Knowledge and perceptions of emergency contraceptive pills among a college-age population: A qualitative approach

Harper, Cynthia

Emergency contraceptive pills, also known as morning-after pills, are a postcoital hormonal treatment that appears to inhibit implantation of the fertilized ovum. The typical regimen--the "Yuzpe" method--consists of 200 mcg of ethinyl estradiol and 2.0 mg of norgestrel (or 1.0 mg of levonorgestrel), usually dispensed as four combined estrogen-progestin oral contraceptives; two pills are taken within 72 hours of unprotected intercourse, and two are taken 12 hours later.*(1) Oral contraceptives, however, are not specifically labeled by the Food and Drug Administration (FDA) for emergency contraception and are not marketed as such, so access for women in the United States has been restricted.

Since the early 1990s, family planning advocates have sought to expand access to emergency contraceptive pills as a cost-effective measure to prevent unintended pregnancies and abortions.(2) Various groups concerned with women's health and reproductive rights have publicized their positions on the issue, encouraging FDA approval and availability of the method, and even the popular press has begun to run stories.(3)

But what do people with access to emergency contraceptive pills think about this method? Do they consider it a useful and appropriate means of fertility control? A university population presents itself as an optimal group among whom to investigate this question, since many university health centers include emergency contraceptive pills in their reproductive health services. This study examines the knowledge and attitudes of students at Princeton University about emergency contraceptive pills, which were available at the health center for more than 15 years and were advertised frequently on campus for two years prior to the study.

The findings can be used as an indicator of the types of problems and attitudes that might prevail in a context of widespread access to emergency contraceptive pills. Students, however, might be expected to look more favorably upon use of emergency contraceptive pills than the larger population, given their general desire to complete their education before having children.

As no research has previously assessed knowledge and opinions about emergency contraceptive pills in the United States, we used both qualitative and quantitative methods to gather as much information as possible. A statistical analysis of survey data, described elsewhere,(4) confirmed our hypothesis that higher levels of knowledge about emergency contraceptive pills (such as knowledge of the ingredients and potential side effects) are associated with more positive attitudes. The survey data also showed political and religious orientation to be significant determinants of student attitudes. This article presents the findings from a series of focus-group discussions, which documented students' opinions on emergency contraceptive pills within a more general context of sexuality.

Methodology

Focus-group methodology, commonly used for market research, has become an important tool for social science research, including the health fields.(5) Focus-group discussions are well suited for topics that have not yet been extensively researched; the open-ended format allows participants to bring up new issues, unforeseen by the researchers. Focus groups are also recommended for studying complex behavior and underlying motivations.(6) Our understanding of reproductive issues has been enriched by several focus-group studies.(7)

A total of 11 focus-group discussions were held: eight with undergraduate students, two with graduate students and one with staff from the university's health center. Half of the undergraduate groups were all-women, and half included women and men. The two graduate-student focus groups were mixed-sex. Each group was limited to approximately 10 participants, and 100 people took part altogether (94 students and six health center staff). This research was approved by the Princeton University Institutional Review Panel.

Table 1 (page 150) summarizes the composition of the student focus groups according to participants' sex, class, academic interests, political affiliation and religion. The focus groups had a higher proportion of women than did the random survey sample (70% vs. 42%).**(8) This overrepresentation of women was an attempt to gather more information from those eligible to take emergency contraceptive pills.

Participants were recruited by both the researchers and trained peer counselors from the Sexuality Education Counseling and Health program of the health center. To minimize selection bias, potential recruits were not informed of the research topic, but were told that the focus groups would explore students' knowledge about and attitudes toward "an important issue." Trained peer counselors led the undergraduate groups, while the researchers led the groups for graduate students and health center staff.

All of the groups commenced with participants' writing a paragraph on emergency contraceptive pills and then reading it aloud. The advantage of opening the groups with individualized statements is that a variety of views are put forth from the very beginning, which helps to encourage a more open atmosphere and greater participation of all discussants.(9) After delivering their statements, the participants began to discuss differing notions. The focus-group sessions lasted for one hour.

