Despite widespread use of “the pill,” half of all pregnancies in the United States remain unplanned. Although nondaily contraceptive options offer a safe, effective alternative to oral contraception, these methods are not widely used.
A total of 18 women aged 18–23 years completed in-depth interviews. Data analysis included a grounded theory approach and constant-comparative method using open and axial coding to reduce the data and identify themes across the data.
Social norms, health uncertainty and limited knowledge emerged as barriers to use of nondaily contraceptive options. Participants understood birth control as “the pill,” and nondaily options were perceived as new and untested. Participants reported a lack of knowledge about the differences between methods and the effectiveness of nondaily options.
These findings offer practical suggestions to health communication campaign planners and health care providers to increase uptake of nondaily contraceptive options to improve method satisfaction and reduce unplanned pregnancies among young women.
Nondaily contraception; Young women; Decision-making; Knowledge, attitudes and practice; Birth control; Qualitative methods
In 1960, the Food and Drug Administration (FDA) approved the sale of the oral contraceptive pill in the United States, making last year the 50th anniversary of “the pill” . Despite widespread use of this highly effective form of birth control, half of all pregnancies in the United States remain unplanned . Although typical use of oral contraception has a failure rate of 8.7% , an analysis of data from the National Survey of Family Growth (2006–2008) found that women using oral contraceptive pills have continuation rates as low as 29% after 6 months . Scholars suggest that contraceptive discontinuation is attributed to method dissatisfaction . Nondaily contraceptive options offer an alternative to the oral contraceptive pill. Studies demonstrate that nondaily options are more effective than the oral contraceptive pill  and . Furthermore, studies suggest that nondaily contraceptive options are acceptable and easy to use for most women, including young women , , ,  and . Despite high rates of unintended pregnancy, reported lack of satisfaction with traditional methods and the success of nondaily options in studies and clinical trials, women in the United States continue to rely on the oral contraceptive pill and the condom as their primary method of birth control , ,  and .
Research indicates that women are increasingly familiar with a variety of contraceptive methods; however, women remain skeptical of pursuing a range of birth control options, and as a result, the contraceptive needs of women continue to be unmet . Nondaily contraceptive options, such as the patch, injection, implant, vaginal ring and intrauterine device (IUD), overcome many of the traditional barriers to appropriate, consistent use of daily methods , , ,  and . These options also address women's concerns about traditional daily methods, such as convenience . Little research has been done to understand why women reject nondaily contraceptive options, despite increased effectiveness of these methods and dissatisfaction with “the pill.”
College women, aged 18–24 years, have the highest rates of unintended pregnancies and induced abortions in the United States, which have largely been attributed to lack of contraceptive use . At least 80% of college females are sexually active and at risk of unintended pregnancy . In a quantitative study among college women at a large, public university, Huber and Ersek  found that of sexually active women, 77% reported using contraception and the most popular methods of contraception were oral contraceptives and male condoms. Among women younger than 30 years in the United States, “the pill” remains the most commonly used method of contraception . As a result, college women are in great need of access to effective contraceptive options.
This study seeks to explore the role of contraception in the lives of college women in order to provide recommendations to improve access to nondaily contraceptive options. Qualitative research is essential to understanding contraceptive use behaviors in order to create improved communication and promotion campaigns aimed at increasing use of nondaily methods  and . In this study, the focus is on understanding “how” and “why” uptake of nondaily contraceptive options occurs or fails to occur. In order to understand young women's knowledge, perceptions and use of nondaily methods, this study asks: How do female college students perceive nondaily contraceptive options?
2. Materials and methods
The research questions were investigated through in-depth interviews. Qualitative methods were essential for gaining a richer, detailed understanding of the role of contraception in the lives of female college students. Interviews were designed to be a “conversational partnership,” where the interviewer guided the conversation, while allowing new ideas and pertinent directions to emerge . In particular, this study examined participants' history of contraceptive use, satisfaction and dissatisfaction with contraceptive methods, and what is important to women when choosing a method of contraception.
