When Plan B Needs a Plan B: The Shortcomings of Emergency Contraception and the Evidence for Need for Improvement in Sexual Education - Lisa Peterson

In 1996, the International Consortium for Emergency Contraception was formed to make emergency contraception (EC) a part of the public health agenda (1). Emergency contraception serves as a means of preventing pregnancy after unprotected sexual intercourse. Several forms of EC have been developed, but Plan B seems to be most prominent. A progestin-based pill, Plan B was first developed in 1999 as a prescriptive drug. Plan B works in a similar way to other hormonal methods of contraception, by inhibiting ovulation, stopping follicular development, and hindering the corpus lutem’s maturation (2). Plan B has been shown to be up to 89% effective in reducing the chance of pregnancy and is marketed to prevent unintended pregnancy after unprotected sex, instances when a contraceptive has failed, or after forced intercourse. (3) In 2006, the FDA approved behind-the-counter access for specific populations.

The Plan B program will not significantly affect pregnancy rates because it is a unilateral, “band-aid” approach to contraception that cannot overcome complex issues related to accessibility, knowledge and social/cognitive context. In the program implementation, public health has failed both to use the Health Belief Model appropriately and to consider factors for which the model does not account.

Accessibility
There are significant barriers to access that have been overlooked in the Plan B intervention. There is a substantial financial barrier. Most pharmacies charge about $45 for one dose of Plan B (3). In addition, Medicaid does not cover Plan B in all states (4). Because of high cost combined with insurance restrictions, Plan B is difficult for people of low SES to obtain.

There is also a geographical barrier. Only nine states (Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Washington, and Vermont) provide Plan B behind-the-counter in pharmacies. All other states require a prescription regardless of age (3). Pharmacies and family planning centers that carry Plan B behind-the-counter also seem to be in more urban areas. This observation is supported by an Internet search of participating pharmacies in the greater Boston area, which revealed one pharmacy in Jamaica Plain, one in Roxbury, two restricted services in Brookline, and six pharmacies in Boston. In contrast, although Plan B is available behind-the-counter in Vermont, there are only four pharmacies in the state that are listed as carrying the product – three in Burlington and one in Williston. There is an option to obtain Plan B online from Planned Parenthood of New England but only with a credit card and this option does not appear to be highly advertised (3). In some states, like Maryland, Virginia, and Washington, D.C. there is a “conscientious objection policy” that gives pharmacists the right to refuse to dispense EC if they feel it is in opposition to their values. With this policy in place, pharmacists can pose a formidable obstacle to someone who has surpassed other barriers and managed to obtain a prescription. A 2000 survey of 27 Catholic hospitals in Washington, D.C. and ten states in the surrounding region revealed that even hospitals that did not explicitly prohibit counseling or prescription of Plan B and other EC reportedly “didn’t like it” and didn’t “promote it” to rape victims (5). Therefore, there is some evidence that women may not have all options presented and available to them if physicians disagree with EC on moral grounds. Even though this example is particular to religiously-affiliated institutions, it is clear the traditional focus on individual responsibility ignores the importance of health professionals in enabling people to perform a specific health behavior (i.e. take Plan B). Therefore, greater care must be taken to encourage health care providers to empower individuals by allowing them to make the choice of Plan B use. Because of limited (or withheld) availability in certain areas, that creates barriers to access for people in more rural regions and those living outside providing states.

The FDA effectively placed an age barrier on ease of access. The FDA restriction prohibits men and women under the age of eighteen or without proof of age from obtaining Plan B behind-the-counter. Young people must obtain a prescription from their doctor. Therefore, because only people over the age of 18 with proof of age can get Plan B over-the-counter, young girls who may not feel comfortable talking to their parents about needing Plan B and do not have transportation may not obtain the drug.