The moderators followed a standard topic guide, consisting of open-ended questions, which helped to organize the data collection and served as an important device for comparison among groups in the analysis stage.(10) The guide for the student focus groups covered three main areas: knowledge, attitudes and availability of emergency contraceptive pills at the university. The section on knowledge asked about the appropriate use, effectiveness, side effects and ingredients of emergency contraceptive pills.

The attitudes section asked about support for availability, specific problems with emergency contraceptive pills, opinions on use in varying circumstances, whether emergency contraceptive pills are more like contraception or abortion, and the male partner's role in the decision to use the method.

The section on availability asked if it was easy to obtain emergency contraceptive pills, if people knew they could obtain them, and about the role of counseling and contraceptive education. The moderators probed specific topics to help to reach a more complete exposition of the line of reasoning behind the opinions expressed.

Moderators provided only minimal information about emergency contraception during the discussion, but at the end, they answered questions and provided information about the method. The moderators summarized the discussion every 15 minutes to allow participants to correct misperceptions or restate their ideas.

We taped and transcribed the focus-group discussions for analysis. After repeated readings of the transcripts from each group, we divided the text into topics, including those specified in the topic guide, as well as some new ones that arose in the discussions. We reorganized the data according to categories and subcategories. (For example, the category sexual responsibility included the subcategories unprotected intercourse, fear of sexually transmitted diseases and AIDS, precoital vs. postcoital contraception and postcoital contraception vs. abortion.)

We then compared different moderators' and groups' discussions to evaluate the quality of the findings, and checked for inconsistencies or idiosyncracies. We noted any differences between the undergraduate and graduate groups, and between the female and mixed-sex groups. In the reporting, we used summarization, direct quotation, and interpretation.(11)

Results

Several common themes arose in the various focus groups. These themes, while closely related to emergency contraceptive pills, also involved other aspects of fertility control. We will discuss each of the principal themes.

Norms Governing Sexuality

Group norms about sexuality and use of emergency contraceptive pills played a large role in the opinions that were voiced. Students were more likely to explore an idea fully after others voiced support for that idea. Opinions frequently changed, even when presented adamantly at first, as new information and ideas were introduced and debated.

Seniors were noticeably more flexible and supportive of individual autonomy in decision-making than were younger students, who were more concerned about consensual norms to direct students toward greater sexual responsibility. Although the graduate students were markedly less aware than the undergraduates of emergency contraceptive pills and their availability at the university, they were even more willing than the seniors to leave individuals the option to assess their needs and solve their own problems. Accordingly, while the older students (as well as the health center staff) thought it important to expand accessibility to other sectors of the population, the younger students expressed concern about frequent use of the regimen and its availability outside the campus clinic setting.

Sexual Responsibility

The discussion of the circumstances surrounding unprotected intercourse was laden with concern about sexual responsibility issues. As in the survey, students more readily gave approval to emergency contraceptive pills for situations in which a woman had less control over the act of unprotected intercourse. They expressed unanimous support for the use of emergency contraceptive pills in the case of rape, strong support in the case of a broken condom and considerable support in cases of unprotected intercourse for other reasons.

Although the students vigorously endorsed the practice of contraception, they had more varied opinions on postcoital contraception. They said that emergency contraceptive pills could undermine sexual responsibility because they are used after intercourse and because they might be substituted for methods that protect against sexually transmitted diseases (STDs):

"I think [emergency contraceptive pills] belittle the problems of STDs and other things that go along with sexual intercourse. But people think of the immediate when they think of the problems with having sex. The first thing people think about is pregnancy. And I think a lot of people...think of STDs later, when they start having symptoms. It kind of eliminates one thing, and then people will not be so cautious about another."--Female undergraduate student

Some students felt that expansive access to emergency contraceptive pills would be problematic because it would encourage use of this method in place of barrier contraceptives. AIDS was mentioned in every group as a reason to stress barrier methods over emergency contraceptive pills. Students feared that if people knew that emergency contraceptive pills were available, they might resort to them too often, although they believed overuse is not currently a problem.

