Contraceptive use during adolescent and young adult years remains a challenge in Canada. According to cross-sectional studies (Table 1),1-5 there is no indication that contraceptive use in these age groups has been increasing. The Canadian Fertility Study of 1995 reports that condom use has increased since 1984, while oral contraceptive (OC) use has significantly decreased.5 In the Canadian Contraceptive Study of 1998, only 68 percent of unmarried, sexually active 18- to 24-year-old women report consistent contraceptive use over the past six months prior to the survey.3
In the late 1990s, with increasing numbers of teen pregnancy in Quebec, a qualitative research study on pregnancy and contraception in adolescents was planned, using the approach of social representation*. The aim of this study was to understand the social representations of teen pregnancy and its prevention, both from the point of view of teens and of professionals working with youth (physicians, nurses, social workers, teachers). Results on attitudes towards contraceptive methods are presented.
*The term “social representation” can be defined as a structured mental (cognitive, evaluative, affective, and symbolic) content about socially relevant phenomena, which takes the form of images or metaphors, and which is consciously shared with other members of a social group.7
The study took place in the region of Quebec City between October 1997 and March 1998. Ten focus groups were done with adolescent girls, eight with adolescent boys, and 13 with health care and school professionals. A standard interview was used and administered by trained interviewers. Specific questions on contraceptive methods were asked. Focus groups lasted approximately two hours and were video- and audiotaped. Tapes were transcribed and content analysis was done through repeated readings. The research protocol was accepted by the ethics committee of Le Centre Hospitalier Universitaire de Québec and funded by Le Conseil Québécois sur la Recherche Sociale. Consent forms were signed by all participants.
The description of the study population is presented in Table 2.
“In your experience, what are the most frequent contraceptive methods used by adolescents?”
According to the adolescents: the condom and the OC are the methods used most frequently by adolescents. The condom is the most popular because it is widely advertised and much information is received about it in schools.
According to the professionals: the condom is the most popular method followed by the OC. Some adolescents use both, while some use no contraception at all.
“What are the advantages and disadvantages of the different contraceptive methods?”
According to the adolescents the condom is the most accessible form of contraception. It is not necessary to see a physician to obtain it. It is affordable, and many teens interviewed knew how to get free condoms. Girls reported that it is easier to use than other contraceptive methods; it is easy to hide and to carry. Adolescent boys and girls are reassured by the double function of condoms: protection against both sexually transmitted diseases (STDs) and pregnancy. They think it is more effective in protecting against STDs than against pregnancy. They are happy with the fact that there are several types and brands of condoms. However, although girls think that condoms offer good protection, they are conscious of potential accidents: some believe they should use OCs combined with the condom to avoid pregnancy. Girls and boys are aware of the risk of tearing and slipping of condoms and some mentioned the risk of allergy to latex. Girls think that the major problem with the condom is that one assumes the partner has a condom. If no condom is available at the time of intercourse, girls believe that it becomes very difficult to refrain from sex. They feel it is the boys’ responsibility to have condoms available. Boys dislike this responsibility. Boys also mention that condoms reduce sensation, and may affect the spontaneity of intercourse.
The oral contraceptive pill (“the pill”) is a well-known contraceptive method, easy to obtain and inexpensive. However, one disadvantage is the need to take it regularly, every day. Although simple to use, girls must find ways to remember to take it. They know of some positive side effects, such as more regular menstrual cycles and lessening of dysmenorrhea, and unanimously recognize its high contraceptive efficacy. Some add that the actual pills are better than those their mothers were taking. Adolescent girls particularly dislike to see a physician to get it and having to undergo a gynaecological exam. Most adolescents know that the pill does not protect against STDs. Girls mention that it is a chemical; it can cause negative side effects like headaches, nausea, weight gain, loss of body shape, risk of cancer, and that a break after five years of use might be necessary. Boys are also convinced that the pill can cause negative effects on girls such as weight gain or loss, infertility, and mood swings. Some girls believe it can become difficult to take the pill when their parents disagree. Reluctantly, some adolescents mention (with a certain degree of humour) that only abstinence is 100 percent effective!