These barriers have great implications for people’s ability to obtain Plan B. In fact, those populations that need Plan B the most are at the greatest disadvantage for ease of access. In a 2005 study, pregnancy rates were higher among adolescents (10%) as compared to adults (6%) (6). Further, rates were highest amongst young adolescents (i.e. younger than 16 years) (14%) and rates decreased to 12% of middle adolescents (i.e. 16-17 years) and 8% of older (18-19 years) (6). In addition, this study found that adolescents tend to rely on less effective methods of contraception (e.g. hormonal methods) and do not use contraception consistently (6). Thus, the age group most at risk for unintended pregnancy are young people who have the greatest barriers to access; they are too young to drive and too young to obtain Plan B behind-the-counter. In terms of EC, the 2005 study also found that EC use was greater (44%) among adolescents with advanced EC than adolescents with clinic access only (29%) (6). The effect of advanced provision on EC use indicates that ease of access is an important determinant of behavior.

The Health Belief Model (HBM) is a model of behavior. It proposes that people weigh the perceived susceptibility and perceived severity of a health condition against the perceived benefits of a specific health behavior and the perceived barriers to action. This rational process determines their intent to perform the behavior. Intent is assumed to dictate behavior. (7) The Plan B intervention uses assumptions from the HBM. However, the intervention underplays the importance of barriers in the model. The use of the HBM is also problematic given its limitations. It focuses on perceptions of barriers instead of actual, external barriers. Regardless of whether a woman intends to use Plan B, the very real barriers of cost, geography and age may make it less likely that she can or will obtain the drug. Relying on the HBM blinds public health to these outside social factors that can override any behavioral predictions it may make.

Knowledge
Awareness and knowledge of EC should also be improved. It is important to note that awareness of EC differs among populations. For example, a 2005 study conducted in Jamaica Plain, MA examined knowledge of EC in 188 women of 18-44 years of age. Of all the participants, 82% had heard of EC, but only 51% of Latina women and 75% of black women were familiar with EC as compared to nearly all (99%) of white women (8). There appears to be a need to tailor the intervention to each sub-population.

Public health does not seem to have a truly nationwide, mass media marketing strategy to promote awareness of Plan B. There does not seem to be national television advertisements or print advertisements. Therefore, the public may be unaware of emergency contraception as an option. Greater awareness of EC could be achieved if public health employed a more direct, marketing intervention. Marketing theory focuses on the importance of researching target populations and packaging a product to fit their specific needs and desires (9). However, the Plan B intervention assumes people will get sufficient information from clinics, doctors, and hospitals. Because time is so important, it is essential for people to know about and understand the Plan B option before the need arises. The implications of this lack of marketing are simple – regardless of a desire to prevent pregnancy, if people do not know about EC, they will not seek the drug after unprotected sexual intercourse.

However, even with greater awareness, there is a need for complete and accurate understanding of EC. While it is true lack of awareness eliminates Plan B as a sought option, misconceptions (i.e. lack of knowledge) might have the same effect. The implications of lack of understanding can be significant determinants of use. Women in rural, western North Carolina aged 18-44 were surveyed on their knowledge and use of the EC pill. Seventy-two percent knew about EC, but more than 80% were unsure of whether it was different from RU-486, the abortion pill (10). The importance of this uncertainty can be seen in reported use. Only 7.5% of the participants said they used EC within the past year. It is likely that this lack of understanding led to the relatively low proportion of use. In another population of Princeton students, nearly all (95%) of students had heard of EC, but only 38% knew that it had to be taken within 72 hours of intercourse (2). In this case, lack of understanding would not affect the likelihood of seeking Plan B or another form of EC, but has the potential to affect EC’s effectiveness.

