Contraception among 16+ women: Qualitative research with users
Summary of findings
Four main audience types emerged from the research:
- Risk Deniers: the youngest (teenage) users, often in denial about the associated risks of pregnancy and were therefore using no, or ad hoc, contraception having given it low, or no, consideration
- Risk Challengers: younger (typically 18-25 years) users, trying more actively to avoid pregnancy and therefore using more reliable methods of contraception; however, their lifestyles can mean that compliance is variable, and greater risks are taken in certain circumstances, for example, when drunk
- Hormone Avoiders: this group was driven by a preference for avoiding the effects of hormonal methods because of concerns about the impact these might have on their fertility levels, and/or on their longer-term health
- Risk Avoiders: these users were very cautious, and were driven by a strong desire to avoid pregnancy, focusing on the risks which this involved; as a result, they were likely to select the most reliable methods of contraception and use them appropriately
Current usage of contraception by audience type was largely as follows:
- Risk Deniers – none, withdrawal, condoms (usage varied), Emergency Hormone Contraception (EHC)
- Risk Challengers – none, combined pill, condoms, EHC; some were using LARCs, especially the injection, and some usage of the implant
- Hormone Avoiders – condoms and IUD with minority use of natural family planning and diaphragm
- Risk Avoiders – combined pill, EHC, and some injection, implant, IUD, and the most cautious using Double Dutch
An array of triggers and barriers impacted on initial take-up and on-going use of a particular method of contraception. These clustered into themes, and had more or less relevance for users, depending on age and audience type. Four main themes were identified in the research, as follows:
- Trust (familiarity, efficacy, control, visibility of action, visibility of method, relevance and suitability)
- Practicality (ease of initial and on-going use, accessibility, away from or at sexual moment, long acting or ad hoc)
- Health-related Issues (perceived negative impact on fertility or general harm or side effects (short and long term)
- Other benefits (STI protection and hormonal control/ regulation) and other barriers (physical impact – invasive, painful, de-sensitises sex)
In overall terms, however, the two main factors driving method of take-up amongst users currently were trust (with familiarity in particular) and practicality (with perceived ease of use in particular).
Familiarity (awareness and knowledge) of the range of contraceptive choices varies, with different age groups being aware of different methods, although none being aware of the full range of methods available. Men in the research sample had the lowest awareness and knowledge of the range of methods, with teenagers and Risk Deniers (see below for a fuller description of this user type) having a fairly low awareness of what was available, and a patchy understanding of those methods of which they were aware.
Older women (35+ years) demonstrated mixed levels of awareness of the range of methods, but were generally less aware of, and knowledgeable about, the newer LARCs (implant and injection). Women in their twenties appeared to have the highest levels of awareness, although even they tended to be less aware of and knowledgeable about certain methods, including some LARCs.
Overall awareness and/or usage of each contraceptive method across the research sample, was summarised as follows:
- Greatest levels of awareness/usage: combined pill (CCP), EHC and condoms
- Medium levels of awareness/usage: progesterone-only pill (POP), IUD, injection and implant
- Lowest levels of awareness/usage: patch, IUS, diaphragm, female condoms, sterilisation, natural family planning
Efficacy was perceived as important, but for many this was assumed to be a ‘given’, at least in relation to the most familiar and established methods of contraception such as the CCP. Perceived efficacy varied by level of knowledge, and – critically for many – the CCP was rated as being as, or almost as, effective as LARCs. In overall terms, perceptions of efficacy levels were as follows:
- Most effective forms – sterilisation, implant, injection, CCP (and IUD/(IUS) for those with some knowledge typically older females)
- Medium/variable efficacy – condoms (male and female), POP, patch
- Least effective – natural family planning, diaphragm
Although there was awareness that efficacy is affected by user error, this was not top-of-mind for some of the user audience, and so needs to be spelled out as a clear benefit of LARCs.
Consideration of contraception followed a fairly typical ‘journey’, with low/ad hoc use for the first sexual encounters, followed by a more considered decision about using a more reliable method of contraception.
In general, women were typically making decisions about which contraceptive method they will use in the absence of any discussion or consultation with their sexual partners, not least because both men and women largely regard contraception as the woman's responsibility (except in the case of carrying and using a condom).