College-age women, between 18 and 24 years of age, were eligible for participation in the study. Women of all races, ethnicities, sexual orientations, religions and abilities were eligible to participate. Initially, a convenience sample of students was identified through acquaintances, informal contacts and the research participant pool in the Department of Communication. To broaden sample diversity, snowball or chain-referral sampling was used to recruit additional participants by asking each respondent to invite or suggest new individuals who would be willing to participate in the study. Purposive sampling, which selects individuals based on predetermined criteria, helped maximize variation in the participants . All participants were enrolled in a large, urban, public university located in the mid-Atlantic region of the United States. All participants were informed about the nature of the project, about their potential participation and that participation was voluntary.
2.1. Data collection
The data collection procedure involved conducting in-person, individual interviews. The research protocol was reviewed and approved by the University Institutional Review Board. Interviews were conducted with participants at an on-campus location convenient to the participant. Interviews lasted approximately 1 h. With participants' permission, all interviews were recorded and transcribed for accuracy. Participants also completed a short, anonymous demographic questionnaire. After 18 interviews, no new concepts emerged, indicating a point of theoretical saturation in the data; therefore, no additional participants were recruited .
2.2. Interview guide
A semistructured interview guide provided structure to the conversation, while allowing participants to lead the discussion . Participants were first asked general questions about their daily routines, leisure time, personal health and media use. Then, general questions about contraceptive use were asked, such as “Could you tell me about a time when you discussed contraception with people in your life?” “What do you think about today's contraceptive methods?” and “Are there any methods of contraception that you know about but would never personally consider using?”
2.3. Data analysis
Analytical techniques from grounded theory methodology  provided an inductive approach to analysis, which honored the voices of participants and allowed their stories and understandings to emerge. A constant-comparative method was used throughout the data collection and analysis process to identify emerging concepts . Memos and observer comments were used to question researcher assumptions and biases in order to maintain reflexivity . Data were analyzed using open and axial coding to reduce the data and identify and relate concepts and themes across the data  and .
A total of 18 individuals completed in-depth interviews. Participants ranged in age from 18 to 23 years, and all participants were enrolled as students including first year, sophomore, junior and senior status. Student majors included Communication, Journalism, Economics, Psychology, Public Health and English. Prior to attending the university, students lived in Maryland, New Jersey, New York and China. Seven participants lived on campus, three participants lived in sorority houses, and eight participants lived off-campus. Participants were mostly white/Caucasian (14); however, some individuals were identified as Asian–American (1), Black (1), Hispanic/Latina (1) and Asian (1).
In the analysis, three primary themes emerged regarding young women's decision-making of nondaily contraceptive options: social norms, health uncertainty and limited knowledge. Themes and subthemes are presented with illustrative quotes in Table 1.
3.1. Social norms
3.1.1. Birth control as “the pill”
Participants equated contraception with the oral contraceptive pill. One participant said, “birth control means the pill.” Participants uniformly described birth control as “the pill.” Among participants, taking the oral contraceptive pill was the “cultural norm.” One participant said, “the pill has become such a norm, it's the first thing I think of.” Most of the participants' social system was “on the pill.” One participant noted, “everybody I know is on the pill.”
Participants felt that using the oral contraceptive pill was associated with their age group and attending college. One participant said, “college women tend to be on the pill, there are few who aren't.” According to another participant, “you do what your friends do, what you see most often is what you stick to. You don't go outside the box. Someone would have to give you the idea. A reliable source — doctor, friends, or family.”
Most of the participants talked with their family members about contraceptive options, either with their mothers or older sisters, or both. A couple of the participants mentioned that their mothers were against birth control; however, they were still able to use “the pill” for medical reasons, such as menstrual cramps or acne. Many participants chose “the pill” because their mother or older sisters used it. One participant said, “my mom was on the pill, so I said I'll get on the pill.” Participants were also influenced by their mother's ideas about nondaily contraceptive options. One participant currently using “the pill” said, “my mom thinks NuvaRing® is weird, she's ‘old school.’” Participants were strongly influenced by family members' opinions; however, the participants negotiated decisions about contraception by simultaneously distancing themselves from these views by describing them as “old school” or by seeking contraception for medical reasons.