According to the professionals: the condom is easy for adolescents to use because it is available everywhere, without prescription. Some think that adolescents are now more at ease when buying condoms because of public campaigning, and because they are affordable. Others, however, think that condoms might be too expensive or that adolescents might be ashamed of buying them. Some of these professionals give free condoms to adolescents. It is noted that certain young people do not know how to use condoms, and that some adolescent girls dislike condoms because of lack of sensation. Professionals mentioned that it is often difficult for a girl to ask her partner to wear a condom, and, if none is available, that they may not use one.
Professionals feel the pill is not easy to obtain it because of the need for a medical consultation. Many professionals have conflicting information about reimbursement for the pill by insurance agencies. Professionals are aware of the way adolescents perceive the pill, some being more conscious of positive and some of negative side effects. They have an important responsibility towards adolescents to give adequate scientific information and support about pill use. It is difficult for girls to integrate regular pill use into their busy lifestyles, especially for those whose parents are not aware that they are using it or who are against it. Professionals encourage adolescent girls to inform their parents about pill use, particularly to receive financial support when buying the pill. According to professionals, the pill is often used by girls who perceive themselves to be in a stable relationship. Apart from depot medroxyprogesterone acetate, other contraceptive methods seem to young people to be either unknown or outdated. The professional opinion is that emergency contraception use is increasing, while abstinence appears incompatible with today’s sexual life.
“Do you think that you must change contraceptive methods according to the kind of relationship you are in (regular or occasional partner)?”
According to the adolescents: contraceptive method use changes with the type of relationship they are in. Girls and boys say that they always use a condom at the beginning of a relationship. They say this is also true if they have occasional partners. In this latter case, the pill is considered too expensive and the risk of STDs too high not to use condoms. Adolescents who fear human immunodeficiency virus (HIV) infection (symbol of death and suffering), or who put more emphasis on STD/HIV prevention than on pregnancy prevention, are also more prone to use condoms. Some boys declare that they prefer to use condoms all the time, because it offers a dual protection. Those who do not see the importance of using condoms explain that they feel STDs are rare at their age, that they know their partner or that they have confidence in their partner. When in a stable relationship, girls and boys think condoms are not necessary, and that the pill combined with STD screening is the best way to handle the situation. However, a stable relationship is not a welldefined concept, and may be defined as a relationship lasting from a few weeks to a year. Girls explain that a stable relationship implies confidence in the partner and mutual faithfulness. However, some doubt that a faithful relationship during adolescence is possible, and thus use condoms all the time.
According to the professionals adolescent boys and girls do not really adjust their contraceptive methods to their relationship. Professionals think that adolescents do not practice regular contraception because of their perception of personal invulnerability at this time in their lives. Professionals think that adolescents do not understand the difference between contraception and STD protection. They believe that adolescents use condoms at the beginning of a relationship or with occasional partners, but that condom use is very quickly abandoned. Professionals believe that adolescents consider a long-term relationship being one that lasts over one month, while professionals consider a long-term relationship as one lasting much longer.
“According to you, is contraception a girl’s business?”
According to the adolescents. girls answer spontaneously that contraception is an issue for both girls and boys. But when the interviewer asks them if it applies in “real” life, girls mention that, most of the time, they are the ones in charge. Several of them admit that they prefer to have control over contraception. Others find it unfair. Boys also spontaneously answer that contraception is not only a girl’s business. Boys say that girls are responsible for pill use and boys for condom use. Some boys, however, prefer to take charge of contraception. Some mention that they can be fooled by a girl who does not take her pill regularly.
According to the professionals: contraception is a girl’s business, because pregnancy is also a girl’s business. Several professionals think that it is better managed in this way, while others regret that the contraceptive information given in schools targets mostly girls. They express the need that adolescent boys be more informed and involved in contraceptive matters. They admit that there have been some positive changes in boys’ attitudes towards contraceptive responsibility, although some professionals feel that boys are more preoccupied with protection against STDs. Some professionals feel that girls are not assertive enough with their partners when it comes to contraceptive use.