On the other hand, participants suggested that students may not find it easy to go to the health center after unprotected intercourse, since the visit would document that unprotected intercourse had occurred. In addition, the decision to take emergency contraceptive pills can itself be difficult. Students discussed the chagrin that surrounds the "failure" to use contraceptives, and noted that it could deter people from going to the health center in time:

"[Using postcoital contraception is] definitely more morally loaded than taking the [birth control] pill is. There's some taboo about it that might scare people away from going to the health center, even if they know about it."--Female undergraduate student

But students also emphasized that since it is too late to use a condom after unprotected intercourse has occurred, taking emergency contraceptive pills is preferable to risking an abortion. And some thought that although the emergency contraceptive pill is not the most pleasant regimen to take, acting quickly to avoid pregnancy is more responsible than delaying until abortion is the only alternative:

"It's not a perfect world. And despite the fact that every time that you pick up a magazine it says not to have sex without a condom, it definitely happens. In my opinion, taking the morning-after pill is definitely emotionally and psychologically and every reason better than having an abortion."--Female undergraduate student

Not all students discussed the options that exist before intercourse and afterward as competing, mutually exclusive approaches. In a comment supporting expanded availability of emergency contraceptive pills along with other contraceptive methods, one student rebutted the notion that there is one best way:

"It's not really any more of a mixed message than if you're encouraging someone to rock-climb with a safety rope. I mean, you're not encouraging that person not to hang on."--Male graduate student

Alcohol and Sexuality

Alcohol was mentioned frequently in the focus groups, usually in connection with unplanned, unprotected intercourse. Students noted repeatedly that drinking decreases the likelihood of contraceptive use, and that alcohol consumption is common on campus. They constructed analogies between alcohol and emergency contraceptive pills that conveyed a message about loss of control or irresponsibility, but that acknowledged the possibility of controlling unwanted fertility through emergency contraception:

"It's the same thing as people drinking. Parents say, 'We won't allow it,' but they're drinking anyway. We all agree that it's wrong to be that irresponsible when you're dealing with a potential child or a life or something. But the fact is that it's happening and people are getting drunk. I think the worst thing in the world is to bring a child onto the planet that isn't wanted, who's going to have zero quality of life and not be loved and be looked at as a mistake."--Female undergraduate student

Another discussant also compared drinking to irresponsible sexual behavior, and suggested that the health center offer more effective counseling about the responsible use of alcohol and, by analogy, sexuality:

"You can compare it with if someone gets really drunk and passes out and gets taken to the health center; the next morning they get this little talk about alcohol and do you have a drinking problem and stuff like that. I know a lot of people who have walked away from that experience, just blowing the whole thing off and making fun of it. So it would have to be done in a very careful way so that it wasn't patronizing."--Female undergraduate student

The students were concerned about the loss of control underlying drinking and unprotected intercourse, and saw emergency contraceptive pills as a way to deal with these lapses.

Gender Issues The discussants repeatedly acknowledged the stakes women have in reproductive issues. They widely agreed that the final decision to take emergency contraceptive pills is a woman's decision, and that the role of the male partner depends on the nature of the relationship:

"I think the [male] role question is a difficult one because of the relationship. Ideally, you would think that if there is a relationship between the woman and the man, that there is some discussion, at whatever level, although I think ultimately the decision rests with the woman. But a lot of times there is no relationship really that would even facilitate a discussion."--Female graduate student

A problem that was brought up by both men and women in the focus groups is that men might use the availability of emergency contraceptive pills to pressure women into unplanned or unprotected intercourse. Ironically, while students recognized the common use of the therapy for rape cases, they worried that expanded access to emergency contraceptive pills might serve to increase cases of coercion in other contexts, by eliminating a commonly accepted reason to avoid intercourse: the absence of contraception. The woman, it was noted, would be the one to bear the physical discomfort and bother of the emergency contraceptive pill regimen, while her control over the decision to have intercourse would have been eroded:

"It seems to me that some guys...if they're taking somebody back to their room and they don't have any condoms or anything, they might say, 'The morning-after pill, no big deal.' I can see that happening more often maybe. I'm not saying I would do that. I'm not saying the average guy would do that. But the guy would be less concerned possibly than the lady might."--Male undergraduate student

"A friend of mine, she's in a serious relationship, and she and her boyfriend occasionally have--not unprotected--yes, unprotected sex, and for him it's almost like an immediate reaction: 'Go get the morning-after pill.' And it's so easy for him to say it because [she's] the one who's going through all the suffering. [The woman's] the one who's putting all these chemicals into [her] body and not really knowing for sure the effects."--Female undergraduate student

Participants also noted, however, the ways that emergency contraceptive pills can be used to improve conditions for women, who incur many of the costs and risks of unprotected intercourse. By preventing abortions, the regimen can lessen women's trauma and alleviate the physical, emotional and financial consequences of unwanted pregnancy. In the case of a pregnancy scare, emergency contraceptive pills increase the latitude women have to make reproductive decisions by offering an alternative to abortion and childbearing:

"I think emotionally taking something like that before you can possibly know that you are pregnant has a different effect on you than having to wait a couple weeks, find out you're pregnant, go have an abortion, which is so much more emotionally loaded...."--Female undergraduate student

As the health center personnel pointed out, emergency contraceptive pills are cost-effective and relatively safe compared with a surgical procedure or childbirth. Debate raged in the focus groups over whether emergency contraceptive pills are more like contraception or more like abortion. But regardless of how the discussants classified the method, they all saw emergency contraceptive pills as holding a distinct place in the range of reproductive health alternatives.

Responsibility for Reproductive Health

Most students supported the availability of emergency contraceptive pills at the university health center, and considered the clinic to be the appropriate provider. They cited the clinic's ability to take medical histories, keep records, give advice and dispense contraceptives. The students frequently mentioned the importance of giving information, both on the medical aspects of emergency contraceptive pills and on safer sex. But many remarked on the hierarchical nature of health care systems, and voiced a desire to avoid being the target of scolding. Some students preferred a value-free information session, while others acknowledged the merit in special sexuality counseling. One student noted:

"It's interesting that when you're talking about medical issues that don't have anything to do with birth control and you're talking to your doctor about options, that's not really thought of as counseling. That's sort of thought of as the information that you get when you're going through a surgical procedure or illness. But suddenly when you get into this birth control situation, it's always 'counseling.' I just think it's an interesting choice of terms. I mean, what needs to happen is information needs to be given out about the use of [emergency contraceptive pills] and about safer sex."--Female graduate student

Another student defended the special treatment that health personnel accord contraception:

"I think the reason that people use the word 'counseling' is that there are a lot of political and moral factors that play a role in making the decision....So although [counseling] should be value-neutral--in other words, the health practitioner isn't saying you should do this or you shouldn't do that--there's some recognition that this is a difficult decision. It's not like saying in your surgery, you have to know about your anesthesia. It's a little different."--Female graduate student

A consensus evident in these comments is that students want to be given as much information as possible so that they can participate in decisions about their reproductive health care. Many students balked, however, at the notion of carrying their responsibility a step further. When questioned about availability of emergency contraceptive pills outside a clinic, most students noted the advantages of clinics and medical personnel, and said they did not know enough to assess the side effects and risks of having the method available outside the doctor's office. The prospect of being in charge of gathering their own information, which they felt is not possible at this point, was daunting to them:

"I think I'd have to know more about the medical risks [of an emergency contraceptive pill], because if there are very few and you can just inform somebody how to use it, then what's so different about using it from the [birth control] pill? But if they are significant--you need to take it in this particular time period, and you have to watch for this, and you have to be under some sort of medical supervision--then it wouldn't be wise."--Female graduate student

Meanwhile, the students' support for the incorporation of emergency contraceptive pills into contraceptive education was unwavering. They all approved of having clinicians inform people about emergency contraceptive pills when giving out barrier methods. And they supported the proposal that clinicians actually dispense emergency contraceptive pills in conjunction with barrier methods, to be used in case of a problem, since clinicians could easily discuss appropriate use, as well as possible side effects and health risks, at that time.