Participants discussed a community around “taking the pill.” Each participant discussed the use of a cell phone alarm as a reminder to take “the pill” at the same time everyday. One participant said, “we are all on the pill, so it always comes up, we all have an alarm on our phones.” Many participants used this method and set the alarm at the same time as their friends, which provided additional social support around this contraceptive method. Despite a strong cultural bias in favor of “the pill,” participants knew that oral contraceptives are not 100% effective. Some participants mentioned that they knew someone who became pregnant while taking “the pill.” Despite these facts, participants still trusted this method of contraception. They did not view effectiveness as a problem.
3.1.2. Nondaily options signal irresponsibility
Participants expressed disillusionment with having to take “the pill” everyday. A common theme emerged around responsibility. One participant said, “you must be very organized and responsible to take it every day.” Yet, taking “the pill” everyday was problematic. According to one participant, “a lot of people forget, especially in college, your lifestyle doesn't make it easy to take [it] at the same time everyday.” In this way, nondaily options were more convenient as “the pill” became “uncomfortable because you have to stay to a schedule, if I forget, I freak out that it doesn't work the same.”
Participants emphasized the importance of being “responsible enough” to use oral contraceptives. One participant said, “I don't think other people are as serious as I am about taking it at the same time everyday.” Another participant said, “I'm perfectly happy taking a pill everyday, I'm not forgetful.” One reason that participants believed their friends used nondaily methods was because “they are bad about taking pills everyday.” Participants suggested that nondaily contraceptive options might be beneficial for people who can't remember to take “the pill” everyday, implying that nondaily methods are for people who are less responsible or forgetful.
3.1.3. Desire a “natural” cycle…with moderation
Seasonale®, the oral contraceptive pill that allows women to get only four periods per year, provided an opportunity for women to discuss their feelings about menstruation. Participants thought that this brand of oral contraceptive was “not as popular.” One participant thought it was “too good to be true.” Other participants suggested that “even when people are on the pill, they are still worried about pregnancy.” As a result, participants felt that a monthly period is a “reassurance,” and “getting your period is good, it is reaffirming. If I didn't get it, I would get scared.” Still, one participant found the idea of skipping periods “appealing.”
Although participants were skeptical of getting only four periods per year, they liked the ability to regulate their menstrual cycle with “the pill” and to know more consistently when they would get it. Still, participants expressed mixed and conflicting feelings about this control:
The pill is good for knowing when you are going to get your period, and you can skip a period. It's not bad, but it's not good. I've heard that it's not good for you. It's probably not good. But the doctor said it's not bad.
Similar concerns emerged around emergency contraception (EC). Although most participants and their friends had used EC, all of the participants felt that “you can't use it all time” and “you shouldn't rely on it” as a primary method of contraception. One participant said, “Lots of people have taken Plan B. I've heard it's not good for you, if you take it too many times, you can become infertile.” Other participants echoed this concern, noting that “it can cause problems” and citing examples of women who have taken it too often and are now “messed up” and “may never be able to have kids now.” Although participants were willing to use EC, they believed that if women use it “too much,” it could cause serious health problems.
3.2. Health uncertainty
3.2.1. Dual protection
Participants often equated contraception with disease prevention and described the use of hormonal contraception in tandem with a barrier method, the male condom. One participant said, “they've come a long way in preventing STDs and pregnancies, but no methods are foolproof.” Participants described the use of “the pill” and condoms as “the safest measure.” There was a general consensus that most college women are “careful [to use] condoms.”
3.2.2. Side effects and switching brands
Participants expressed concern about taking “the pill” consistently for a number of years. This concern led to peers' discontinuation of contraceptive use when they were not in a long-term relationship. However, participants were not worried about serious side effects of taking the oral contraceptive pill. According to one participant, “I haven't heard of people who didn't already have a condition” experiencing a stroke or other serious side effect. Another participant said, “blood clot, stroke, just doesn't apply at 21.”
