|Year : 2014 | Volume
| Issue : 1 | Page : 100-105
Health education alone and health education plus advance provision of emergency contraceptive pills on knowledge and attitudes among university female students in Enugu, Nigeria
SU Arinze-Onyia1, EN Aguwa2, Ed Nwobodo3
1 Department of Community Medicine, Enugu State University College of Medicine, Parklane, Nigeria
2 Department of Community Medicine, University of Nigeria Enugu Campus, Nigeria
3 Department of Human Physiology, Nnamdi Azikiwe University Medical School, Nnewi, Nigeria
|Date of Acceptance||17-Apr-2013|
|Date of Web Publication||10-Dec-2013|
S U Arinze-Onyia
Departments of Community Medicine and PHC, Enugu State University College of Medicine, Parklane, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This was an intervention study to compare the effects of health education alone and health education plus advance provision of emergency contraception (EC) pills on the knowledge and attitudes to EC by female students of University of Nigeria in South-East Nigeria.
Materials and Methods: A structured questionnaire was used to collect data in February, 2009 from 290 female students of a tertiary educational institution (140 in the study group and 150 from the control group) who were selected by multistage sampling. Subsequently, health education was conducted among all the students. In addition, a pack containing 2 tablets of EC pills (Postinor) was given only to the students in the study group. Three months after this intervention, its effects were assessed through a survey using the same structured questionnaire employed in the baseline survey.
Results: knowledge of EC was significantly higher among the study group than the controls at post-intervention, P < 0.05. Attitudes to EC were also more favorable at post-intervention survey among the study group, P < 0.05 in most of the variables.
Conclusion/Recommendation: Health education plus advance provision of EC pills effectively improved knowledge and attitudes to EC among female students of tertiary institutions more than health education alone and this should be promoted.
Keywords: Advance provision, attitudes, emergency contraception, female students, health education, knowledge, tertiary institutions
|How to cite this article:|
Arinze-Onyia S U, Aguwa E N, Nwobodo E. Health education alone and health education plus advance provision of emergency contraceptive pills on knowledge and attitudes among university female students in Enugu, Nigeria. Niger J Clin Pract 2014;17:100-5
|How to cite this URL:|
Arinze-Onyia S U, Aguwa E N, Nwobodo E. Health education alone and health education plus advance provision of emergency contraceptive pills on knowledge and attitudes among university female students in Enugu, Nigeria. Niger J Clin Pract [serial online] 2014 [cited 2020 May 28];17:100-5. Available from: http://www.njcponline.com/text.asp?2014/17/1/100/122858
| Introduction|| |
University undergraduates are at high risk of unplanned pregnancy. This is because being away from parental supervision, they engage in sporadic and unprotected sexual intercourse. A large percentage of students of senior secondary and post-secondary institutions engage in pre-marital sex. ,, Moreover, about half of Nigerian female undergraduates are sexually active (defined as having had sexual intercourse within the past 4 weeks).  This has resulted in increased rate of abortion in the country. Each year, Nigerian women obtain approximately 760,000 abortions, usually under unsafe conditions.  Hence, unsafe abortions cause about 20,000 deaths every year in Nigeria and account for about 30% of all gynecological admissions in most developing countries. ,
Added to above, unintended pregnancies are particularly seen in individuals for whom they are more likely to be most disruptive and who are less likely to have the resources needed to deal with the consequences of becoming pregnant unintentionally (e.g., school drop outs, higher rates of mental health problems and are more likely to be physically abused). Indeed among women who are teenaged, unmarried, or low-income, the proportion of pregnancies that are unintended exceeds 60% in some countries.  In Nigeria, the crude birth rate is still high and the fertility rate is about 6 births/woman.  Teenagers contribute a fair share to this high fertility rate. Results of the 2008 Demographic and Health Survey in the country showed that 23% of all teenage women had either given birth or were expecting their first child. 
