Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growth demonstrates that, despite a reduction in unintended pregnancies among adolescents, college-educated, and higher-income women, 49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintended pregnancies, 42% ended in abortion. Furthermore, 48% of unintended pregnancies occurred in women who were using contraception during the month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse, requires several steps to reduce the risk of unintended pregnancy. She must perceive that her risk of pregnancy is real and must be motivated to prevent it. She must be aware that a post-coital contraceptive method exists that could reduce her risk of conception. She also must have specific knowledge about how to obtain it and time its administration. She must have access to it, including a place to get it, a way to pay for it, and the time to invest in getting it. Any of those steps can be barriers to actually using emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

1. Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci 2006;1092:1-32.

2. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005(25):1-160.

3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

4. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497.

5. Services DoHAH. Healthy People 2010; 2007 October.

6. Petersen R, Albright JB, Garrett JM, Curtis KM. Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial. Contraception 2007;75(2):119-25.

7. Pisaniello ML. Importance of counseling patients about contraception. Am Fam Physician 2007;75(5):624; author reply 624.

8. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17(2):87-96.

9. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006;108(5):1098-106.

10. Adler NE. Contraception and unwanted pregnancy. Behav Med Update 1984;5(4):28-34.

11. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71(3):202-7.

12. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Womens Health Issues 2007;17(2):66-74.

13. Trussell J. The cost of unintended pregnancy in the United States. Contraception 2007;75(3):168-70.

The Challenge of Antibiotic Resistance, Animal Production, and Enacting Change: A Critique of U.S. Public Health Strategies – Kimber Wukitsch