Participants found most side effects associated with the oral contraceptive pill “frustrating.” The most common side effects were weight gain, moodiness and depression. Side effects led participants to switch between oral contraception prescriptions and to discuss different brands with their friends. Participants compared different brands of “the pill” and discussed side effects with their friends. Although all of the participants talked about using the Internet if they wanted to find out more about contraception, they also valued word of mouth, “asking around about personal experiences is just as helpful as the facts.”
3.2.3. Mistrust of “newer” nondaily options
Through a series of questions about contraception, participants revealed familiarity with nondaily contraceptive options. Despite this familiarity, participants expressed concern about how “new” nondaily contraceptive options may not be safe or “fully tested.” Participants perceived nondaily options as newer and were more hesitant to try them. One participant noted, “the NuvaRing® is more recent than the pill, more experimentative.” According to one participant, “I know enough people who have used the pill, it's more common. I would want to be on something that they know enough about, that they know about the side effects.” Participants trust “the pill” because they view it as an established method of birth control, while nondaily options were perceived as newer and experimental. One participant noted that “the pill” has “been around for a long time, so there must have been a lot of studies on it.”
3.2.4. Medical authority
Doctors were the most trusted source of information and advice about contraceptive methods. Many participants described a similar scenario of going to the doctor and asking for a prescription for oral contraceptives. One participant said, “I went to the doctor saying I want the pill, the doctor recommended a pill and said, ‘I'm going to prescribe you this,’ she didn't mention other options.” Two participants used the patch in high school at their doctors' suggestion, so that they wouldn't have to remember to take a pill everyday. These two participants subsequently switched to “the pill.” Only one participant had a conversation with her doctor about the various nondaily contraceptive options. All but one of the participants felt that doctors were their most trusted source of information because “they are schooled on it and they deal with women all day, so they have the most exposure.” Even participants who said they weren't interested in considering nondaily contraceptive options said that they would take a doctor's recommendation.
3.3. Limited knowledge of nondaily contraceptive options
Participants could not explain the differences between nondaily contraceptive options and the oral contraceptive pill. They made assumptions about the effectiveness of these options. Participants noted that they did not know the “science” behind the nondaily options; however, they perceived the effectiveness as the same as “the pill” or less effective. One participant said, “the pill is the most effective, other methods are less popular, so they must be less effective.” Other participants believed that nondaily methods were as effective as “the pill.” One participant said, “all hormonal methods work the same, when used properly, they are equally effective.” Participants did not see the differences between “the pill” and nondaily methods.
3.3.2. Mechanism of action
Participants were most familiar with the ring and the patch, followed by the injection and the implant. Participants had friends that used the ring, the patch and the injection. None of these participants knew anyone who had used the implant.
Although all participants were aware of the ring, this nondaily method was the most nebulous in how they understood and interpreted it. Most participants knew that the ring was something that you didn't have to think about everyday; however, they discussed a variety of ways that the ring might work. Some of the participants accurately said, “the NuvaRing® is inserted monthly, vaginally, not everyday, just once per month,” noting that “you physically put it in for three weeks, then take it out to get your period” and that “you can do it yourself.” Other participants thought that a doctor had to insert it once a month. These participants were unsure about how or where it was inserted. Other misconceptions included the actual substance of the ring (one participant thought it might be “a plastic film or something”) as well as where you would need to store the ring at home: “it has to be refrigerated.”
Aside from these misconceptions, participants expressed other concerns about the ring. One common concern was that it could fall out: “if it could fall out, I would be worried about putting it in right.” Overall, participants expressed mixed feelings about the ring. Participants thought the ring was “a little scary,” “it seems weird for me,” “uncomfortable, just physically gross,” and one participant said, “it didn't seem easy enough, someone would have to show you how to use it, and that would be uncomfortable.” Other participants thought that the ring would be “easy to maintain” and “more reliable.”