Most of these problems could be reduced by emergency contraception (EC), which is a method of birth control used to prevent pregnancy from occurring after an act of unprotected sexual intercourse.  It consists of emergency contraceptive pills which are 70-85% effective if taken within 72 h after an unprotected intercourse,  and a copper intra-uterine contraceptive device, which if inserted within 5 days after an unprotected sex is over 95% effective. ,
However, despite the great potential of EC to protect women's health, its use in Nigeria is still sub-optimal at 11.8-20%. , Several studies have highlighted the need for a health education intervention in promoting access to, and utilization of EC by Nigerian youths. ,, Surprisingly, no study to the researchers' knowledge has compared the effects of health education alone and health education plus advance provision of EC pills on the knowledge and attitudes to EC by female students in tertiary institutions in this part of the country and the present study achieves this. The findings will also be of assistance in designing appropriate programs to promote the reproductive health of Nigerian youths.
| Materials and Methods|| |
The study was an intervention study conducted among female students of the University of Nigeria, Enugu Campus (UNEC) between February and May 2009. UNEC is a branch of the University of Nigeria, Nsukka located in the heart of Enugu, the state capital. It houses the faculties of law, medical sciences, health sciences, management studies, and environmental studies.
The study population was selected using a multistage sampling technique. Ten departments were selected by picking 10 ballot papers from a ballot box containing 35 ballot papers representing the 35 departments (made up 5,217 female students) in the campus. From the 10 departments, 290 students (out of 3,359 eligible female students) were recruited by proportionate sampling taking into account the female population size of each department. The following students were therefore selected accordingly: 106 from law, 59 from accountancy, 30 from banking and finance, 26 each from marketing and business management, 17 from estate management, 12 from urban and regional planning, 9 from radiography, 3 from architecture and 2 from geo informatics and surveying.
In each department, a list of all the female students was made using the departmental register. Subsequently, the required number of students was selected from this list by simple random sampling. Medical students (who could have received lectures on EC), final year students (who could be very busy with their degree examinations) as well as those less than 18 years of age (who require parental permission) were excluded from the study. Inclusion criteria were absence of pregnancy (elicited from their last menstrual period) and informed consent. Subsequently, a baseline data were collected from participants using a pretested, self-administered questionnaire. The questionnaire was first transcribed to the local language "Igbo" by an independent person and later translated back to English by another person. Information was sought on their socio-demographic data, knowledge and attitudes to EC.
The 290 students were grouped into 2 by simple balloting. The first group of 140 students was the study group while the remaining 150 made up the control group. All the participants received three sessions of health education on EC held on Saturday mornings to avoid interference with regular lectures. The contents of the lectures include: Definition and explanation of the term: 'EC; Indications and Contra-indications for EC (e.g. pregnancy); types of EC including the chemical contents; trade names of common EC pills; modes of administration and abuse of EC pills; timing of administration; advantages of EC; side-effects of EC; limitations of EC; misconceptions of EC pills including its misnomer 'the morning after pill' and sources of EC. In addition, EC pills (a pack containing 2 tablets of postinor which is 1.5 mg of levonorgstrel and effective in preventing pregnancy if taken within 72 h of unprotected sex) were given to each of the respondents in the study group. Three months after intervention, the effects were assessed using the same household questionnaire employed in the baseline study.
The data was analyzed using Statistical Packages for Social Sciences, and EPi Info. version 3.4 software and tests of significance were conducted using Chi-square. The entire statistical calculations were done at 95% confidence level and significance assessed at 0.05 probability.
Scoring knowledge questions
Every correct answer is scored as one point while wrong answer is scored zero point. The average score is calculated as total correct answer divided by the total possible correct answer multiplied by 100%. Average score of less than 50% is regarded as poor knowledge; scores of between 50% and 75% is fair knowledge while scores greater than 75% is good knowledge.
Approval for the study was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Enugu and Management of UNEC (Ref: UNTH/CSA.329/Vol. 5/). A written informed consent was also obtained from participants after explaining clearly the purpose and methodology of the study.
| Results|| |
The age range of the respondents was 18-26 years with a mean age group of 21.35 years, SD: 2.314 and SEM: 0.136. Majority of them were single, in their first year of study and all were Christians [Table 1]. [Table 2] shows the knowledge of EC at the pre-intervention survey. Awareness of EC was good among the study and control groups. The difference was not statistically significant. However, only 17.1% of respondents in the study group and 16.7% of the controls could identify postinor as an EC pill. Knowledge of the correct timing of EC pills was equally low among the two groups.
|Table 1: Distribution of respondents according to some demographic characteristics |
Click here to view
Again, knowledge of the advantages of EC was similar in both groups at baseline. Seventy seven (55%) respondents of the study group knew that EC reduces unwanted pregnancies. This is not statistically different from those in the control group who had the same knowledge. Similarly, there was no significant difference between the respondents in the study group and respondents in the control group who knew that EC induces vomiting. In summary, both groups had poor knowledge of EC at baseline. The difference was not statistically significant (P = 0.889).