Provider Issues

The staff at the health center, however, were not supportive of the idea of dispensing emergency contraceptive pills routinely in conjunction with barrier methods. They felt that providing both at the same time would send a mixed message, and that when a student seeks out emergency contraceptive pills, it is a good opportunity for interaction and counseling. Giving out emergency contraceptive pills ahead of time, they believed, might make more sense if a person were traveling somewhere distant.

The staff considered the real access problem with emergency contraceptive pills to be outside the university, rather than on the campus or among those served by the health center. And they expressed concern for people not served by the health center. They noted the problems encountered by visitors and postdoctoral students, whose health care is not covered on campus, and the difficulties faced by graduates who know about emergency contraceptive pills, but no longer have a provider after they leave the university.

However, they pointed out that since the regimen is a series of oral contraceptives, possible use actually extends to many other people. Anyone with access to combined oral contraceptives, be it through the health center or elsewhere, has access to the emergency contraceptive pill regimen:

"Everybody has access to somebody who has birth control pills, and if you know how many to take and know when to take them, it may be something that people may just be able to do by themselves."--Health center staff

The staff mentioned that emergency contraceptive pills were free at the health center, but that outside the university, someone in need would have to buy a whole package of oral contraceptives:

"Until the pharmaceutical companies come out with individual packages, until they acknowledge [emergency contraceptive pills] as a method, I think the cost will be high. But I guess they don't want that liability."--Health center staff

Expanded Availability

When discussing populations that do not have daily access to a health clinic, students offered conflicting opinions. The freshmen were concerned that in the absence of clinical regulation, people with different levels of education would tend to overuse emergency contraceptive pills, substituting them for other forms of birth control:

"I think it's okay personally if [they're] available here at the health center. [But] I don't think [they're] something you should be able to buy in any drugstore or something, because that would increase the possibility of people just being more careless and relying on [them] as sort of a method of birth control."--Female undergraduate student

The graduate students were supportive of expanding access to emergency contraceptive pills beyond college campuses, certain clinics and a few physicians' offices. They were more cognizant of the health needs of people outside the university setting, and considered access to emergency contraceptive pills insufficient:

"It's a really short period of time, it seems sort of silly that you should have to scramble around, miss work, to do what you have to do to get to a clinic or get to your doctor. Especially considering the huge barriers to health care....And particularly how those barriers are different among different socioeconomic [groups] or geographic areas of our population."--Male graduate student

"I wonder about the people who may not go to the doctor very often or who may not have health insurance, or do not feel comfortable going to clinics....This [option], in effect, would not be available to them. Or would be less available, and for a population who would probably use it. It seems to me if it were available over the counter, and there were a lot of information on it, it could really benefit a lot of women."--Female graduate student

The older students held stronger views about autonomy and the right to control one's own life without interference from others:

"I don't think there should be a higher authority like the doctor or the government just saying to people, 'We want you to use condoms and diaphragms, but if that doesn't work, then we will allow you to use something else.' [Emergency contraceptive pills] should probably be available in every drugstore or over the counter."--Female graduate student

Information Scarcity

A common reaction to the idea of increased availability of emergency contraceptive pills was concern about the lack of information on their mechanism of action and possible side effects. Although the students have basic facts, they still think that they do not have enough information to make a reasoned choice about whether to use emergency contraceptive pills. Virtually all students in the focus groups knew that emergency contraceptive pills are hormonal pills taken after unprotected intercourse, yet several students noted that statistical and anecdotal information about the method is kept quiet, unlike information about oral contraceptives and abortion:

"[Postcoital contraception] seems like such a secretive thing. You really don't hear about it or know any examples. I don't hear about any lectures on it. You don't see any people who have tried it and have positive things to say. Whereas there's so much literature on contraceptives such as the [birth control] pill,...and people are familiar with it. But this seems relatively new. Maybe there should be more experience expressed; it just seems like it's taboo."--Female undergraduate student