Friends' experiences with the ring were divided. Most of the participants heard positive things about the ring. They said, “I've heard people say great things about it” and “my friends love it.” One participant said, “I know people who are on it and love it. It's convenient. They don't have to worry about it. They don't mind it, it doesn't bother them, they can't feel it.” Another participant said, “I've heard you don't really know it's there.” Participants also heard negative comments about the ring, including “I heard NuvaRing® falls out,” “I've heard of friends using it that didn't like it, it was uncomfortable” and “my roommate uses NuvaRing® and she said it's uncomfortable and difficult to use when having sex.”
Participants described the patch as a hormonal method of birth control, in which the method of delivery was a patch placed directly on the skin. Two participants had used the patch in high school; however, they were not satisfied with this method. One said, “I was young, I had to change it once a week and it hurt to put it on and take it off. It was strange, I didn't like it.” Other participants echoed this idea, “I wouldn't want a patch on my skin.” One participant mentioned a friend who used the patch, “she said it would show, she only used the patch because taking the pill wasn't an option.” Participants expressed concern about the aesthetic and functional components of this nondaily method. Participants said, “I would be nervous it would fall off or get damaged” and “it would be easy to come off or get tampered with, and that could affect absorption, and it might itch or something.”
Participants felt strongly in favor or against the injection. Participants noted that in order to use the injection, you have to be okay with needles, maintain a good relationship with a doctor and have transportation to visit the doctor's office every 3 months for the injection. Participants thought these requirements were either “easy” or “a lot of work.” Some participants were interested to learn more about this option, which they viewed as “reliable,” while others ruled it out because “I'm not a needle person” or “I just don't like needles.” Participants perceived stronger irregular reactions to the injection. One participant said, “my friend was taking the shot, once every 3 months, and there was this hormone overload, she went a little crazy.” Participants viewed the injection outside the mainstream of contraceptive options because it lacked individual control and required frequent visits to the doctor. According to one participant, “I would never use [the injection] — it would be difficult to get a shot from a doctor every 3 months.”
Participants thought that the implant was a more permanent method of birth control. One participant said, “it is hormonal, it's effective, you don't have to worry about it everyday, but there is a thing under your skin.” Participants acknowledged that “it is medically inserted, you have to go in and get that done.” Participants thought that this method “doesn't sound pleasant” and “it weirds me out.” Despite this overall negative view of the implant, participants didn't completely rule it out. One participant said, “at certain stages in life, maybe, but not for right now.”
3.3.3. Perceived benefits of nondaily methods
Participants evidenced a mixed perception of the advantages of nondaily options. Overall, participants were not willing to rule out any nondaily methods, but one participant said, “they seem out of my comfort zone, personally.” Participants felt that nondaily options would be more convenient. At the same time, nondaily methods were perceived as high complexity. As described above, participants reported a lack of knowledge about the differences between methods and the effectiveness of nondaily options. Perhaps as a result of the perceived complexity, participants viewed nondaily methods as too similar to the oral contraceptive pill to warrant consideration. They did not see the benefits of nondaily methods.
Participants were satisfied with their current method; they were “set on the pill.” Participants did not think that they would switch to a nondaily method. One participant said, “I am set on the pill, I know the most about it, I am happy with it.” Participants found “the pill” comfortable and familiar. They noted, “there is no reason to get off it for another method.” Participants described inertia, “I'm not sure I would bother with the others.”
Eighteen in-depth interviews were conducted to explore young women's attitudes and perceptions of nondaily contraceptive methods. To summarize, barriers to use of nondaily contraceptive options emerged regarding social norms, health uncertainty and limited knowledge. Participants believed that birth control was synonymous with “the pill,” and nondaily options were perceived as new and untested. Participants reported a lack of knowledge about the differences between methods and the effectiveness of nondaily options. In addition to avoiding pregnancy, participants were equally concerned with disease prevention and engaged in dual protection. Friends and family were the most influential source of messaging about nondaily contraceptive options, while doctors were the most trusted source of information about contraception.