Antibiotic resistance has been called one of the world's most pressing health problems. According to the Centers for Disease Control, almost every type of bacteria in the last decade has become stronger and less responsive to antibiotic treatment when it is really needed (1). The World Health Organization has raised concerns that we are entering a post-antibiotic era in which resistance is developing for virtually all currently available drugs, meaning that many life-threatening infections may be rendered untreatable (2). While healthcare practitioners and patients alike have been charged with limiting the distribution and use of antibiotics, a major contributing factor to the problem of resistance has been virtually ignored: that of antibiotic use in agricultural animal production. While leaders in public health recognize this as a global threat to human health, strategies to initiate change in the United States are proving unsuccessful because the general public have not been engaged.
Although resistance to antibiotics is a natural phenomenon to a certain extent, the CDC and the WHO cite both their overuse and incorrect use as causing the current accelerated rates of resistance. In large-scale animal agriculture, antibiotics are routinely administered to livestock for the treatment and prevention of infection, as well as to promote growth and improve feed efficiency. The latter purpose, termed “nontherapeutic” use, is designed to promote growth by administering low doses of antibiotics over prolonged periods of time, sometimes for the entire duration of production. The Union of Concerned Scientists estimates that nearly 70% of all antibiotics in the United States are used for nontherapeutic purposes in agriculture—almost 8 times the amount given to humans to treat disease (3). This routine usage is rapidly contributing to the development of resistant microbes that can be transmitted to humans via improperly cooked meat, farm workers, and even the air (2, 4). Several European countries have banned the use of nontherapeutic antibiotics in agriculture and subsequently observed dramatic reductions in resistance rates (5). Moreover, both the WHO and the Institute of Medicine have called for a rapid phase-out of antibiotic growth promotant use on a global scale. In the United States, health officials have directed their efforts at the federal legislative level by proposing bills to restrict or eliminate nontherapeutic antibiotic administration in livestock. However, the urgency of the resistance problem and its potentially severe consequences demand that U.S. public health experts step up their efforts by informing the public and gaining their support.
One way this could be achieved in order to expedite the process of addressing agricultural antibiotic use is by engaging the media. The mass media determine to a great degree what the general public find important, and the news media in particular play an increasingly large role in communicating health risks (6). According to Hierarchy of Effects models designed to explain the psychological basis of consumer habits, public awareness is a key to action; thus, informing the population of antibiotic overuse in the agricultural industry is the first step to creating change. To this end, the media can serve as the messenger. For example, McGuire's Information Processing Model suggests that people ascend through a sequence of steps prior to making a behavior change, with the first crucial step being exposure to information which eventually leads to action (7). According to the model, if people are not exposed to the risks of antibiotic resistance from antibiotic-laden meat, there is no reason to make a decision leading to behavior change, advocacy, or similar action.
Theories of agenda-setting also suggest that the media are an effective means to heighten awareness in order to initiate a change in behavior. For example, McCombs’ Agenda-Setting theory describes the role the media play in determining which issues are deemed important by the public. Studies have shown that the mass media can influence popular opinion regarding political issues, as well as their efficacy in dictating how people think about an issue (8). If the media were strategically utilized to place health risks from food-based antibiotics on public agendas, it could create an outcry and impel both U.S. legislature and agricultural workers to initiate change in the way meat is produced.
A recent New York Times article on methicillin-resistant Staphylococcus aureus (MRSA) provides an example of the role media can play in this context. The article cited a Journal of the American Medical Association study depicting MRSA as “a virulent strain of bacteria that resists many antibiotics and caused an estimated 19,000 deaths in 2005—more people annually than AIDS, emphysema or homicide [in the U.S.] (9).” In addition to providing facts about the increasing difficulty of treating infections such as MRSA, the article offered suggestions on how individuals can protect themselves and elicited nearly 400 comments from concerned readers in an online forum. While antibiotics in the food supply were not addressed (the editor admitted to a reader that she knew very little about the subject), the editor was clearly successful in heightening awareness about general antibiotic resistance and invoking a substantial response from readers. This example of agenda-setting demonstrates that the problem of antibiotic resistance and food production could be broached in context and met with similar receptivity. If public health figures applied such theories to addressing antibiotics in food, they may find that people would emulate their concern, resulting in a more timely resolution of the problem.
Another way to raise awareness among the general population and initiate change is to re-frame the problem of antibiotic resistance. Framing theory imparts that the way in which an issue is presented can profoundly influence decision outcomes (10). Despite recognition of and efforts to significantly restrict antibiotic use in the food supply, antibiotic resistance has been framed as a problem caused primarily by human medical overuse. As such, public messages about antibiotic use in agriculture are virtually nonexistent. A prime example can be found on the Antibiotic/Antimicrobial Resistance section of the CDC website, wherein the vast majority of prevention information relates to either correct antibiotic prescription usage, immunizations, or hand washing techniques (11). Downloadable brochures for hospitals further emphasize these points; the only information regarding food urges readers to “always handle, prepare, and store food correctly,” with no ensuing explanation (11). While medical overuse and improper use of antibiotic prescriptions among human populations are certainly contributing factors to resistance, they do not reflect the evidence-based extent of the problem.
To their credit, the CDC offers a page within the same section entitled “Get Smart on the Farm,” with information geared toward agricultural workers on the appropriate use of antimicrobial agents in animals. Farm worker education is an undeniably essential step in the long term reduction of resistance rates, yet a disparity exists between consumer messages and the scope of the problem. In this instance, the CDC acknowledges both medical and agricultural overuse as contributors to resistance by providing informational web pages on each, but frames them differently depending on the audience—the general public versus farmers. It is thus unlikely that the average consumer seeking information on antibiotic risks will ever visit the agricultural section of the website, where they would be exposed to the entire picture. If framing can profoundly influence decision outcomes, influential public health organizations like the CDC need to broaden the frame of antibiotic resistance so consumers can become more thoroughly informed about the issue.
Critics of the notion that increased antibiotic resistance stems in part from the food supply claim that it is difficult to quantify this occurrence, largely due to the lack of federal regulations requiring those administering antibiotics to report to a central source. While this could explain why public health officials are hesitant to caution people against consuming foods produced with antibiotics, compelling evidence of resistance associated with antibiotic growth promotants has been emerging for decades to support this message (5). For example, when researchers purchased 200 samples of ground meat in the Washington, D.C. area in 2001, they found that 20% contained Salmonella, of which 53-84% were resistant to up to three antibiotics tested (5). Several European studies have demonstrated the frequent transmission of resistant organisms from swine to pig farmers such as methicillin-resistant S. aureus (cited by 5), and a 2005 U.S. investigation found that 98% of the bacteria isolates collected from air samples on a large-scale swine farm displayed resistance to two or more of four antibiotics commonly used as growth promotants (4).
