The use, knowledge and attitudes regarding hormonal contraceptive products of female first-year students in a Faculty of Health Sciences The use, knowledge and attitudes regarding hormonal contraceptive products of female first-year students in a Faculty of Health Sciences PM van Zyl*, C Brisley, L Halberg, M Matthysen, M Toerien and G Joubert Department of Pharmacology, University of the Free State, Bloemfontein, South Africa *Corresponding author, email: vzylpm@ufs.ac.za Background: Effective contraception plays a major role in the economic advancement of women. New hormonal products offer more effective solutions with fewer side effects. This study aimed to assess the use, knowledge and attitudes regarding hormonal contraception of female first-year students across various health profession courses. Methods: A descriptive study was conducted during August to October 2017 targeting all female first-year students of the Faculty of Health Sciences at the University of the Free State. Results: Self-administered anonymous questionnaires were completed by 261 students (response rate 81.6%). At the time of the study, 29.6% of the study population reported using hormonal contraceptive products; 51.7% of users cited acne as the indication. Among users of hormonal contraceptives, combined oral contraception was the most commonly used (86.0%), and was regarded as the most effective (33.2%). A third of the students (36.2%) were aware that some medication could influence the effectiveness of combined oral contraception. Half (52.3%) had no knowledge of the subdermal implant and 34.8% did not know what an intrauterine system was. According to 28.2%, post-coital use of hormonal products is not an acceptable method of contraception. Almost 90% (87.3%) indicated that an education intervention regarding hormonal contraception is needed at the university. Conclusion: The study population lacks detailed and sufficient knowledge of critical aspects of contraception, such as relative effectiveness, and factors that affect these; long-acting reversible contraceptives; and emergency contraception. A formal education intervention is proposed. Keywords: emergency contraception, hormonal contraceptives, long-acting contraceptives, university students Introduction The introduction of oral hormonal contraception and its wide- spread acceptance revolutionised the lives of women across the globe. The seminal work of Bailey, Hershbein and Miller1 described how oral hormonal contraception gave women control over their reproductive function, resulting in greater equality and economic freedom. The ability to postpone the first pregnancy allowed many women to complete their edu- cation; the ability to space their pregnancies allowed them to pursue a career, thus shrinking the wage gap between sexes. Economists2 regard the implementation of effective contracep- tion as primarily an economic intervention with health impli- cations. Costing of health benefits such as reduction in child and maternal mortality shows these costs to be considerably lower for sub-Saharan Africa than for other developing regions.2 The topics of the use, knowledge and attitude towards con- traception among young women are commonly investigated in economically disadvantaged groups in developed countries3–4 as well as in developing nations,5 including South Africa.6–8 The range of hormonal contraceptive methods has expanded to include products that are specifically formulated for the treat- ment of acne and long-acting reversible contraceptives (LARCs), as well as emergency contraception.9 Hormonal pro- ducts are commonly used as a treatment for acne, to regulate the menstrual cycle and to manage dysmenorrhea. Many ado- lescent girls and young women are therefore using these pro- ducts, even before becoming sexually active.9–11 Acne-specific hormonal contraceptive products include anti-testosterone agents, cyproterone acetate and drospirenone, which are effec- tive methods of contraception.9–11 Progestogen-only injection remains a popular method for pro- viding affordable long-term control of fertility in South Africa and was the only coitus-independent method that was widely available, provided free of charge at government clinics.6–8 However, it is associated with delayed return of fer- tility and other adverse effects. New LARCs provide effective contraception options that are less dependent of compli- ance.12 Intrauterine devices (IUDs) remain effective for five years. These products prevent fertilisation by disrupting sperm migration and trigger a foreign-body reaction in the endometrium to prevent implantation.2 Intrauterine systems (IUSs) release small amounts of progesterone that change the composition of the cervical mucus.9,12 In some cases the system even suppresses ovulation. The South African Govern- ment launched a sub-dermal implant-based programme in 2014, providing these hormonal devices free at state hospi- tals.13 Once implanted, the system provides effective contra- ception for three