Many of the students did not know the time frame for taking emergency contraceptive pills or the method's chances of working effectively. Nor were they generally familiar with the side effects. Students had many hesitations about emergency contraceptive pills because of unknown side effects. They wanted more evidence, for instance, that the large dose of hormones was neither physically nor psychologically destabilizing:

"Hormones make a difference in how you feel. They really don't have any quantification on it in terms of depression, psychological changes and things like that."--Female graduate student

Amid the uncertainty, biological concerns were not clearly distinguished from ethical ones in the remarks of focus-group participants:

"I really would prefer to know the biology behind [emergency contraceptive pills] and exactly how [they] work before I would think about [their] widespread use. For rape victims, that's a really clear-cut answer. But...I really do base things on a moral basis first, and it's hard to think about that when I don't really realize what might be the implications of the morning-after pill."--Female undergraduate student

Students appealed for more factual information and more discussion of emergency contraceptive pills. Aside from a few students who suggested that the availability of emergency contraceptive pills be kept quiet to prevent their overuse, most participants in the focus groups mentioned the importance of increasing awareness. Not even this university campus, where every sophomore, junior and senior surveyed had heard of emergency contraceptive pills,(12) was exempt from the criticism of too little discussion. The students characterized emergency contraceptive pills as a secret that is let out every once in a while:

"I don't think people see [postcoital contraception] as a guaranteed method. It's usually not even an option that people discuss. It's assumed that if you get pregnant, you have to have an abortion. I don't hear much that says, 'I think I may be pregnant, I have to use the morning-after pill.' I've never heard that discussion. But I have heard discussions about 'If I get pregnant, I would get an abortion."--Male undergraduate student

Discussion

In this university population, which has relatively high access to emergency contraceptive pills, the level of basic awareness is sound, although more precise knowledge is lacking. Students do not generally know that the emergency contraceptive pill regimen consists of a larger dose of combined oral contraceptives, nor what its side effects are. They are confused about the time frame in which emergency contraceptive pills must be taken, how this regimen works and its effectiveness in reducing the chances of pregnancy. And they are uncertain when and where emergency contraceptive pills can be obtained.

The attitudinal research shows approval of emergency contraceptive pills to be widespread among both women and men. The few students who disapprove cite health and ethical reasons.

The students--undergraduate, graduate, male and female--were united in their resounding support for contraceptive use in general. They explained why, in the face of this consensus, unprotected sexual intercourse frequently occurs, and they discussed how alcohol works to increase the risk of unprotected intercourse. In addition, they pointed out that in order to use emergency contraceptive pills, one has to confront the fact that a lapse of control has occurred. The embarrassment of having to admit to unprotected intercourse loomed large in the students' minds. However, the students generally agreed that knowledge about the regimen and access to it were very important to avoid abortions and unwanted births.

Education on emergency contraceptive pills should be incorporated into routine student visits for contraception. This information should include the nature of possible side effects, and should explain the emergency contraceptive pill regimen, since these two factors influence health concerns. It should also indicate how and when emergency contraceptive pills disrupt fertilization, so that potential users can make ethical judgments.

Emergency contraceptive pills will be more widely accepted if they are promoted as a special method tailored for a particular situation. Students were concerned that emergency contraceptive pills would be used as a substitute for other methods, rather than as a complement, at a time when other methods are no longer effective. Classification of the therapy as a last resort would appeal to the students with concerns about responsibility and fears of overuse.

Efforts need to be made to educate the population as a whole about emergency contraceptive pills. Until this method gains a more prominent place in the discussion of methods of fertility control, it will remain a choice that is restricted to far fewer people than necessary. Discussion that places emergency contraceptive pills in the front of people's minds can play a particularly significant role because of the short time period in which the method can be used. Any delay that results from uncertainty or embarrassment could prevent effective use.