Public health’s greatest marketing failure of Plan B has been that any advertising campaigns that exist strive to create awareness of EC’s existence or availability without educating people about its mechanisms (i.e. they focus on awareness, not knowledge). The Pacific Institute of Women’s Health (PIWH) in California devised bus shelter advertisements in New York City, San Francisco, and Los Angeles to heighten awareness. These pictorial advertisements, which depict EC pills with the words “Oh” and “$#*!” with the caption: “EC: Because $#*! happens,” make a lot of assumptions (11). They assume the targeted teenagers know what EC is, what the benefits are, and how it works, but need to be reminded of its existence or informed the drug is now available. As the North Carolina and Princeton studies indicated, simply having heard of Plan B does not correlate with understanding or use. If people incorrectly associate EC with the abortion pill, they may reject the drug on moral grounds or fear of potentially causing harm to themselves or a fetus. If people do not understand the timeliness of dosage, they may not take Plan B within the appropriate window of time, thereby reducing effectiveness. Therefore, any intervention using a marketing strategy needs to incorporate an educational component that states that Plan B is most effective if taken within 72 hours and is not the same as the abortion pill.

Notwithstanding complete knowledge and understanding on the part of the public, if there are misconceptions about EC among the physicians responsible for counseling women and the pharmacists responsible for the drug’s dispersal, women may be prevented from using EC. A pharmacist or physician who is misinformed about the mechanisms of Plan B may be hesitant to prescribe someone the product or may disseminate incorrect information about it. A 2007 “secret shopper” study of pharmacies in Jacksonville, FL revealed staff unfamiliarity with Plan B and its proper use. Only half of the 40 pharmacy staff people correctly answered that Plan B must be taken with 72 hours of intercourse (12). In addition, when “secret shoppers” called asking if Plan B would be available if they entered with a prescription, 31% of the pharmacies did not offer Plan B or any other EC options (12). Therefore, women may have been misinformed about correct use, thereby diminishing effectiveness in reducing the risk of pregnancy or they may not have been given any information about EC options. A 2000 study of Washington, D.C. pediatricians’ knowledge, attitudes and practices revealed that knowledge-related variables were associated with administration of EC in the previous year and counseling of adolescents about EC, while attitude was not. Pediatricians who knew the timing of EC and were aware that EC was FDA-approved were more likely to prescribe or counsel about EC. The researchers pointed out that knowledge can be affected with educational interventions (13). This study is somewhat dated as it was conducted prior to the FDA authorization of Plan B behind-the-counter, but it does suggest that a normative re-educative approach would be helpful in addressing the health professional population.

Context
The promotion of Plan B (as encompassed by the tenets of the HBM) assumes intention to prevent pregnancy will translate into use of Plan B and presupposes rational, well-informed thinking. In reality, women may fail to use both contraception and emergency contraception due to irrationality or misinformation about sexual reproduction and sexual health. The implication of these social/cognitive factors is that even with access to Plan B, people may not use it. For this intervention to be truly effective, public health needs to address other factors that contribute to unsafe sexual intercourse initially and may decrease the likelihood of people getting and using Plan B.

The Plan B intervention assumes a comprehensive understanding of sexual health and reproduction. However, this is a risky assumption to make considering use of Plan B hinges on adequate understanding of these concepts. Deficiencies in sexual education programs result in misconceptions of methods of contraception that lend a false sense of security to unsafe sex practices so that individuals do not view themselves as susceptible to pregnancy and, therefore, would not seek Plan B. For example, the calendar method predicts when a woman is least likely to conceive using a written record of her menstrual cycle (14). Consequently, individuals who use the calendar method and believe it is an effective form of birth control would likely not consider themselves at risk for pregnancy after engaging in unprotected sex during what their calendar deems an “infertile” time of the month.

