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Womens' Reasons for Choosing the Pill, Patch, or Ring

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Womens' Reasons for Choosing the Pill, Patch, or Ring

Results


The CHOICE study (began in April 2009 and ended in October 2010) included 1730 HCPs. The HCP study logs from nine countries (HCPs in Israel and the Netherlands did not keep logs) indicated that 65,603 women consulted their HCPs for contraception during the study period. Of those women, 18,787 expressed an interest in starting or switching to a new CHC method and completed Part B of the study questionnaire. The target number of participants per country was exceeded (range, 1749–2629 women/questionnaires) in all countries except the Netherlands, where only 727 women were recruited. The mean age (± standard deviation) of participating women was 25.8 ± 6.4 years (Table 1).

Many characteristics, including education and full-time employment, varied considerably between countries. Prior to counseling, women were most likely to use COCs (41.8%), condoms (25.2%), natural family planning (5.5%) or no method (10.2%) (Table 1). COC and condom use varied widely between countries. Nearly one-fifth of women had experienced either unintended pregnancy, induced abortion, or both; rates of unintended pregnancy and induced abortion were especially high in Russia (both 40%) and Ukraine (48% and 45%, respectively) and low in Belgium (9% and 6%, respectively) (Table 1).

In the 11 countries combined, a statistically significant increase was noted in the proportion of women who chose the method after counseling versus those who intended to use it before counseling for the patch (+3.7%, 97.5% CI 3.3 to 4.2; P < 0.001; McNemar's test) and the ring (+21.7%, 97.5% CI 21.0 to 22.5; P < 0.001) (Figure 1). A statistically significant decrease in proportions was observed for the pill (−0.9%, 95% CI −1.7 to −0.2; P = 0.018), other combined methods (−3.1%, 95% CI −3.6 to −2.7; P < 0.001), and for women who were undecided regarding which method they preferred to use (−21.4%, 95% CI −22.1 to −20.7; P < 0.001). The difference in proportions for each individual country was also calculated.



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Figure 1.



Difference in proportions between women's selection of a contraceptive method after counseling versus before counseling (using questionnaires where both post-counseling and pre-counseling contraceptive choices were non-missing). Pill, combined oral contraceptive pill; patch, transdermal patch; ring, vaginal ring; other method, other contraceptive method; undecided, women did not show a preference for the pill, patch, ring, or other method. P < 0.001; 0.001 ≤ P < 0.01; 0.01 ≤ P < 0.05; not significant (P ≥ 0.05).





Reasons for choosing a method after counseling are shown in Table 2 and Additional file 1: Table S1. Women who chose the pill or patch after counseling were most likely to cite 'easy to use' as a reason that led to their selection. 'Regular menstrual bleeding' and 'relief from menstrual pain' were also often cited as a reason why women chose the pill. 'Nondaily administration' was the first and second most frequently given reason for selecting the ring and patch, respectively. 'Will not forget it' was cited by 56.8% of women who chose the ring and 53.1% of women who chose the patch compared with 21.7% of pill adopters. More than half (60.5%) of women who chose the ring did so because their doctor recommended it.

Reasons for choosing a method were similar in most countries. However, within certain countries, the most prominent reasons varied from the percentage in all countries combined by a statistically significant margin (P < 0.001 for each reason listed in this paragraph). In Ukraine, women who selected the pill were less likely to state 'daily use' as one of the reasons they selected the pill. Women in Russia and Ukraine who selected the pill were more likely to state they chose it because it was 'recommended by my doctor' and was a 'well-researched method'. If they chose the patch or ring, women in Russia and Ukraine were more likely to state that they selected these methods because they were 'not dangerous'. Conversely, women in Belgium and the Netherlands who selected the pill were less likely to cite 'well-researched method' as a reason for choosing it. In Austria, 'convenience' mattered to fewer women who selected the pill, patch, or ring. 'Convenience' also mattered to fewer women in Switzerland who selected the patch and ring. In the Czech Republic and Slovakia, women were more likely to cite 'weekly use' and 'monthly use' as reasons to choose the patch and ring, respectively. In the Netherlands, women were less likely to state they selected the patch and ring because they are 'easy to use'. In Poland, 'discretion' was more frequently given as a reason for women choosing the pill and ring relative to the percentage in all 11 countries combined.

Reasons for not choosing a method are shown in Table 3 and Additional file 1: Table S2. The top two reasons women did not select the pill included 'daily use' and 'will forget to take it'. Women who did not select the patch cited 'not discrete, visible' and 'can fall off'. For women who did not select the ring, 'don't like to use foreign body' and 'more convenient methods are available' were the most common reasons. For 21.8% of women who did not choose the ring, cost was a factor that led them to choose an alternative method.

Within certain countries, many of the reasons that women cited for not choosing the pill, patch, or ring varied from the (pooled) response across all countries combined by a statistically significant margin (P < 0.001 for each reason listed in this paragraph). In Belgium, Israel, and the Netherlands, women were less likely to cite 'daily use' as a reason for not selecting the pill. Women in Austria, Belgium, Israel, and the Netherlands were less likely to cite 'more convenient methods are available' as the reason they did not select the pill. In Poland, women who did not select the ring were more likely to state they were 'not interested in monthly contraception'. In Russia, women who did not select the patch were more likely to cite that the patch 'can irritate skin'. Women in the Netherlands were more likely to avoid selecting the patch because they did not know anybody else who used it. Women in the Czech Republic/Slovakia and Ukraine were more likely to cite cost as a reason for not choosing the ring. In Russia and Ukraine, women were more likely to state that they 'do not like to use a foreign body' as a reason for not choosing the ring. In contrast, women in Belgium, Sweden, and Switzerland were less likely to cite 'do not like to use a foreign body' as the reason for rejecting the ring. In Ukraine, women more often stated that their partner did not like the ring.