At post-intervention survey, all the respondents in both groups were aware of EC. However, 68% of respondents in the control group identified Postinor as an EC pill while all the respondents in the study group did the same [Table 3]. The difference was statistically significant. Similarly, a significantly higher number of respondents in the study group than those in the control group knew the correct timing of EC pills (P < 0.05). Knowledge of the advantages as well as the side-effects of EC was significantly higher in the study group than among the controls at post-intervention. Overall knowledge score of the study group respondents was fair as against the poor knowledge scored by the controls.
[Table 4] displays the respondents' attitudes to positive statements on EC. At baseline, the respondents in both groups were similarly disposed to EC, but at post intervention survey, attitudes of respondents in the study group were significantly better than those of the controls. For instance, at baseline, 17.1% of respondents in the study group and 11.3% of the controls were in support of selling EC pills at chemist shops without doctor's prescription. The difference was not statistically significant. At post-intervention survey; however, 92.9% of the study group and 33.3% of the controls were similarly disposed. The difference was statistically significant. In addition, at pre-intervention, there was no significant difference between the number of respondents in the study group and those in the controls who were in support of increasing awareness of EC through advertisement but at post-intervention, the number in favor of this was significantly higher among the study group (P < 0.05).
Furthermore, unlike findings at baseline, there was a greater reduction in the number of respondents who were in favor of negative statements on EC among the study group than in the controls at post-intervention survey [Table 5]. Twenty eight respondents (20%) in the study group and 25.3% of the control group respondents agreed that EC was an abortifacient which should be banned at baseline. The difference was not significant, P > 0.05. However, after intervention, only 20 (13.4%) of respondents in the control group were in support of the above statement. This number was nevertheless significantly higher than those in the study group who totally disagree with the statement.
| Discussion|| |
Awareness of EC was high in the present study. This is similar to previous reports among tertiary school students in South-West and South-South Nigeria. , The present finding is however lower than that reported among medical doctors in Port Harcourt which showed that 98% of them were aware of EC.  The disparity could easily be attributed to the study population used in the previous study, for as doctors, they did not only learn about EC in the medical school, but they also prescribe it for their clients. However, the present finding is higher than 61% reported among female undergraduates in Eastern Nigeria.  This result indicates that if the efforts on sensitization was maintained for a long time in developing countries, we can hope for an increase of awareness of EC among young women in the following years.
After intervention, although awareness of EC was similarly increased in both groups, knowledge summary of EC was significantly higher in the study group than among the controls. This is not surprising as people are more likely to understand better what is seen and touched than what is only heard of. Moreover, the drug information on the drug pack could have served as reinforcement for what was learnt during the health education sessions. In addition, advance provision of EC pills could have increased interest in EC and may also have served as a motivator towards the desire to have a better understanding of the pill.
Similarly, following intervention, attitudes to EC was significantly better among the study than the controls. More respondents in the study group than in the controls were in favor of easy accessibility to EC through removal of obstacles such as 'doctor's prescription.' Previous studies have also noted that advance provision of EC can circumvent obstacles to timely use. , This is particularly important in EC use where timely use is of the essence in determining its efficacy.
The present findings show that an intervention program which combines health education with advance provision of EC pills is more effective in improving knowledge and attitudes to EC than that which involves health education alone. This is similar to previous finding where there was significantly higher use of EC in the group who received both health education and EC pills than in the group that received only health education. 
| Conclusions and Recommendations|| |
This study has shown that when health education is combined with advance provision of EC pills, it significantly improves knowledge and attitudes to EC than if health education is delivered alone. It is therefore, recommended that reproductive health programs combining health education and advance provision of EC pills should be promoted in post-secondary school institutions in Nigeria and that EC services should be offered at subsidized cost in Government Hospitals and clinics and at youths' centers to enhance its affordability by every woman in need.