Public health also does not take the cognitive and social developmental stages of Plan B’s target audiences into account. There are several instances in which irrational thought may prevail. Teenagers tend to have feelings of indestructibility and view themselves as less susceptible to potential risks than other people (15). Developmental psychology data supports young adolescents’ tendency to take risks. An increase in risk behavior can be seen in the aforementioned statistics of adolescent sexual behavior (i.e. 14% pregnancy rate in younger adolescents compared to 8% of older adolescents (3)). It is important to consider from where these tendencies toward risk behavior stem so that the likelihood of adolescents seeking Plan B can be determined. Gonzalez, Field, Yando, and Gonzalez cited research on “personal fables” of adolescence as defined by “belief in one’s immunity from negative consequences” (15). These personal fables may cause teenagers to seek out risk or to be blinded to risk severity. The researchers also reported findings by Dolcini et al that attribute adolescent risk-taking behavior to feelings of indestructibility arising from teenage egocentrism (15). These developmental theories suggest that adolescents may not seek Plan B either because they are intentionally seeking the risk of unsafe sex and/or possible pregnancy or because they view themselves as “immune” to the risk of pregnancy. By not considering the psychology of its audience, public health’s use of the HBM for the Plan B intervention is doomed to fail. The HBM relies on an individual’s perception of severity and susceptibility to motivate him/her to do a behavior. If people do not think they are susceptible, they will not see the benefits of performing the behavior of EC use. Therefore, they may engage in unsafe sex and judge their likelihood of pregnancy as too low to seek EC.

Finally, feelings of shame and fear can be strong motivators and override rational decision-making. These feelings may be especially important for adolescents and rape victims. In terms of teenagers, male adolescents participating in focus groups cited that getting sexual health services was stressful and that they feared stigma, loss of social status, shame, and embarrassment (16). A lack of communication between parents and children may prevent children from seeking help in getting transportation or funds for Plan B. This effect is supported by interview data conducted by nurses showing themes of poor communication and unstable relationships with parents and adolescents prior to the adolescent’s pregnancy (17). Victims of rape or young teenagers may not seek Plan B because they are ashamed or afraid to ask for help (18). A survey of college students in 2006 identified shame, guilt, embarrassment, and not wanting family members to know as the most important barrier to reporting rape and sexual assault (18). Female students also rated fear of retaliation by the perpetrator of great importance as a barrier to reporting (18). Stewart and Trussell estimated that the 330,000 rapes and sexual assaults reported in 1998 may have resulted in 25,000 pregnancies, most of which could have been prevented with prompt medical care (19). However, the researchers cited data from the Women’s Health Study in 1992 revealing that only 24% of women sought a medical examination after a rape and only 17% saw a physician within the first week (19). The low likelihood of women to seek any medical care after a rape decreases the chance they will receive counseling about Plan B and suggests that they might not try to obtain Plan B from a pharmacy either. In restricting access to Plan B, the intervention does not give any consideration to the inhibiting role of fear or shame. It is possible, women who have been victims of rape would obtain Plan B from a pharmacy behind-the-counter, but it seems less likely they would seek a clinical for a prescription given the low probability of seeking a medical examination. The time sensitive nature of Plan B is also a potential problem given that women may seek medical attention too late for the drug to be effective.

All of these examples demonstrate “irrational” thought, which the HBM does not consider. The Plan B intervention assumes that people just need to know the risks of pregnancy and the ease of emergency contraception and they will use Plan B, but the reasoning process is not always so deliberate. As explained, reasoning may be impaired due to other factors like incorrect information or strong emotions.

Implications for Future Public Health Programs and Recommendations
Public health needs to make Plan B more of a concerted intervention that really aims to make EC an important part of women’s health options. In addition, to make any EC intervention more effective, sexual education needs to be strengthened first as it is the root of many of the problems EC is aimed at solving. Better sexual education programs would be more comprehensive and focused on changing social expectancies to decrease adolescent pressures to engage in intercourse while also opening up the lines of communication between children and adults about discussing sex.

Conclusion
It may be too early for public health to make Plan B an effective intervention. Given that access to the EC is so restricted and understanding is so limited, existing promotions of Plan B will not reach the desired audiences. Public health has depended too heavily on the Health Belief Model to create the intervention, thus ignoring important social and cognitive factors limiting its use. As the intervention stands today, it is unlikely to affect significantly pregnancy rates in the United States, especially those among adolescents and disadvantaged populations.

References
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