Background: Contraceptive methods (CM) are important resources in the prevention of adolescent pregnancy. This study aimed to investigate adolescent knowledge, attitudes and practices related to contraception. Study Design: A cross-sectional and exploratory study was conducted with 7th to 9th grade adolescents in northeastern Brazil. Their knowledge, attitudes, and contraceptive method use were analysed by gender, age and sexual initiation groups. Results: A sexual debut had been experienced by 21% (n = 120) of all respondents (n = 570). The majority of the respondents who had experienced a sexual debut were male (73.3%, n = 88), their mean age was 15 years (SD = 1.46), and 49.3% (n = 59) never used any CM. The participants displayed low knowledge and unfavourable and ambivalent attitudes concerning contraception. Conclusion: Adolescents initiate sexual intercourse with knowledge and attitudes that limit the use of CM, which makes them more at risk of pregnancy. Further research that will be representative of the specific population in need of interventions is necessary.
Adolescent pregnancy is considered one of the main factors of vulnerability that can severely affect adolescent development. Pregnancy has a direct cause and effect relationship with poverty and low education, which to- gether impose limits on the opportunities that adolescents will have throughout their lives [
In particular, because adolescent pregnancies are often unwanted, unintended and in the majority of cases do not have family or social support [
Furthermore, adolescent pregnancy is a condition that maintains the intergenerational cycle of poverty [
Given that the world’s population has 1.2 billion adolescents, that there are 21 million adolescents in Brazil and the increasing incidence of girls who have become pregnant early in adolescence [
Thus, contraceptives constitute a major method of confronting this reality [
Recognising contraception as an important solution in the prevention of adolescent pregnancy and believing that the major difficulty preventing use of this resource is the adherence of adolescents themselves, this study investigates the knowledge, attitudes and practices of adolescents about contraceptive methods.
This cross-sectional exploratory study was conducted in four public schools in João Pessoa city, which is located in northeastern Brazil.
A non-probabilistic sample was drawn with an aim of meeting the study purposes. The inclusion criteria for the selection of the schools were as follows: public schools with more than 100 teen students enrolled in the 7th and 9th grade. The adolescent selection criteria were as follows: be enrolled in one of the four schools among those that were selected and an age between 11 and 19 years.
We collected data in the classroom during a time period corresponding to one lesson (50 minutes) without a teacher present. We used self-administered material consisting of three parts. The first part was a form that collected sociodemographic data, sexual and contraceptive behaviours and a self-declaration whether the adolescent knew contraceptive methods. The second part was a questionnaire with 10 multiple-choice questions (MCQ) about both basic and specific knowledge in relation to contraceptive methods. The MCQ focused on the following topics: the calendar method to birth control, the cervical mucus method (Billings method), the condom, the pill, the emergency pill, the injectable contraceptive, the IUS (intra Uterine system), the female and male sterilization (tubal ligation and vasectomy). This questionnaire was valid with a Cronbach’s alpha index of 0.703. The third part involved a Likert scale consisting of 14 items related to attitudes about contraception. These items were validated with a Cronbach’s alpha index of 0.700. The instruments used in the second and third parts of data collection can be accessed through at the following website: http://www.ccm.ufpb.br/images/documentos/instrumentodecoletadedadosversaoingles.pdf.
A database was built by using Epi Info software, version 3.5.1 (2008). The data was double-entered by different professionals.
The statistical analysis was performed using STATA 10 software [
Two groups were considered for the age variable based on the phase of adolescence: up to 14 years old (initial phase) and 15 years old or older (late phase). The variable sexual initiation was analysed as a dichotomous variable, allowing for adolescents with and without an experienced sexual initiation. Whether CM was used was as- sessed in the group of adolescents with sexual experience.
Frequencies, means and standard deviations were generated for the descriptive statistics. Chi-square analyses and t tests were performed to analyse the associations among the variables and to compare the means.
This study was approved by the ethics committee of the University Hospital Lauro Wanderley Federal University of Paraiba under the number 328/09.