| References|| |
|1.||Adhikari R, Tamang J. Premarital sexual behavior among male college students of Kathmandu, Nepal. BMC Public Health 2009;9:241. |
|2.||Assefa S, Dessalegn W. Premarital sexual practice among school adolescents in Nekemte Town, East Wollega. Ethiop J Health Dev 2008;22:167-73. |
|3.||Zhang L, Gao X, Dong Z, Tan Y, Wu Z. Premarital sexual activities among students in a university in Beijing, China. Sex Transm Dis 2002;29:212-5. |
|4.||Aziken ME, Okonta PI, Ande AB. Knowledge and perception of emergency contraception among female Nigerian undergraduates. Int Fam Plan Perspect 2003;29:84-7. |
|5.||Bankole A, Oye-Adeniran BA, Singh S, Adewole IF, Wulf O, Sedgh G et al. Unwanted Pregnancy andInduced Abortion in Nigeria: Causesand Consequences. New York: Guttmacher Institute; 2006. p. 1-36. |
|6.||Raufu A. Unsafe abortions cause 20 000 deaths a year in Nigeria. BMJ 2002;325:988. Available from: http://www.bmj.bmjjournals.com/cgi/content/full/325/7371/988/d. [Last Accessed on 2012 Jan 10]. |
|7.||Ekanem EI, Etuk SJ, Ekabua JE, Iklaki C. Clinical presentation and complications in patients with unsafe abortions in University of Calabar Teaching Hospital, Calabar, Nigeria. Niger J Med 2009;18:370-4. |
|8.||Monea E, Thomas A. Unintended pregnancy and taxpayer spending. Perspect Sex Reprod Health. 2011:43:88-93. |
|9.||Population Institute. Population and Failing States Nigeria. Population Reference Bureau. Available from: http://www.populationinstitute.org/external/files/Nigeria.pdf., http://www.elon.edu/student/enilsen/health1.htm. [Last Accessed on 2013 Apr 24]. |
|10.||National Population Commission.Fertility and Determinants. National Demographic and Health Survey (NDHS). 2008. 3 Available from: http://www.measuredhs.com/pubs/pdf/SR173/SR173.pdf. [Last Accessed on 2013 Apr 24]. |
|11.||Weismiller DG. Emergency contraception. Am Fam Physician 2004;70:707-14. |
|12.||Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 h after unprotected sexual intercourse. Am J Obstet Gynecol 2001;184:531-7. |
|13.||Harper CC, Speidel JJ, Drey EA, Trussell J, Blum M, Darney PD. Copper intrauterine device for emergency contraception: Clinical practice among contraceptive providers. Obstet Gynecol 2012;119:220-6. |
|14.||Turok DK, Gurtcheff SE, Handley E, Simonsen SE, Sok C, North R, et al. A survey of women obtaining emergency contraception: Are they interested in using the copper IUD? Contraception 2011;83:441-6. |
|15.||Arowojolu AO, Adekunle AO. Perception and practice of emergency contraception by post-secondary school students in southwest Nigeria. Afr J Reprod Health 2000;4:56-65. |
|16.||Obi SN, Ozumba BC. Emergency contraceptive knowledge and practice among unmarried women in Enugu, southeast Nigeria. Niger J Clin Pract 2008;11:296-9. |
|17.||Alubo O. Adolescent reproductive health practices in Nigeria. Afr J Reprod Health 2001;5:109-19. |
|18.||Arinze-Onyia SU, Onwasigwe CN, Uzochukwu BS, Nwobi EA, Ndu AC, Nwobodo E. The effects of health education on knowledge and attitudes to emergency contraception by female students of a tertiary educational institution in enugu, South East Nigeria. Niger J Physiol Sci 2010;25:165-71. |
|19.||Abasiattai AM, Umoiyoho AJ, Bassey EA, Etuk SJ, Udoma EJ. Misconception of emergency contraception among tertiary school students in Akwa Ibom State, South-south, Nigeria. Niger J Clin Pract 2007;10:30-4. |
|20.||Oriji VK, Omietimi JE. Knowledge, attitude, and practice of emergency contraception among medical doctors in Port Harcourt. Niger J Clin Pract 2011;14:428-31. |
|21.||Ikeme AC, Ezegwui HU, Uzodimma AC. Knowledge, attitude and use of emergency contraception among female undergraduates in Eastern Nigeria. J Obstet Gynaecol 2005;25:491-3. |
|22.||Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention: A meta-analysis. Obstet Gynecol 2007;110:1379-88. |
|23.||Meyer JL, Gold MA, Haggerty CL. Advance provision of emergency contraception among adolescent and young adult women: A systematic review of literature. J Pediatr Adolesc Gynecol 2011;24:2-9. |
|24.||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;17:87-96. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]