Barriers to use of nondaily contraceptive options emerged regarding social norms, health uncertainty and limited knowledge. Social norms influenced participants' decision-making regarding nondaily contraceptive options, including understanding birth control as “the pill,” believing that nondaily options signaled irresponsibility, and desiring a “natural” menstrual cycle with the ability to control timing and frequency of monthly periods. Beliefs regarding female reproductive health and sexuality determined acceptable behavior and appropriate forms of contraception. In particular, young women connected the convenience of nondaily options with irresponsibility. This finding builds on previous research, which found that perceptions of responsibility played an important role in the use and provision of EC among young women and health care providers . Participants were most comfortable with the traditional 28-day cycle oral contraceptive pill. This finding contributes to research explicating beliefs surrounding “natural” menstruation and the role of hormones in contraception .
Health uncertainty emerged in participants' understanding of dual protection, side effects causing switching between brands, mistrust of “newer” nondaily options and the role of medical authority in contraceptive decision-making. Findings revealed dissatisfaction with traditional contraceptive options. Although participants understood that oral contraceptives were not 100% effective and knew people who became pregnant while taking “the pill,” nondaily contraceptive options were not seen as a solution to these problems. Instead, participants relied on dual protection, using a condom when they were not in a monogamous relationship. This finding reflects recent research highlighting the discontinuous nature of contraceptive use based on current partner . Participants discussed the “frustrating” side effects of oral contraceptive pills and revealed the common practice of switching between brands of pills. Although nondaily methods, such as the ring, have been approved by the FDA for at least 10 years, participants still felt that nondaily options were “new” and “untested.” However, participants suggested that they would be willing to try nondaily options at the recommendation of their doctor, which reflects research that revealed limited conversations between health care providers and patients about contraceptive options  and studies that found that counseling by a health care provider could increase awareness of nondaily methods and improve consistency between method and reasons for initiating contraception ,  and .
Participants exhibited limited knowledge of differences between methods in terms of effectiveness and mechanism to prevent pregnancy. This lack of knowledge impacted their perceptions of the benefits of nondaily methods. Although most participants could identify friends who were happy using a nondaily method, they had mixed feelings about the acceptability of these methods. This study found inertia among female college students who didn't want to take a pill everyday, but couldn't see themselves trying a nondaily method. These results reflect previous demographic research, which illustrated the strong preference of “the pill” among women under 30 years  and found that willingness to use nondaily contraceptive options was negatively associated with currently using the oral contraceptive pill .
These findings also suggest practical opportunities to increase uptake of nondaily contraceptive options. Health campaign planners should consider college students as a critical audience for prevention of unplanned pregnancies. Findings suggest that messages should emphasize the increased effectiveness of nondaily methods. Campaign planners should address young women's concerns regarding the testing and long-term use of nondaily options. Improving interpersonal communication between health care providers and patients offers an opportunity to address these concerns. Finally, campaign planners must understand social norms surrounding nondaily options. In particular, campaigns may be ineffective when they emphasize the convenience of nondaily methods because young women perceive responsibility as a key social norm around birth control, leading nondaily methods to be stereotyped as a solution for “irresponsible” women.
Qualitative methods provided an opportunity to gain in-depth understandings of female college students' attitudes and perceptions of nondaily contraceptive use. However, there were several limitations to this study. The study was conducted at a large mid-Atlantic public university and cannot be generalized to other populations. The sample was fairly homogenous; therefore, a greater number and more varied participants would have contributed to understanding of this complex subject. However, previous research found no significant difference in contraceptive use and attitudes between female college students by race, age, marital status, years of college education and income . Thirteen of 18 participants (approximately 72%) had ever used the oral contraceptive pill. While these participants may have been predisposed to favor “the pill,” this percentage mirrors national trends, where 82% of women in the United States have ever used the oral contraceptive pill . Although the interview guide treated all nondaily contraceptive methods equally, most participants focused on the ring in our discussions and did not mention the IUD. Future research should address the disparity among different nondaily options. Following the completion of this study, in July 2011, the American College of Obstetricians and Gynecologists published new clinical guidelines for the IUD, removing restrictions for nulliparous women and adolescents, providing an opportunity for future studies to explore college women's opinions about the IUD . This study offers practical aims to target health communication campaigns to improve access and uptake of nondaily contraceptive options in an effort to increase method satisfaction and reduce unplanned pregnancies among young women in the United States.