The profile of the study participants is presented in
The sample distribution according to sexual initiation for gender, age and educational level is shown in
Of the sexually active adolescents, 49.3% (n = 59) had never used any contraception method. Condoms were the contraceptive method most cited among those who had used some form of contraception (45%, n = 54). Other methods used included hormonal contraception (3.3%, n = 4) or a combination of condoms and hormonal contraception (2.4%, n = 3). Among those who reported having used condoms, the majority were male (77.8%, n = 42).
More than half of respondents (53.9%, n = 307) stated that they did not know any contraceptive method. This
| Items descriptive | No sexual initiation | Sexual Initiation | p | |
|---|---|---|---|---|
| Adolescents respondents* | 441 (77.4%) | 120 (21.1%) | - | |
| Gender | Male n(%) | 218 (49.4%) | 88 (73.3%) | 0.001** |
| Female n(%) | 223 (50.6%) | 32 (26.7%) | ||
| Age | 10 to 14 years n(%) | 344 (78%) | 42 (35%) | 0.001** |
| 15 to 19 years n(%) | 97 (22%) | 78 (65%) | ||
| Years of education | Mean | 7.86 | 8.03 | 0.018*** |
| Standard Deviation | 0.79 | 0.83 | ||
*1.6% (n = 9) of the total sample did not respond to the item about their sexual initiation; **Chi-square test; ***t test.
| Gender | Age | Sexual Initiation n(%) | Never used contraception n(%) |
|---|---|---|---|
| Male | 11 to 15 | 55 (62.5) | 29 (65.9) |
| Up 15 | 33 (37.5) | 15 (34.5) | |
| Total | 88 (100) | 44 (100) | |
| Female | 11 to 15 | 18 (56.3) | 09 (60.0) |
| Up 15 | 14 (43.8) | 06 (40.0) | |
| Total | 32 (100) | 15 (100) |
was most evident in the female group (n = 154, 59.8%, p = 0.016), younger adolescents (n = 221, 57.6%, p = 0.025) and in the group of adolescents without sexual initiation (n = 261, 59.7%, p = 0.001).
Among those who self-declared knowing some type of CM, condoms were cited by 74.5% (n = 190), hormonal contraception was reported by 5.9% (n = 15), and condom and hormonal contraception together were mentioned by 18.5% (n = 47). In addition, 1.1% of respondents (n = 3) answered “Option: other methods” and did not answer the question concerning the type of CM used. Most adolescents who mentioned knowing about condoms were male (68.4%, n = 130). On the other hand, the majority of adolescents who knew about hormonal contraceptives were female, both for the use of hormonal contraceptives alone (86.7%, n = 13) and in association with condom use (61.7%, n = 29).
When assessing the teens who had started their sexual practices, we observed that 64.2% (n = 77) of those respondents reported knowing at least some CM. Among these respondents, most stated that knew of condoms (77.9%, n = 60); contraceptive methods were reported by 9.1% (n = 7), combined condom and hormonal contraception use was cited by 11.7% (n = 9), and 1.3% of these respondents (n = 1) stated that they used other methods. Among those declaring some knowledge of CM, 23.4% (n = 18) reported never having used any method.
Regarding the questionnaire on knowledge of specific methods, the item on the effectiveness of condoms had the highest percentage of correct answers of respondents (57%, n = 322), and the second highest percentage of correct answers (40.7%, n = 231) was for the item concerning knowledge of condoms and dual protection. For other items, the percentage of correct answers did not reach 25%, and the cervical mucus method (Billings) item had the lowest number of correct answers (4%, n = 23). As shown in
The items with the lowest percentages of recorded favourable attitudes to contraception correspond to the association of use of CM with the seriousness of the relationship (n = 94) and the negative effects of HC including increased weight (21.7%, n = 123), impaired future fertility (24.1%, n = 137), or injury on general health (28.1%, n = 158). In addition, whereas 89.8% (n = 507) of adolescents agreed that contraception should be a concern of the couple, only 35.6% (n = 201) of them disagreed that contraception is a concern exclusive to women.