years. Emergency contraception is taken post-coitally to prevent preg- nancy, often in cases of unprotected coitus such as rape and condom breakage.9,14 The awareness of emergency contracep- tion is low among South African women, though, and its use stigmatised.14 Regimens for emergency contraception entail either high doses of combined oral hormonal contraception, high-dose progesterone-only containing products, anti-proges- tin tablets or the insertion of a copper-releasing IUD. South African Family Practice 2019; 61(5):190–196 https://doi.org/10.1080/20786190.2019.1643197 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC 4.0] http://creativecommons.org/licenses/by-nc/4.0 S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2019 The Author(s) ARTICLE South African Family Practice is co-published by NISC (Pty) Ltd, Medpharm Publications, and Informa UK Limited (trading as the Taylor & Francis Group) mailto:email: vzylpm@ufs.ac.za http://crossmark.crossref.org/dialog/?doi=10.1080/20786190.2019.1643197&domain=pdf&date_stamp=2019-09-23 http://creativecommons.org/licenses/by-nc/4.0 The safe and effective use of hormonal products requires the user to have sufficient knowledge regarding available options, proper administration, and common and serious side effects. Oral hormonal contraceptives are schedule 3 drugs in South Africa and require a prescription from a doctor as well as pro- fessional intervention during dispensing.15 Emergency contra- ception can, however, be obtained from healthcare providers without a prescription.14 School curricula include sex education. The question, however, remains as to whether school-leaving youth have adequate knowledge of hormonal contraception to manage their own reproductive function. Female students studying for a healthcare profession represent a group that might benefit from contraceptive use, while they at the same time are developing a repository of knowledge for future healthcare users. This population thus provides an oppor- tunity to study the state of current knowledge, attitudes and practice among a unique sub-group of young women and even- tually may provide a basis for how transfer of knowledge regard- ing hormonal contraception may proceed. Aim of the study The aim of the study was to assess the use, knowledge and atti- tudes regarding hormonal contraceptive products of first-year female students across various health profession courses in the Faculty of Health Sciences, University of the Free State (UFS). Specific objectives were to assess aspects of personal use, knowledge of critical aspects of hormonal contraceptives and attitudes regarding the use of these products. Such knowl- edge may help to determine whether the student population could serve as a conduit of knowledge regarding the use of hor- monal contraceptives to their peer group. Methods Study design A descriptive study was performed. Setting The Faculty of Health Sciences at the University of the Free State consisted of three schools at the time when the research was conducted: The School of Medicine; the School of Nursing and the School for Allied Health Professionals. All three schools were included. Selection of participating students The target population included all female first-year students of the Faculty of Health Sciences in 2017, and comprised 320 stu- dents from the following courses: Medicine (n = 114), Radiation Science (n = 4), Physiotherapy (n = 22), Nutrition and Dietetics (n = 12), Biokinetics (n = 11), Occupational Therapy (n = 42), Optometry (n = 25) and Nursing (n = 90). Students who were willing to complete the questionnaire were included in the sample. An age limit for inclusion was set at 18– 35 years to ensure homogeneity. Students who were not present during the distribution and completion of the questionnaires were excluded. Data collection and tools Development and validation of the questionnaire Participants completed an anonymous self-administered ques- tionnaire in English. The questionnaire was compiled by the research team using information obtained from the literature. The questionnaire contained limited demographic data to ensure anonymity. It covered items to ascertain personal use and related aspects, items to determine knowledge regarding key aspects of hormonal contraception, as well as items aimed at testing their attitude regarding hormonal contraception, dis- cussing this with others and the need for formal intervention. Ten second-year female medical students participated in a pilot study to test the application of the questionnaire. Participants were asked to comment on the intrusiveness and clarity of the questions. Data collected during the pilot study remained confi- dential and were not included in the main study. Recruitment of study population and administration of questionnaire The questionnaire was distributed to potential participants during August to October 2017 for immediate completion. A classroom setting was selected for data collection. Convenient timeslots on each of the