As expected, the adolescents and professionals in our study reported that the most frequently used contraceptive methods were the condom and the pill. Other contraceptive methods were merely mentioned. This confirmed the results of the Canadian Contraceptive Study,3 in which a low level of familiarity and minimal rates of use were reported with contraceptive methods other than the condom and the pill.
Adolescent boys and girls seemed fairly well informed on the two major methods of contraception they use. However, barriers to condom use and misinformation and misperceptions about the pill persisted. This was confirmed by the professionals. As many suggest,349 both counselling and public and school health education have serious deficiencies. First, unless an individual is capable of accepting the fact that he or she is a sexual being with sexual feelings and needs, sexual and reproductive behaviours aimed at preserving health are unlikely to take place.$ Health professionals have an important role to play in assessing sexual health during clinical consultations with adolescents, as well as promoting sexual self-concept in sex-education programs. Moreover, when professionals provide contraceptive counselling, they have the opportunity not only to describe different contraceptive methods, but also to dispel negative attitudes towards contraceptive methods. This is achieved by emphasizing any non-contraceptive benefits, by reinforcing assertiveness of the adolescent, by developing his or her negotiating and communication skills, by identifying barriers to regular use, and by facilitating daily compliance.
Our study shows that contraceptive use and protection against STD/HIV varies according to the type of relationship an adolescent has. Condom use seems to be confined to recent relationships or relationships with multiple partners, while pill use occurs when the relationship is defined as stable. Among heterosexual adolescents, it is thus clear that dual protection is still a very unclear concept, and that “stable relationship” has a very unstable definition. Some have suggested that interventions for STD/HIV prevention may be improved by addressing the characteristics of a relationship, particularly the length of a dating relationship.’° Although this may be useful on an individual basis, it is important to develop general behavioural guidelines. From our study and others on contraceptive effectiveness, we suggest that simple slogans could be developed on these particular issues, such as “Double or quits!”: use dual protection (condom and pill, or condom and long-acting contraceptives) or do not engage in sexual intercourse. A stable relationship does not last three hours, three days, or three weeks ... It’s at least three months!’: use condoms for at least three months before having screening tests. Check the results of your screening tests before stopping condom use. `Prefer quality to quantity’: with fewer sexual partners, there are fewer STDs.
Finally, our study shows that adolescent boys are willing to take contraceptive responsibility. The message that contraception is both boys’ and girls’ business, although not new, is still a very important message. In view of the perception by health and school professionals that adolescent boys are concerned with preventive behaviours for reproductive health, some new strategies could be developed and tried. For example, when adolescent boys were confronted in roleplaying with the possibility that, if an unplanned pregnancy occurs, paternity could be identified and that they would have to support the child’s education, they reacted very intensely and intended to develop contraceptive behaviours. Involving adolescent boys in reproductive health preventive behaviours is still an area to develop.
In conclusion, counselling teens about contraception and STD/HIV protection remains an extraordinary challenge. Listening to teens gives us clues to reinvent our approaches and answer their needs in better ways.
|Table 1:Percentage Distribution of Women Age 15 to 17 years and 19 to 24 years, by current Contraceptive Practice, According to survey and year|
|Status||15- 17 years||15- 17 years||15- 17 years||18- 24 years||18- 24 years|
|Study group||CCS 1994 (n = 165)||CCS 1995 (n = 124)||CCS 1998 (n = 91)||CCS 1984 (n = 91)||CCS 1995 (n = 600)|
|Pregnant or not using contraceptive method*||51||65||66||42.8||43.4|
|* The proportion of sexually active women is not known in these studies except for CCS 1998 (64%)|
|Table 2: Description of the study population|
|Characteristics||Adolescents n = 150||Health care and school professionals n = 90|
|Mean age (yrs)||16.2||39.3|
|Religious affiliation (yes)||82%||80%|
|Religious practice (yes)||22%||29%|
|Low socioeconomic background||59%||48%|
|High socioeconomic background||14%||32%|
|Sexually active (yes)||71%||N/A|
|Type of professional||N/A|
|- physician or nurse||55%|