Considering the significant differences between the groups with and without sexual initiation,
| Contraceptive Methods | Age | p | Sexual Initiation | p | ||
|---|---|---|---|---|---|---|
| 10 - 14 years n(%) | 15 - 19 years n(%) | No n(%) | Yes n(%) | |||
| Dual protection of condom | 152 (39.1) | 79 (44.4) | 0.23 | 174 (39.6) | 54 (45.4) | 0.26 |
| Condom-Effectiveness | 229 (59.0) | 93 (52.5) | 0.15 | 248 (56.6) | 68 (57.6) | 0.85 |
| Calendar method | 35 (9.0) | 27 (15.2) | 0.03 | 42 (9.6) | 18 (15.3) | 0.08 |
| Cervical mucus method (Billings) | 17 (4.4) | 06 (3.4) | 0.58 | 15 (3.4) | 08 (6.7) | 0.11 |
| Oral contraceptive | 63 (16.3) | 27 (15.3) | 0.78 | 65 (14.9) | 22 (18.6) | 0.32 |
| Emergency pill | 58 (14.8) | 32 (18) | 0.34 | 70 (15.9) | 19 (15.8) | 0.98 |
| Injectable contraceptive monthly | 75 (19.1) | 33 (18.8) | 0.91 | 79 (17.9) | 24 (20.3) | 0.55 |
| IUS | 79 (20.2) | 39 (21.9) | 0.64 | 95 (21.5) | 22 (18.5) | 0.47 |
| Tubal ligation | 85 (21.8) | 53 (30.3) | 0.03 | 100 (22.9) | 36 (30.3) | 0.10 |
| Vasectomy | 85 (21.7) | 38 (21.7) | 0.99 | 93 (21.1) | 28 (23.9) | 0.52 |
IUD―Intra Uterine Sistem.
| Likert scale items | Favourable attitudes | Difference regarding to SI | |||||
|---|---|---|---|---|---|---|---|
| Total adolescents (n= 570) | No Sexual debut (n= 441) | Sexual Debut (n= 120) | |||||
| % | (n) | % | (n) | % | (n) | x2 (p) | |
| It is hard to acquire birth control methods. | 46.7 | (265) | 46.1 | (202) | 48.3 | (58) | 0.667 |
| The sex with a condom is not good. | 43.8 | (249) | 43.3 | (190) | 46.7 | (56) | 0.862 |
| Using a method of birth control indicates a lack of confidence in your partner. | 48.3 | (274) | 47.5 | (208) | 52.5 | (63) | 0.330 |
| Using methods of birth control increases commitment in the relationship. | 16.6 | (94) | 16.4 | (72) | 17.6 | (21) | 0.754 |
| I have difficulty talking about sex with my friends. | 53.7 | (304) | 50 | (219) | 66.7 | (80) | 0.001 |
| Hormonal contraceptives (pill or injection to birth control) affect female health. | 28.1 | (158) | 26.9 | (117) | 31.7 | (38) | 0.302 |
| The hormonal contraceptive is fattening. | 21.7 | (123) | 21 | (92) | 25.2 | (30) | 0.325 |
| After using contraceptive methods, it is difficult to become pregnant. | 24.1 | (137) | 23.6 | (104) | 26.9 | (32) | 0.463 |
| Birth control should be a female concern. | 35.6 | (201) | 35.6 | (156) | 36.1 | (43) | 0.917 |
| Birth control methods provide more sexual freedom. | 60.5 | (340) | 56.4 | (246) | 73.7 | (87) | 0.001 |
| Pregnancy is more fattening than the use of hormonal Contraceptives. | 62.9 | (352) | 62.2 | (272) | 65.2 | (75) | 0.557 |
| Birth control should be the responsibility of the couple. | 89.7 | (507) | 90.2 | (396) | 88.1 | (104) | 0.519 |
| It is important to know the methods of birth control even before starting sexual life. | 84.5 | (474) | 83.6 | (366) | 87.8 | (101) | 0.261 |
| There are no difficulties with using birth control methods. | 57.4 | (324) | 55.3 | (242) | 64.4 | (76) | 0.074 |
SI―Sexual Initiation.
sex with friends (p = 0.001) and who agree that the use of CM gives more sexual freedom sexual (p = 0.001) is higher.
The percentage of favourable attitudes about contraception and its distribution according to gender was not statistically significant.