In Table 4, women's perceptions about the pill, patch, or ring after counseling are shown for all countries combined. While more than 90% of women strongly agreed that the pill 'prevents pregnancy effectively', fewer than 75% of women strongly agreed that the patch and ring do so. Although a lot more women strongly agreed that the pill had 'many side effects' than the patch or ring, approximately the same percentage of women strongly disagreed with this statement. About one quarter of women strongly agreed that the pill 'can be dangerous for your health', yet fewer than 10% of women had the same belief about the patch and ring. More women believed the pill was 'easy to use' and 'easy to forget' compared with the patch or ring. Women were also more likely to associate 'regular menstrual bleeding' with the pill than the patch or ring. More than 85% of women strongly agreed that many women use the pill, although only 15% had the same perceptions about the patch or ring.

We also looked at these perceptions in the subset of women who eventually selected the method concerned (Table 5). Although more women in the total sample agreed that the pill is effective compared with those who thought the patch or ring are effective (Table 4), the percentage who agreed that their selected method is effective were similar for all three methods. Women who selected the pill after counseling were more likely to believe that it had 'many side effects' (25.2%) compared with women who had chosen the patch (10.1%) or ring (6.7%). Although 18.3% of women believed that the pill 'can be dangerous for your health', one in three women who selected the pill 'did not know' or had 'no opinion' regarding its dangers. Nearly all women who chose the pill, patch, or ring felt that their method was 'easy to use'. More than half of women who chose the pill agreed that it is 'easy to forget'; this is in contrast to the 15.3% of women who chose the patch and 13.3% who chose the ring. Women believed that all three chosen methods provided good cycle control. More than 50% of women who chose the pill, patch, or ring 'did not know' or had 'no opinion' regarding whether the method they chose protected against some types of cancer.

We also looked at women's perceptions among those who did not choose the method concerned (Table 5). This analysis indicated that women most often agreed or strongly agreed with the statements about the pill (e.g. the method is effective, has 'many side effects', is 'easy to use', is 'easy to forget', provides regular cycle control, and is used by many women). While women who did not choose the patch or ring recognized that the patch and ring are effective, they often 'did not know' or had 'no opinion' about the other statements.

In Figure 2, results are shown from the multiple logistic regression models investigating the extent to which the probability of choosing a particular method (pill, patch, or ring) was related to women's perceptions about these methods. Women who agreed or strongly agreed that the pill is effective, 'easy to use', and that 'many women use it' had a higher probability (statistically significant at the 5% level) of choosing this method compared with women who had 'no opinion' or 'do not know' (the reference category). Women who disagreed or strongly disagreed that the pill has 'many side effects' and 'can be dangerous for your health' had a higher probability of choosing it compared with the reference category. Women who agreed that the patch is effective, 'easy to use', and that 'many women use it' or disagreed that it has 'many side effects' and is 'easy to forget' had a significantly higher probability of choosing it compared with women who had 'no opinion' or 'do not know'. Women who agreed that the ring is effective, 'easy to use', allows 'regular menstrual bleeding', and that 'many women use it' or disagreed that it has 'many side effects' and is 'easy to forget' had a significantly higher probability of choosing the ring compared with women who had 'no opinion' or 'do not know'. For the pill, patch, and ring, 'easy to use' was the strongest distinguishing factor between adopters and non-adopters.



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Figure 2.



Results of the multiple logistic regression analyses relating to a woman's likelihood of choosing the pill, patch, or ring to the perception statements about these methods. The models fit the data well (c-statistic was 0.795, 0.802, and 0.820 for the models for the pill, patch, and ring, respectively, which was considered acceptable to excellent discrimination). The likelihood of selecting the pill, patch, or ring is higher if the odds ratio (OR) is > 1 or lower if the OR is < 1 for women who 'strongly agree/agree' (or 'strongly disagree/disagree') compared with women who indicated they had 'no opinion' or 'do not know' about the perception statement in relation to the method. Two-sided 95% confidence intervals (CIs) are based on asymptotic normality of the OR estimates. The likelihood of selecting a method is higher (by a statistically significant margin at 5% level) if the lower limit of the CI is > 1. Conversely, the likelihood of selecting a method is lower (by a statistically significant margin at 5%) if the upper limit of the CI is < 1. If the CI contains 1, women who 'strongly agree/agree' (or 'strongly disagree/disagree') compared with those who had 'no opinion' or 'do not know' do not differ by a statistically significant margin with respect to the probability of choosing the method.





Agreement or disagreement with the statements the patch 'can be dangerous for your health' and enables 'regular menstrual bleeding' did not appear to relate to women's selection of the patch. In addition, agreement or disagreement that the ring 'can be dangerous for your health' had no relationship with selection of the ring. A woman's perception of the statement 'protects against certain forms of cancer' did not typically influence whether a woman chose a method, yet women who disagreed with this statement for the ring were less likely to choose it.

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