different time schedules of the various disciplines were identified with the help of the class leader and the research team. Permission was obtained from the respective lecturers to engage with students after a lecture. Completed questionnaires were deposited in empty sealed boxes. Data management Data were entered into an Excel spreadsheet (Microsoft Corp, Redmond, WA, USA). The answers were checked for consistency and contradictory answers were marked as missing data. Since not all students answered all of the questions, the number of participants for each question and each option are indicated in the Results section (for example, 66/211 indicates that 66 of the 211 students who responded to the question chose a specific option). Data analysis Data analysis was performed by the Department of Biostatistics, Faculty of Health Sciences, UFS using SAS version 9.4 (SAS Institute, Cary, NC, USA). Results were summarised by frequen- cies and percentages for categorical variables and medians and interquartile ranges (IQR) for numerical variables due to skew distributions. Ethical considerations The protocol was approved by the Health Sciences Research Ethics Committee, UFS (HSREC-S 26/2017) and adhered to the Declaration of Helsinki. Permission was obtained from the Dean of the Faculty of Health Sciences, the Heads of the School of Medicine, School for Allied Health Professions and School of Nursing, respectively, the Dean of Student Affairs and the Vice-Rector of Research of the UFS to conduct the study. An information leaflet was distributed to the students stating that participation in the study was voluntary, that non- participation would not be held against the person in any way, that completion of the questionnaire implied consent and that participants could suspend participation at any time. Results Of the 320 first-year female students, 261 completed the ques- tionnaire (response rate 81.6%). Almost half (46.5%) of the par- ticipants were 19 years of age, ranging between 18 and 26 years (median age 19 years, IQR 19–29). The use, knowledge and attitudes regarding hormonal contraceptive products of female first-year students in the Faculty of Health Sciences 191 The highest percentage of participants (40.6%) was enrolled in Medicine followed by Nursing (28.0%). The response rates per course ranged between 50.0% and 100.0% (Table 1). Personal use of contraceptives A third (31.3%, 66/211) of participants reported that they had used hormonal contraceptives in the past and 29.6% (60/203) were using hormonal contraceptives at the time of the study. Only 2.3% (6/219) of all participants reported that they had ever used emergency contraception. Of these six individuals, five had used it twice or more. Of the 134 participants who reported that they were not cur- rently using hormonal contraceptives, 73.9% (n = 99) stated ‘not sexually active’ as reason, 14.2% (n = 19) used other forms of contraception, and 16.4% (n = 22) listed costs, effort of taking pills, stigma associated with the use thereof and embar- rassment to talk to a healthcare worker. Half (51.7%, 31/60) of the participants currently using hormonal contraceptives cited acne as the reason for the use of the pro- ducts. Other reasons given included menstrual cycle regulation (36.7%, n = 22) and menstrual pain (28.3%, n = 17). Less than a quarter (23.3%, n = 14) stated preventing pregnancy as the reason. Participants using hormonal contraception reported having started to use hormonal contraceptives between the ages of 12 and 26 years (median 17 years, IQR 16–19). Almost half (47.7%, 31/65) of the participants had been using hormonal contraceptives for less than 12 months followed by 26.2% who had been using hormonal contraceptives for 12–23 months. The main type of hormonal contraception used was combined oral contraceptive pills (Table 2). With regard to compliance, 77.0% (57/74) of participants took their oral contraceptive pill at more or less the same time each day, 21.6% (n = 16) took it at the same time, and 1.4% (n = 1) took it at different times. Most (61.2%, 30/49) reported that they never forget to take their contraceptive pill; 32.7% (n = 16) said that they forget one pill a month, while 6.1% (n = 3) forget to take their pill at least twice a month. More than half (55.1%, 27/49) would ingest two pills if they forget to take their pill and 42.9% (n = 21) would carry on with the rest of the month’s supply. Side effects reported by participants on hormonal contraception included weight gain (44.4%, 20/45), mood swings (28.9%, n = 13), breast tenderness (26.7%, n = 12), increased appetite (24.4%, n = 11) and headaches (22.2%, n = 10). Less than 20% reported nausea, water retention, spotting between periods, depression, and darkening of freckles or skin on the face. Of the participants who indicated that they were sexually active, almost half (47.6%, 30/63) reported that their sexual partner encourages the use of hormonal contraception. A quarter (25.4%, n = 16) each reported that their partner