The relationship between attitudes and age is shown in
Among the major regions of Brazil, the highest rate of education discrepancies is found in the northeast. The average school delay estimated for the country is 1.1 years, but the delay is 1.4 years in the northeast [
Similar to a survey of American teenagers [
The high percentage of sexually active teens that never used any contraceptive method strengthens the evidence that at this age, sexual activity is often unprotected and often occurs without permission or without contraceptive orientation [
As in other studies [
| Likert scale items | Favourable attitudes | ||
|---|---|---|---|
| 10 - 14 years n(%) | 15 - 19 years n(%) | p | |
| It is hard to acquire birth control methods. | 181 (46.3) | 84 (47.1) | 0.751 |
| The sex with a condom is not good. | 184 (47.1) | 65 (36.7) | 0.177 |
| Using a birth control method control indicates a lack of confidence in your partner. | 189 (48.5) | 85 (48) | 0.923 |
| Using birth control methods increases commitment in the relationship. | 68 (17.4) | 26 (14.9) | 0.454 |
| I have difficulty talking about sex with my friends. | 205 (52.7) | 99 (55.9) | 0.475 |
| Hormonal contraceptives (pill or injection to birth control) affect female health. | 107 (27.7) | 51 (28.8) | 0.789 |
| The hormonal contraceptive is fattening. | 93 (23.8) | 30 (17) | 0.069 |
| After contraceptive methods are used, it is difficult to become pregnant. | 95 (24.3) | 42 (23.7) | 0.884 |
| Birth control should be a female concern. | 137 (35.3) | 64 (36.2) | 0.845 |
| Birth control methods provide more sexual freedom. | 224 (58) | 116 (65.9) | 0.076 |
| Pregnancy is more fattening than the use of hormonal contraceptives. | 240 (62) | 112 (64.7) | 0.538 |
| Birth control should be the responsibility of the couple. | 344 (88.4) | 163 (92.6) | 0.129 |
| It is important to know the methods of birth control even before starting sexual life. | 319 (82.2) | 155 (89.6) | 0.026 |
| There are no difficulties with using birth control methods. | 220 (56.7) | 104 (59.1) | 0.595 |
effectiveness depends on the discipline of users and contraception orientation from relations, which is not a reality of teen sexual practices, we can infer that even teens who say they use some method are exposed to a unplanned pregnancy. This inference is reinforced by various studies that indicate that even when contraception is used, adolescents frequently use a less effective method, such as condoms [
Cognitive competence has been identified as an important predictor of sexual and reproductive health [
These results indicate that even after initiation of sexual activity, there is no increase in adolescent knowledge of CM. Even among adolescents who declared knowledge of CM, there were a large number who have never used CM. These results reveal that adolescents are starting their sexual practices without enough knowledge to enable them to use contraception. These data reinforce the evidence that sexual initiation does not promote knowledge and use of CM. It is also consistent with a study that highlights the missed opportunities when it is expected to delay contraceptive orientation until adolescents become older or start a romantic or sexual relationship [
Positive attitudes towards CM are most likely related to the use of CM by adolescents [
Although the sample is not representative for a population-based study and does not allow for generalisation, the profile of participants displays the common characteristics of the strata of Brazilian adolescents in which there is the increasing prevalence of teenage pregnancy. In addition, the results reported contribute to highlighting that those adolescents at risk of pregnancy need programs to enable and motivate them to use contraception consistently and regularly.
Adolescents in northeastern Brazil, with social conditions similar to those groups at greater risk of pregnancy in adolescence, have initiated their sexual activity with knowledge and attitudes that limit the use of CM.
Even after sexual initiation, adolescents have little knowledge about the main contraceptive methods and pos- sess ambivalent and unfavourable attitudes towards the use of contraception. The knowledge, attitudes and practices of the both sexually active adolescents and adolescents who are likely to start their sexual practices suggest that there is a predisposition not using contraception. These data indicate a greater risk of unplanned pregnancy for these adolescents. We hope our results will contribute to the development of further studies that will be rep- resentative of the specific population in need of urgent intervention.
None of the authors have any conflicts of interest to disclose.
MCQ―Multiple-Choice Questions;
MC―Contraceptive Methods;
IUS―Intra Uterine Sistem.