The complaint that emergency contraceptive pills do not provide protection against all of the consequences of sexual activity reveals the bewilderment that young people face while attempting to exercise control in an arena that is not always amenable to clear-cut solutions. The complexity of pregnancy and disease avoidance is not consistently emphasized to students in sexuality education. However, advice to wear a condom, for example, is worth more when accompanied by advice on what to do if the condom breaks. The discussions on male-female dynamics and emergency contraceptive pills indicate that another possible role for sexuality education would be to give women the wherewithal to avoid intercourse if they wish, and to modify the attitude that there has to be an explicit reason not to consent to intercourse, such as the lack of contraception.

The focus-group discussions show that students preferred to receive information on sexuality from peer educators, and were receptive to a reasoned, mature approach to fertility control. The students pleaded for more information, and university health centers are in a position to provide a wealth of evidence collected over many years on the use of emergency contraceptive pills.

Many studies have already been conducted in Europe and Canada,(13) but very few have taken place in the United States.(14) The health centers that provide emergency contraceptive pills not only should collect data on the women who have used them, but also should release these data for analysis, since people frequently have questions about effects that could be well-known at this point. Women want to know the emotional and physical effects of taking emergency contraceptive pills, and they want well-documented scientific information, rather than anecdotal information.

* The most common brand of oral contraceptive used for emergency contraception in the United States is Ovral. Lo/Ovral, Nordette, Levlen, and the yellow tablets of Triphasil and Tri-Levlen also may be used in the Yuzpe regimen, but since they contain a lower dosage of hormones, eight tablets were required in total. See: reference 1.

** The survey sample is assumed to be closely representative of the student population, as it was randomly drawn and the response rate exceeded 80%.

Table 1. Percentage distribution of student focus-group participants, by selected characteristics (N=96)

Characteristic--%

Sex

Female--70

Male--30

Class

Freshman--31

Sophomore--19

Junior--11

Senior--20

Graduate student--19

Academic interests

Republican--18

Democrat--50

Independent--21

Not these--8

Not sure--3

Importance of religion

Very--27

Somewhat--33

Not very--17

Not at all--23

Total--100

References

1. R. Hatcher et al., Contraceptive Technology, 16th ed., Irvington Publishers, New York, 1994, pp. 415-432.

2. J. Trussell et al., "Emergency Contraceptive Pills: A Simple Proposal to Reduce Unintended Pregnancies," Family Planning Perspectives, 24:269-273, 1992.

3. National Women's Health Network, "Postcoital Contraception: Time for Cautious Approval," Washington, D. C., 1993; American Medical Women's Association, "Resolution on Postcoital Contraception," Alexandria, Va., 1993; J. Benshoof, "Ever Had a Pregnancy Scare?," Glamour, May 1995, p. 121; and J. Hoffman, "The Morning-After Pill: A Well-Kept Secret," The New York Times Magazine, Jan. 10, 1993 p. 12.

4. C. Harper and C. Ellertson, "The Emergency Contraceptive Pill: A Survey of Knowledge and Attitudes Among Students at Princeton University," American Journal of Obstetrics and Gynecology, 1995 (forthcoming).

5. C. Basch, "Focus Group Interview: An Underutilized Research Technique for Improving Theory and Practice in Health Education," Health Education Quarterly, 14:411-448, 1987.

6. D. Morgan, Focus Groups as Qualitative Research, Sage Publications, Newbury Park, Calif., 1988; and D. Morgan and R. Krueger, "When to Use Focus Groups and Why," in D. Morgan, ed., Successful Focus Groups, Sage Publications, Newbury Park, Calif., 1993, pp. 3-19.

7. J. Knodel, N. Havanon and A. Pramualratana, "Fertility Transition in Thailand: A Qualitative Analysis," Population and Development Review, 10:297-328, 1984; E. Kisker, "Teenagers Talk About Sex, Pregnancy and Contraception," Family Planning Perspectives, 17:83-90, 1985; R. Stone and C. Waszak, "Adolescent Knowledge and Attitudes About Abortion," Family Planning Perspectives, 24:52-57, 1992; and S. Edwards, "The Role of Men in Contraceptive Decision-Making: Current Knowledge and Future Implications," Family Planning Perspectives, 26:77-82, 1994.