was either neutral about hormonal contraception use or they did not know how their partner felt about this. Only one (1.6%) student’s partner disagreed with using any form of contraception. Knowledge of contraceptives The majority of participants (70.4%, 183/260) perceived their own knowledge regarding contraceptive methods as ‘moder- ate’, 18.5% (n = 48) regarded their own knowledge as ‘very little’, and 11.2% (n = 29) ‘a lot’. As shown in Table 3, the highest percentage of participants believed that combined oral contraception is the most effective hormonal contraceptive in preventing pregnancy. Only a few individuals knew that the correct answer for how long, after unprotected sex, emergency contraception is still effective in preventing pregnancy is within 5 days. Almost half of the partici- pants felt that these products would still be effective in prevent- ing pregnancy when one pill is skipped. More than half were unsure about whether other medications might lower the effec- tiveness of hormonal contraceptives. Most participants (89.6%, 232/259) learnt about contraceptive methods in high school. Almost half of the participants reported that they had been informed about a subdermal contraceptive implant that releases Table 1: Current course that participants were enrolled in (n = 261) Current course Frequency (n = 261) Population (n = 320) Response rate per course (%) Percentage of participants (%) Medicine 106 114 93.0 40.6 Radiation Science 2 4 50.0 0.8 Physiotherapy 13 22 59.1 5.0 Nutrition and Dietetics 10 12 83.3 3.8 Biokinetics 11 11 100.0 4.2 Occupational Therapy 27 42 64.3 10.3 Optometry 19 25 76.0 7.3 Nursing 73 90 81.1 28.0 Table 2: Type of hormonal contraceptive product used by participants at the time of study (current users) and by the participants who were not currently using contraceptive products (past users) Type of hormonal contraception Current users* (n = 57) Past users* (n = 52) n % n % Oral contraceptive pills 49 86.0 45 86.5 Post-coital contraception 0 0 6 11.5 Implant 2 3.5 1 1.9 Injection 6 10.5 6 11.5 Intrauterine system 1 1.8 0 0 *Participants, either current or past users, could select more than one option for the type of product used, for example oral contraceptives as well as emergency contraception. 192 South African Family Practice 2019; 61(5):190–196 progesterone (Table 4). Of these, 41.1% correctly noted that it was effective in preventing pregnancy for more than a year. Only 21.1% of the participants claimed to know how an intrau- terine system works. Of these, 73.1% correctly stated that the system is effective in preventing pregnancy for more than a year. Almost 90% of participants did not know the difference between an intrauterine system and an intrauterine device. Personal attitude and opinions concerning hormonal contraceptives Just over half (54.4%, 141/259) of participants reported that emergency contraception is only acceptable when used as an emergency contraceptive. More than a quarter (28.2%, n = 73) found this unacceptable while 17.4% (n = 45) felt that this was an acceptable method of contraception. Regarding the discussion of hormonal contraception with differ- ent parties (Table 5), a minority of participants indicated that they would be unable to discuss matters regarding contracep- tion. Participants expressed higher levels of confidence in more informal relationships. A similar trend appeared for discus- sion of sexual issues. The vast majority of participants (87.3%, 227/260) indicated that they think an education intervention regarding hormonal con- traception is needed at UFS. Discussion The current study shows that 60 (23.0%) of the study population of 261 female students at the Faculty of Health Sciences at the UFS currently use hormonal contraceptive products. Only 14 (23.3% of users) claimed to use these for contraception pur- poses, while 19 (7.3% of the total population) indicated that they use ‘other forms of contraception’. Twenty-two (8.4% of the total population) indicated that they do not use hormonal contraception due to shyness, effort to obtain the product or Table 3: Knowledge of hormonal contraceptives including combined oral contraception (‘the pill’) and emergency contraception (‘the morning after pill’) Questions n % According to your knowledge, what type of hormonal contraceptive is the most effective in preventing pregnancy? (n = 244)* The ‘pill’ 81 33.2 The ‘morning after pill’ 15 6.2 Implant 57 23.4 Injections 61 25.0 Intrauterine system 47 19.3 How long after unprotected sex can someone take the morning after pill to effectively prevent pregnancy? (n = 259) I don’t know 72 27.8 Within 24 hours after unprotected sex 103 39.8 Within 48 hours after unprotected sex 25 9.7 Within 72 hours after unprotected sex 54 20.9 Within 5 days after unprotected sex 3 1.2 Within 7 days after unprotected sex 2 0.8 Do you know about the side effects of the hormonal contraceptive you are using? (n = 59) Yes, I know all about all the possible side effects 23 39.0 I know a lot of the