n = 183) the majority of the participants (50.2%) mentioned that Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 9 of 11 Table 5 Association between sociodemographic variable and attitude of college students regarding emergency contraception (n = 183) Characteristics Attitude level X (p value) Negative attitude (0–12) Positive attitude (13–18) Total N (%) Age Less than 25 86 (71.1) 35 (28.9) 121 (100) 21.5 (< 0.001) 25 and above 22 (35.5) 40 (64.5) 62 (100) Gender Female 69 (62.7) 41 (37.3) 110 (100) 1.6 (0.210) Male 39 (53.4) 34 (46.6) 73 (100) Marital status Married 16 (41) 23 (59) 39 (100) 6.6 (0.010) Unmarried 92 (63.9) 52 (36.1) 144 (100) Course Arts 44 (77.2) 13 (22.8) 57 (100) Science 45 (63.4) 26 (36.6) 71 (100) 24.1 (< 0.001) Professional 7 (25) 21 (75) 28 (100) Research scholars 12 (44.4) 15 (55.6) 27 (100) Year I 37 (66.1) 19 (33.9) 56 (100) 2.5 (0.286) II 55 (53.9) 47 (46.1) 102 (100) III 16 (64) 9 (36) 25 (100) Institution type Government 82 (72.6) 31 (27.4) 113 (100) 22.4 (< 0.001) Private 26 (37.1) 44 (62.9) 70 (100) Place of matriculation Rural school 52 (62.7) 31 (37.3) 83 (100) 0.8 (0.362) Urban school 56 (56) 44 (44) 100 (100) Socioeconomic status Rs 6574 and above 76 (67.9) 36 (32.1) 112 (100) Rs 3287 to 6573 12 (48) 13 (52) 25 (100) 13.1 (0.011) Rs 1972 to 3286 12 (42.9) 16 (57.1) 28 (100) Rs 986 to 1971 4 (30.8) 9 (69.2) 13 (100) Rs 985 and below 4 (80) 1 (20) 5 (100) Religion Christian 12 (36.4) 21 (63.6) 33(100) 9.4 (0.009) Hindu 80 (62.5) 48 (37.5) 128(100) Muslim 16 (72.7) 6 (27.3) 22(100) Residence Day scholar 19 (32.8) 39 (67.2) 58(100) 24.2 (< 0.001) Hosteler 89 (71.2) 36 (28.8) 125(100) p < 0.05 is taken as significant it will not have any effect on next menstrual period participants believed that EC will increase high-risk be- [30]. Sixty percent will recommend EC to others which haviour among youths. Other studies in Nigeria [31] is similar to studies conducted at Ahmadabad [22]and and Trinidad [32] also showed similar results. Most of Mangalore [16]. In our study, only 35.5% of the the students (82.5%) agreed to have the knowledge of EC in Davis et al. Journal of the Egyptian Public Health Association (2020) 95:1 Page 10 of 11 Table 6 Association between the knowledge score and attitude score towards emergency contraception among college students (n = 183) Characteristics Awareness level Total X (p value) Poor awareness (%) Moderate awareness (%) High awareness (%) Attitude level Negative attitude 36 (33.3) 62 (57.4) 10 (9.3) 108 (100) 21.9 (< 0.001) Positive attitude 6 (8) 48 (64) 21 (28) 75 (100) Total 42 110 31 183 educational institutions. Similarly, the South African study Acknowledgements The authors wish to thank all the study participants for their contribution in by Hoque et al. also showed that 70.3% of participants this research. agreed to have the knowledge of EC in study programmes [19]. Authors’ contributions PD coordinated and supervised the data collection process, carried out the On assessing the attitude level, there is significant statistical analysis, drafted and critically reviewed the manuscript and association seen with the participants who are 25 years prepared the manuscript for submission. MS designed the data collection and above, married participants, professional group, forms and coordinated and supervised data collection. JK coordinated and supervised data collection. LB and NK performed statistical analysis and private institutions, class IV socioeconomic status, revised the manuscript. All authors read and approved the final manuscript. Christian participants and days’ scholar. A study in Adama, Ethiopia, also showed a significant association Funding This research did not receive any specific grant from funding agencies in the between the age of the participants, marital status and public, commercial or not-for-profit sectors. religion with the attitude level [18]. Another study at Uttar Pradesh, India, also showed association with the Availability of data and materials course of study and religion with the awareness level The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. of the participants [26]. In our study, the participants with a positive attitude aresignificantlyand most Ethics approval and consent to participate likely to have moderate awareness regarding EC. Stud- The approval of the study protocol was obtained from the Internal Human Ethics Sub-Committee of the Central University of Tamil Nadu, Thiruvarur, ies by Gajera et al. [20] and Bugssa et al. [33]also India, vide the reference no CUTN/IHESC/2019-001 dated: 07/02/2019. After showed significant association between the knowledge getting permission from the college administration, the objectives and pro- and attitude level of the participants. ceeding of the study were explained to the study participants and assured that the information collected will be kept confidential. The participants who gave written consent were only given pre-tested self-administered anonym- ous questionnaire. 4.1 Limitations of the study Consent for publication As convenience sampling was used in the study, so the Written informed consents from study participants were obtained for sample may not represent the target population. Though publication. the anonymity was ensured, the accuracy of the response provided by participants cannot be guaranteed since the Competing interests The authors declare that they have no competing interests EC is a sensitive issue. Author details Health Centre, Central University of Tamil Nadu, Thiruvarur 610005, India. 2 3 Hospital, National Institute of Technology, Tiruchirappalli, India. Department 5 Conclusions of Life Sciences, Central University of Tamil Nadu, Thiruvarur, India. The accurate knowledge about EC was low. The majority Department of Epidemiology & Public Health, Central University of Tamil Nadu, Thiruvarur, India. of the participants had moderate awareness and a negative attitude about it. So, there is a need to improve the know- Received: 9 July 2019 Accepted: 15 November 2019 ledge and the attitude level of the participants about EC. Strategies to promote EC should be developed through References IEC materials, and information about EC should be given 1. United Nations, Department of Economic and Social Affairs, Population within the curricula of the educational institutions. Many Division (2019). 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Published: Jan 29, 2020

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