The main driver to consideration of contraception was, unsurprisingly, avoidance of pregnancy, but the degree of perceived risk which drove this behaviour (that is, to use contraception at all, the choice of method, and compliance with the method) varied across the user audience.
This lack of homogeneity across the user audience means that there are different needs to be considered in moving some users towards usage of contraception generally, and in and moving others towards usage of LARCs in particular.
Focus on Wider Choice/LARCs
Various opportunities exist to increase the take-up of LARCs in particular via a public campaign, given the lower familiarity of these methods with users, and a corresponding lower awareness of their potential benefits. Any campaign would need to overcome key barriers around trust and around concerns about use (and fitting in particular) amongst users, which currently prevent take-up, especially for younger women and teenagers. For these groups (and for all users), it will be important to provide education at a detailed level, and in the right context (ideally face-to-face with a healthcare provider), so that appropriate attention can be given to overcoming concerns.
In aiming to move audiences towards using more effective methods of contraception, the types of method each audience appeared to be warmest towards were as follows:
- Risk Deniers were more likely to consider the contraceptive pill, since this was the most familiar and trusted method; the patch, the injection and possibly the implant were also considered by some
- Risk Challengers were open to consideration of LARCs (mostly the implant and the injection, unless they already had children, in which case the IUS was a candidate for consideration); those who struggled, or had issues, with contraceptive pill usage were especially likely to consider LARCs because of their ‘fit and forget’ aspect
- Hormone Avoiders were likely to find the IUD of most appeal (of the LARC methods), although the diaphragm could appeal to some; there was also some possibility that the IUS and the POP might also be considered by some of these users, given the lower levels of hormone (and therefore being seen as lower risk) which they contained (in comparison with other methods)
- Risk Avoiders were open to LARCs, given their high levels of efficacy (although preferences for individual methods differed by age and lifestage); at present, however, many were wedded to the CCP, and perceived little or no reason to convert to a LARC method
Implications for a Campaign
Messages around the concept of ‘choice’ appeared likely to appeal across the target audience groups. Messages with most appeal (covering top level benefits) were as follows:
- A large range of choices (15)
- Choices to suit individual needs (emotional, physiological, biological)
- There are improvements in terms of ease and simplicity of methods (so you don’t have to have the hassle of remembering to take a pill everyday)
- Along with highly effective methods (that don’t depend on you having to remember when and how to use them)
For example, a communication along the lines of: ‘You don’t know how good contraceptive options are these days – so easy and simple – with choices so you can find the right one to suit you’, supported by a message about having the opportunity to take advantage of expert advice (about the best option for you), and reinforced by the message that this is ‘what everybody else is doing’.
However, although there is a benefit in communicating that there are about 15 types of contraceptive method (since this is markedly different from user expectations), there would be little point in communicating (in a face-to-face consultation) about some of the set to some users, since they are likely to be perceived as of very low interest or relevance; for example females condoms, the diaphragm, or sterilisation.
In considering ‘double Dutch’, users understood the rationale for this method, but it was of extremely low salience. The clear link with STIs makes ‘double Dutch’ very difficult to discuss alongside contraception (especially with users who are in what they consider to be a ‘stable’ relationship, regardless of how short-term this is). Whilst the message about ‘double Dutch’ should be retained in any campaign, as omitting it altogether, could be interpreted by the audience as a licence not to use condoms; this would work better in the form of a low level communication or reminder.
Specific messages by audience type to prompt them to consider moving towards LARCs were as follows:
Risk Avoiders and Hormone Avoiders: These groups had minimal issues about using contraception, since they were committed and reliable users. The main task here is to broaden their perceptions of choice, and a general campaign is highly likely to achieve this. Some are likely to continue using CCP but others are very likely to take up a LARC method, given the high levels of efficacy.
Risk Challengers: The requirement would be to readjust the way in which they consider relative risks. This group of users responded to messages about the benefits of ease, simplicity, and a ‘no hassle’ (fit and forget’) element (in relation to the combined pill which demands user compliance). These messages, alongside the message about choice, are likely to be very compelling for these users. In addition these users have minimal service delivery issues compared to Risk Deniers.