side effects 14 23.7 I know of a few side effects 19 32.2 I am not aware of any possible side effects 3 5.1 How effective is the pill? (n = 258) It is 100% effective in preventing pregnancy 17 6.6 It reduces the chances of getting pregnant dramatically 197 76.4 It reduces the chances of getting pregnant slightly 42 16.3 It does not prevent pregnancy at all 2 0.8 If someone forgets to take the pill for one day, will the pill still prevent pregnancy? (n = 260) Yes, it will still be 100% effective 4 1.5 The chances are good that the pill will still be effective 119 45.8 There is a slight chance that the pill may be effective 108 41.5 No, the pill is definitely not effective when skipping a day 29 11.2 Is the pill effective when used with other medication? (n = 260) Not sure 144 55.4 Yes, it will still be effective when taking other medication as well 18 6.9 I know of some medication that may lower the effectiveness of hormonal contraceptives 94 36.2 All other medication lowers the effectiveness of hormonal contraceptives 4 1.5 *More than one option could be selected. Table 4: Knowledge of the subdermal contraceptive implant and intrauterine system Questions n % Have you been informed of a subdermal (under the skin) contraceptive implant releasing progesterone? (n = 239) Yes 114 47.7 If you have heard of this device: (a) How long do you think it is effective in preventing pregnancy? (n = 112) A week 4 3.6 A month 6 5.4 Three months 25 22.3 Six months 18 16.1 A year 13 11.6 Longer than a year 46 41.1 (b) Where did you hear about this device? (n = 114)* In school 38 33.3 From parents 9 7.9 From friends 50 43.9 Other 24 21.1 Do you know what an intra-uterine system is? (n = 247) I don’t know what it is 86 34.8 I have heard of it, but am not sure of how it works 109 44.0 I know how it works 52 21.1 If you do know what an intra-uterine system is, how long is it effective for prevention of pregnancy? (n = 52) A week 1 1.9 A month 0 0 Three months 4 7.7 Six months 3 5.8 A year 6 11.5 Longer than a year 38 73.1 Do you know what the difference between an intra- uterine system and an intra-uterine device is? (n = 258) Yes 28 10.9 *More than one option could be selected. The use, knowledge and attitudes regarding hormonal contraceptive products of female first-year students in the Faculty of Health Sciences 193 costs involved. Ninety-nine (37.9% of the total population) stated that they did not need contraception because they were not sexually active. In a population-based survey, MacPhail et al.6 reported that of 6217 South African women between the ages of 15 and 24, two-thirds were sexually active of whom 52.2% used contracep- tion. They reported an association between using contraceptives and being employed or being a student. Among contraceptive users, 25.5% used male condoms and 66.6% only hormonal con- traceptives, while 6.8% used dual methods. In another popu- lation-based survey across four provinces in South Africa among sexually active youth (n = 3 123), Seutlwadi et al.7 found 89.1% of sexually active women using contraception, 57.6% using male condoms, 25.6% using injectables, 5.2% IUDs and 5.5% emergency contraception. In a study by Coetzee and Ngunyulu16 comprising 400 female undergraduate students at a Gauteng tertiary institution, 74% of participants were sexually active, of whom 79% used contra- ception: oral contraceptives were preferred by 38% and male condoms by 25%. An earlier study by Oyedeji and Cassimjee17 among university students at KwaZulu-Natal showed a prefer- ence for male condom use among unmarried female students due to the stigma of using pills or visiting the clinic for injections. The current study population therefore shows a relatively low percentage of participants being sexually active compared with both population-based studies and studies involving undergraduate female students elsewhere in the country, with relatively high use of hormonal contraceptive products and a high percentage of participants using oral hormonal contracep- tives for medical reasons. The preference for oral hormonal contraception in the current study is in line with the claim of medical use of hormonal pro- ducts and is similar to the trend in Gauteng students,16 where oral hormonal products are preferred. Knowledge of hormonal contraception Most of the participants (70.4%) regarded themselves as having ‘a moderate amount of knowledge’ regarding hormonal contra- ception and 18.5% admitted to having ‘very little knowledge’. The wide range of methods of population selection and ways of reporting results complicate direct comparisons with other studies done in the region. The study by Chersich et al.8 found that a large proportion of South African women, especially younger ones, have never heard of IUDs and emergency contraception. Indongo18 reported on the knowledge with regard to contraceptives among sexually experienced Namibian women aged 15–24 years. Most of these participants knew about the pill and inject- ables, while 50–55% knew about male