Dozens of studies have reported similar findings, and when several European countries banned nontherapeutic antibiotic use in agriculture, significant reductions in rates of resistance were observed (5). Given evidence from the research as well as the adamant encouragement from the World Health Organization, Institute of Medicine, Infectious Diseases Society of America and others to eliminate the use of antibiotics in animal production, it is clear that such an elimination has been identified as critical in curbing resistance rates. If the growing threat of resistance is to be wholly addressed, it is thus necessary to include the risk of consuming antibiotic-laden animal products in messages discouraging antibiotic use.
Another way in which public health practitioners could gain support and achieve change is by organizing people at the community level. Grassroots community groups have made advances in local policy advocacy when national policy had stalled, such as local tobacco regulation, gun control, and living wage policies (13). Since antibiotic resistance poses a threat that impacts entire populations, targeting communities is an effective means to change the current state of the agricultural industry. To date, public health officials have lobbied almost exclusively at the federal level in order to gain passage of bills amending current agricultural regulations. While these initiatives are imperative, they lack the public support necessary to realize a more immediate change that reflects the urgent nature of the resistance problem.
Past community mobilization efforts in public health encompass a wide range of activist movements such as the anti-abortion movement or anti-smoking and HIV/AIDS activism, and entail raising community member awareness to address a problem (14). One way that communities could act on antibiotic use in the food supply is by demanding wider availability of antibiotic-free meat, which is currently sold by most health food retailers but less frequently available in commercial stores. Public demand, or lack thereof for meat produced with antibiotics, would make an economic statement to farmers about what people want to consume. Advocating for policy change is another way in which community change can be effective (14). For example, the Preservation of Antibiotics for Medical Treatment Act of 2007 (PAMTA) is a proposed bill to withdraw FDA approval for all antibiotics used as feed additives in livestock in order to preserve the effectiveness of medically important antibiotics (15). The bill was introduced to the House of Representatives in February 2007 (16), yet the House sees hundreds of bills a year which may never make it past committees. By raising awareness at the community level, community members would have the opportunity to show their support for federal bills like PAMTA or apply pressure to local legislators to amend agricultural regulations more rapidly.
One caveat to adopting theories of community mobilization for public health practitioners is that it is essential to begin with a target community’s priorities in mind if the initiative is to be successful (17). Fortunately, this would not present as an obstacle in the case of antibiotic resistance. As discussed, the present culture depicts resistance as a problem of overuse among human patients and medical practitioners. However, the high reader response to the aforementioned New York Times article demonstrates that people are concerned about how to protect themselves from resistant bacteria. Moreover, the Infectious Diseases Society of America has a section of its website dedicated to the personal stories of those who have experienced a drug-resistant infection or lost someone as a result of such an infection (18). Thus, it would not be difficult to find communities to whom the issue of resistance is important, and subsequently mobilize members to support public health initiatives against the use of antibiotics in agriculture.
Public health efforts to address antibiotic resistance in the United States are headed in the right direction by targeting all the angles that impact resistance: medical overuse, patient misuse, and nontherapeutic agricultural use. However, their methods are flawed because they have neglected to involve the general population in ways that reflect the breadth of the problem. By failing to inform people about the use of antibiotics to agriculture, they are missing an important opportunity to bring about changes to the agricultural industry that could ultimately save lives. Furthermore, by neglecting to emulate other countries who have already implemented such changes—some for over a decade—the U.S. is falling behind as a prominent leader in public health advancements towards antibiotic resistance reduction. While federal legislation is important, it can also be tedious, and world public health leaders are calling for immediate action. Health officials in the U.S. need to gain support by utilizing media outlets to expose, inform, and set the public agenda, re-frame antibiotic resistance to incorporate health warnings regarding antibiotics in the food supply, and identify and mobilize communities who will make progress through their consumer and local legislative actions. Only by engaging the general public will the issue of antibiotic resistance be more immediately addressed in order to effectively mitigate the problem.
REFERENCES
1. Department of Health and Human Services: Centers for Disease Control and Prevention. About Antibiotic Resistance. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugresistance/community/anitbiotic-resistance.htm.
2. World Health Organization. Antimicrobial Resistance. Geneva, Switzerland: WHO Media Centre. http://www.who.int/mediacentre/factsheets/fs194/en/.
3. Union of Concerned Scientists. Antibiotics and Food. Cambridge, MA: Union of Concerned Scientists. http://www.ucsusa.org/food_and_environment/antibiotics_and_food/.
4. Chapin, A. et al. Airborne multidrug-resistant bacteria isolated from a concentrated swine feeding operation. Environmental Health Perspectives 2005; 113:137-141.
5. Gilchrist, M. et al. The potential role of Concentrated Animal Feeding Operations in infectious disease epidemics and antibiotic resistance. Environmental Health Perspectives 2007; 115:313-316.
6. Glik, D. Risk communication for public health emergencies. Annual Review of Public Health 2007; 28:33-54.
7. McGuire, W.J. Some internal psychological factors influencing consumer choice. Journal of Consumer Research 1976; 2:302-219.
8. McCombs, M. and Shaw, D. The agenda-setting function of the mass media. The Public Opinion Quarterly 1972; 36:176-187.
9. The New York Times. Drug-Resistant Staph: What You Need to Know. New York, NY: The New York Times. http://well.blogs.nytimes.com/2007/10/23/drug-resistant-staph-what-you-need-to-know/
10. Iyengar, S. Framing effects of news coverage (pp. 11-16). In: Iyengar, S. Is Anyone Responsible? Chicago, IL: The University of Chicago Press, 1991.
11. Department of Health and Human Services: Centers for Disease Control and Prevention. About Antibiotic Resistance. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugresistance/prevtips.htm.
12. Tversky, A. and Kahneman, D. The framing of decisions and the psychology of choice. Science 1981; 211:453-458
13. Themba, M. Making Policy, Making Change. Chardon Press, Berkeley, CA: 1999.
14. Edberg, M. Social, Cultural, and Environmental Theories (pp. 65-75). In: Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
15. Union of Concerned Scientists. Food and Environment. The Preservation for Antibiotics as Medical Treatment Act of 2007. Cambridge, MA: Union of Concerned Scientists. http://www.ucsusa.org/food_and_environment/antibiotics_and_food/the-preservation-of-antibiotics-for-medical-treatment-act.html.
16. U.S. Government Printing Office: Congressional Bills. H.R. 962. Washington, D.C.: U.S. Government Printing Office. http://www.gpoaccess.gov/index.html.
17. U.S. Department of Health and Human Services: National Institutes of Health. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Cancer Institute 2005; 23-27.18. Infectious Diseases Society of America. Strategies to Address Antimicrobial Resistance Act. Arlington, VA: Infectious Diseases Society of America 2007. http://www.idsociety.org/STAARAct.htm#Patient_Stories

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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