Risk Deniers: The need with this group was to focus them on the uptake of contraception at all, as opposed to encouraging the use of LARCs specifically. These users need an ‘education’ message in order to challenge their current mindset of denial by focusing them on relative risk, and to convert them into becoming ‘planners’ where contraception is concerned. This requires legitimising becoming sexual for them, so that this can be admitted, not least to themselves, as the first step on a journey to encourage a transition from stage one (none/ad hoc use of contraception as experimentation) to stage two (proper use, as a ‘real’ user, not an experimenter), emphasising along the way that contraception is a ‘normal’ thing to do (‘everyone does this’). These users also have key service delivery needs around the following areas:
- anonymity and confidentiality
- easy access, but brought to them, since they are not proactive
- friendly, informal and accessible tone of approach, in order not to alienate users
The overall objective of the research with users was to understand the myths, knowledge and attitudes held by 16+ women (and males who influence their decisions) in relation to every form of contraception, identifying gaps or inaccuracies in their knowledge and seeking potential ways to motivate usage. In addition, the research needed to explore the acceptability amongst this audience of “double Dutch” – using a condom as well as another method of contraception, as a method of protecting against pregnancy and STIs.
Achieving these objectives involved exploring:
- Users’ knowledge about how pregnancy occurs, their perceptions of risk, current contraceptive usage, the factors affecting consideration of contraception and partner’s perceptions and role in relation to this.
- Awareness, knowledge, experience, misconceptions, perceived relevance/suitability and perceived benefits and barriers for each form of contraception.
- The impact of new, accurate information for each method.
- Any differentiation within the audience, in terms of whether different groups within the audience have specific communication needs.
- Tone and language considerations when ‘discussing’ sexual health.
- Main and preferred sources of information about contraception generally.
- Information needs in relation to the facilitation of service use.
The Department of Health (DH) have a key policy objective to increase and improve access to all methods of contraception, which should thereby also increase uptake of the long acting reversible methods (LARCs) specifically the implant, injection, IUS and IUD), which are not subject to user error.
To achieve this, DH need to improve the knowledge of both health providers and the user audience about the range of contraceptive options available.
Communications and marketing activity is therefore being developed aimed at improving knowledge amongst the audience groups. To help inform development of this activity, research was required to fully understand current knowledge, attitudes and perceptions in relation to the range of contraceptive choices which are available to women in England.
Two separate studies were conducted – one with health professionals and one with the user audience. This summary details the findings from the health professional study. Findings from the user study can be found in a separate stud.
This research highlighted that attitudes, awareness and understanding of various contraception methods are varied, with 4 audience types emerging from the research (risk deniers, risk challengers, hormone avoiders and risk avoiders). The research also shows that various opportunities exist to increase the take up of LARCs (Long Acting Reversible Contraception), in particular via a public campaign, given the lower familiarity of these methods with users and a corresponding lower awareness of their potential benefits.
A mixed method qualitative approach was used as follows:
- 18 extended mini-groups lasting 120 minutes (4-5 respondents per group) with currently sexually active females (18-46 yrs)
- 9 depth interviews with non-sexually active females (18-46 yrs)
- 4 close friendship pairs lasting 90 minutes with currently sexually active females (16-17 yrs)
- 2 close friendship pairs lasting 45 minutes with currently non-sexually active females (16-17 yrs)
Across the above sample:
- All were heterosexual or bisexual
- Spread of ages with age bands
- Range of attitudes to pregnancy
- Mix of SEG
- Mix of users and non-users of services in mini-groups
- Mix of ethnicity and religion as appropriate to area in mini-groups
- Range of different relationship status and type
9 extended mini-groups (4-5 respondents per group) lasting 120 minutes with sexually active males (18-46 yrs)
- All were heterosexual
- All were willing to discuss contraception within a group discussion
- Spread of ages within age bands
- Mix of SEG
- Mix of users and non-users of services
- Range of attitudes to pregnancy
- Mix of ethnicity and religion as appropriate to area
- Range of different relationship status and type
Data collection methodology
Other data collection methodology
c.111 female and 45 male respondents
The research was conducted in London, Berkshire, Hertfordshire, Bristol, Gloucestershire, Birmingham, Coventry, Loughborough, Oldham, Sheffield, Wirral, Liverpool, Leeds, Yorkshire (across urban, suburban and rural locations).