condoms. In another neighbouring country, Akintade et al.19 conducted a survey among undergraduate students at a university in Lesotho. Of the 360 participants, 95% knew about condoms; 79.2% about the pill; 75.6% about injectables; and 61.4% about emergency contraception. In comparison, the current study population were aware of the majority of methods, yet lacked knowledge when more detailed questions were asked. Participants ranked combined oral con- traceptives as the most effective form of hormonal contracep- tion, followed by the injectable hormones. In fact, subdermal implants and IUSs are more effective than combined oral contraception.9,12 A considerable percentage of participants may be at risk of unin- tended pregnancies because of contraceptive failure, as only 36.2% of participants knew that some medication, such as anti- biotics, certain diet pills and tuberculosis medication could lower the effectiveness of hormonal contraceptives.9 Participants knew about LARCs, yet lacked detailed knowledge. Over 61% of the total study population had heard of IUSs, yet 90% did not know how it worked or what the difference is between an IUD and an IUS. Just over half (52.3%) of participants in the current study were informed about the subdermal hormonal implant provided at state hospitals.13 Only 41.1% of these knew that this device is effective for more than one year. Eisenberg et al.20 reported that women who selected IUDs and implants were more likely to have accurate knowledge concer- ning the effectiveness of their method of contraception, while Table 5: Participants’ confidence in discussing hormonal contraception and sexual issues with different parties Factor With a doctor With patients With fellow students With friends n % n % n % n % Hormonal contraception: n = 258 n = 258 n = 256 n = 259 I will not be able to 17 6.6 17 6.6 13 5.1 13 5.0 I will discuss only the most necessary 56 21.7 32 12.4 48 18.8 25 9.7 I will be uncomfortable but will discuss if needed 61 23.6 40 15.5 46 18.0 34 13.1 Cautious but confident 55 21.3 80 31.0 79 30.9 69 26.6 Very confident to discuss in detail 69 26.7 89 34.5 70 27.3 118 45.6 Sexual issues: – n = 258 n = 258 n = 258 I will not be able to – – 18 7.0 24 9.3 19 7.4 I will discuss only the most necessary – – 37 14.3 64 24.8 39 15.1 I will be uncomfortable but will discuss if needed – – 73 28.3 56 21.7 40 15.5 Cautious but confident – – 73 28.3 68 26.4 74 28.7 Very confident to discuss in detail – – 57 22.1 46 17.8 86 33.3 194 South African Family Practice 2019; 61(5):190–196 60% of users of contraceptive pills and condoms overestimated the efficacy of their method of contraception. In a society where rape is common, knowledge regarding emer- gency contraception is vital. Only 1.2% of the 259 participants in the current study were aware that emergency contraception is effective for up to five days after unprotected sex. Six students reported having used emergency contraception. The study of Coetzee and Ngunyulu16 done in Gauteng found that 53.3% of female undergraduate students were familiar with emergency contraception. Similar results were reported by Hoque and Ghuman21 for female university students in KwaZulu-Natal where 49.8% of students had heard of emer- gency contraception and 21.2% of sexually experienced stu- dents had used emergency contraception. Several studies have been done on emergency contraception knowledge and use among female student populations in a variety of African countries with wide ranging prevalence of use. Gebrehiwot et al.22 reported on 616 female students at an Ethiopian University: 67.3% had heard of emergency contra- ception; 24.2% had used it. Nibabe and Ngutshini23 undertook a study at three Ethiopian tertiary institutions among 352 female students: 69.9% of students had heard of emergency contracep- tion; 10% had used it. Ahmed et al.24 reported on female stu- dents at another Ethiopian university where 75% of students who had unprotected sex had used emergency contraception. Byamugisha et al.25 reported that, among 379 female students at a Ugandan university, 45.1% had heard of emergency contra- ception; seven students had used it. In contrast, Kgosiemang and Blitz26 reported that, among 371 female undergraduate stu- dents in Botswana, 58% were sexually active; and 22% had used emergency contraception. They suggested that the high figure may be because of abortions being illegal in Botswana. Attitudes regarding hormonal contraception Kistnasamay et al.27 conducted a study among 162 undergradu- ate students at the Durban University of Technology. Almost a third (27%) of these students indicated that emergency contra- ception should not be used at all. In the current study a high per- centage of participants indicated that emergency contraception is acceptable only when used as an emergency contraceptive, or is completely unacceptable. The low awareness and uptake of subdermal implants are not surprising. Rees et al.28 showed that the use of the implant by the South African