8. C. Harper and C. Ellertson, 1995, op. cit. (see reference 4).

9. D. Morgan, 1988, op. cit. (see reference 6).

10. J. Knodel, "The Design and Analysis of Focus Group Studies," in D. Morgan, 1993, op. cit. (see reference 6), pp. 35-51.

11. For discussion of analysis, see D. Morgan, 1988, op. cit. (see reference 6); and J. Knodel, 1993, op. cit. (see reference 10).

12. C. Harper and C. Ellertson, 1995, op. cit. (see reference 4).

13. A. A. Haspels and R. Andriesse, "The Effect of Large Doses of Estrogens Post Coitum in 2000 Women," European Journal of Obstetrics & Gynecology and Reproductive Biology, 3:113-117, 1973; A. A. Haspels, "Interception: Post-Coital Estrogens in 3016 Women," Contraception, 14:375-381, 1976; A. Yuzpe and W. Lancee, "Ethinylestradiol and d1-Norgestrel as a Postcoital Contraceptive," Fertility and Sterility, 28:932-936, 1977; A. Yuzpe, R. Percival Smith and A. W. Rademaker, "A Multicenter Clinical Investigation Employing Ethinyl Estradiol Combined with d1-Norgestrel as a Postcoital Contraceptive Agent," Fertility and Sterility, 37:508-513, 1982; B. Tully, "Post Coital Contraception--A Study," British Journal of Family Planning, 8:119-124, 1983; M. Van Santen and A. A. Haspels, "A Comparison of High-Dose Estrogens Versus Low-Dose Ethinylestradiol and Norgestrel Combination in Postcoital Interception: A Study in 493 Women," Fertility and Sterility, 43:206-213, 1985; A. Kubba et al., "The Biochemistry of Human Endometrium After Two Regimens of Postcoital Contraception: A d1-Norgestrel/ Ethinylestradiol Combination or Danazol," Fertility and Sterility, 45:512-516, 1986; R. Percival Smith and B. Abercrombie, "Postcoital Contraception with d1-Norgestrel/ Ethinyl Estradiol Combination: Six Years Experience in a Student Medical Center," Contraception, 36:287-293, 1987; G. Zuliani, U.F. Colombo and R. Molla, "Hormonal Postcoital Contraception with an Ethinylestradiol-Norgestrel Combination and Two Danazol Regimes," European Journal of Obstetrics & Gynecology and Reproductive Biology, 37:253-260, 1990; A. Webb, J. Russell and M. Elstein, "Comparison of Yuzpe Regimen, Danazol, and Mifepristone (RU 486) in Oral Postcoital Contraception," British Medical Journal, 305:927-931, 1992; and A. Webb and J. Morris, "Practice of Postcoital Contraception--The Results of a National Survey," British Journal of Family Planning, 18:113-118, 1993.

14. G. Dixon et al., "Ethinyl Estradiol and Conjugated Estrogens as Postcoital Contraceptives," Journal of the American Medical Association, 244:1336-1339, 1980; and S. Buttermore and C. Nolan, "Six Years of Clinical Experience Using Postcoital Contraception in College Women," Journal of American College Health, 42:61-63, 1993.

Cynthia Harper is a doctoral candidate, and Charlotte Ellertson is visiting research collaborator, at the Office of Population Research, Princeton University. The authors are grateful to the project adviser, James Trussell, director of the Office of Population Research. They also acknowledge the support of the GynoPharma Corporation, the Center of Domestic and Comparative Policy Studies of the Woodrow Wilson School, and the Princeton University Health Services. The authors would like to thank the following people for comments and assistance: Elizabeth Armstrong, Haishan Fu, Karen Gordon, Thomas Heller, Amy Richardson, German Rodriguez, Margaret Thomas and the Sexuality Education Counseling and Health peer advisers.

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