population was only apparent in three pro- vinces: Gauteng, Limpopo and KwaZulu-Natal. Even here, usage declined rapidly after introduction of this free service. The lack of uptake is ascribed to lack of training of nursing staff and lack of access at government hospitals. Study limitations The study population is not representative of all young South African adults, or of the university population as a whole. It is therefore not generalisable to the general population or to student populations in tertiary education. It does, however, provide a reference point for assessing use, knowledge and atti- tudes in similar student populations in South Africa and other developing countries. The fact that the questionnaire was self-administered poses a risk of under-reporting. The researchers tried to counteract this by ensuring anonymity. The way in which the questionnaire was structured to enhance confidentiality during completion led to inconsistent responses. The study did not assess the relationship status or sexual behav- iour of students per se, or assess the influence of religion and culture. The study also did not include the use and knowledge of barrier methods; neither did it include information on whether participants obtained their contraception via prescrip- tion or over-the-counter. It is recommended that future studies on this topic take these issues into consideration. Conclusion and recommendations The participants showed an openness and confidence to discuss hormonal contraception yet lacked sufficient knowledge on vital aspects of hormonal contraception such as the relative effective- ness of different forms of hormonal contraception and factors that affect that emergency contraception, as well as long- acting reversible contraceptives. There is a need for focused education interventions with regard to contraception at the UFS. Students within the Faculty of Health Sciences should be provided with adequate access to information to be able to use oral hormonal products safely themselves. This will enable them to convey these aspects accu- rately to their friends and future patients. The sensitivity of the issue of emergency contraception needs to be taken into account in the design and implementation of such an intervention. Acknowledgements – The authors thank all the students who took the time to participate in this study, the lecturers who offered up their class time for completion of the questionnaires, Mr M Mamba, Department of Biostatistics, Faculty of Health Sciences, UFS, for computing assistance, and Ms T Mulder, medical editor, School of Medicine, UFS, for preparation of the manuscript. Disclosure statement – No potential conflict of interest was reported by the authors. Funding – None. Conflict of interest – The authors declare that they have no finan- cial or personal relationships that may have inappropriately influenced them in writing this article. References 1. Bailey MJ, Hershbein B, Miller AR. The opt-in revolution? 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[cited 2019 Apr 11] Received: 27-11-2018 Accepted: 08-07-2019 196 South African Family Practice 2019; 61(5):190–196 https://doi.org/10.7196/SAMJ.2017.v107i4.12141 https://doi.org/10.7196/SAMJ.2017.v107i4.12141 https://doi.org/10.1080/20786204.2010.10874034 https://doi.org/10.5812/ijem.4158 https://doi.org/10.5812/ijem.4158 http://www.sanews.gov.za/south-africa/government-unveils-free-contraceptive-device-women http://www.sanews.gov.za/south-africa/government-unveils-free-contraceptive-device-women https://doi.org/10.7196/SAMJ.9411 https://doi.org/10.4102/curationis.v38i2.1535 https://doi.org/10.4102/curationis.v38i2.1535 https://doi.org/10.11564/23-1-312 https://doi.org/10.1016/j.%20ajog.2012.04.012 https://doi.org/10.1016/j.%20ajog.2012.04.012 https://doi.org/10.1371/journal.pone.0046346 https://doi.org/10.1371/journal.pone.0046346 https://doi.org/10.4102/phcfm.v6i.538 https://doi.org/10.4102/phcfm.v6i.538 https://doi.org/10.1186/1471-2458-12-110 https://doi.org/10.4102/phcfm.v10i1.1674 https://doi.org/10.1080/20786204.2009.10873896 https://doi.org/10.1080/20786204.2009.10873896 https://doi.org/10.7196/SAMJ.2017.v107i11.12903 https://doi.org/10.7196/SAMJ.2017.v107i11.12903 Abstract Introduction Aim of the study Methods Study design Setting Selection of participating students Data collection and tools Development and validation of the questionnaire Recruitment of study population and administration of questionnaire Data management Data analysis Ethical considerations Results Personal use of contraceptives Knowledge of contraceptives Personal attitude and opinions concerning hormonal contraceptives Discussion Knowledge of hormonal contraception Attitudes regarding hormonal contraception Study limitations Conclusion and recommendations Acknowledgements Disclosure statement Conflict of interest References << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles false /AutoRotatePages /PageByPage /Binding /Left 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