Background: Unwanted pregnancy is a serious problem, especially
considering its impact on the lives of young people. Currently, emergency
contraception (EC) is an effective method to prevent unwanted pregnancies that
result in unsafe abortions and harm women’s health. It is essential that
university students, one of the risk groups for unwanted pregnancies, be familiar
with this method. The aim of this study is to determine university students’
knowledge of emergency contraception, influencing factors and e-health literacy
levels. Methods: The cross-sectional study was conducted on 1003 senior
undergraduate students at a public university. Data were collected via a Personal
Information Form, Emergency Contraception Test, and e-Health Literacy Scale. For
data analysis, descriptive analyses, t-test, ANOVA/Pearson correlation
tests were used. Results: The e-HL score mean of students was found to
be 25.68
Adolescence is seen as important in the life cycle in terms of protecting and improving sexual health [1]. Starting to use birth control methods in youth is seen as effective in adopting these methods in the longterm [2, 3]. On the other hand, this age group presents risks of unintended pregnancies via lower use of contraceptives due to lack of information and difficulty in accessing family planning services [3, 4]. Beyond health and legal problems associated with the termination of unplanned pregnancy, problems arise of care, accommodation, financial hardship and dropping out of school following delivery [5]. The consequences of unintended pregnancy on the physical, psychological, health and socioeconomic well-being of adolescent girls are far more detrimental than for boys [6, 7]. Young girls who experience unwanted pregnancies are frequently stigmatized, more likely to drop out of school and to die from unsafe abortion or (in certain countries) marriage [7, 8]. In conservative countries where sexuality is taboo, problems arise in societies that consider premarital sex religiously and culturally improper [9]. Sexuality is considered as a taboo in Turkish culture [10]. Women may face severe results such as being victims of honor killings; the term “honor” traditionally refers to women’s attaining importance to virginity before marriage and refraining themselves from sexual relations outside marriage. In such cultures, fears of such retribution result in unwanted pregnancies occurring outside marriage. This social perspective pushes young people to conceal their sexuality and increases sexual problems [11].
National data in Turkey suggest that young people (15–24 years old) account for 15.6% of the total population; the mean age of first marriage is 24.6 for women and 27.7 for men [12], and the age of first sexual intercourse is reported as 17–24 [13, 14]. Such data indicate that young people are sexually active over a long period. A study by Erenel and Gölbaşı reported that 1/8 of the young people in Turkey who had sexual intercourse experienced unplanned pregnancy and 3/4 of these resulted in abortion [15]. Another study reported that 10.9% of young people had received an abortion [16]. These results reveal that the risks of sexual behavior such as pregnancy are high in Turkey [15].
The first choice in the prevention of unwanted pregnancies is the use of an appropriate contraceptive method. However, since premarital sex is not generally acceptable in Turkish society, the lack of a regular sex life and/or often unplanned sexual intercourse may be factors preventing young people from using contraception [17]. With this in mind, it is important for young people to know and use emergency contraception (EC) to prevent unwanted pregnancy due to unprotected sexual intercourse [17, 18, 19]. Methods are hormonal and mechanical, including EC pills (ECP), commonly referred to as morning after pills, and intrauterine device (IUD). Hormonal methods are levonorgestrel (LNG), ulipristal acetate (UPA), combined oral contraceptives known as Yuzpe regimen (COC) and mifepristone, a medicine that is not authorized for use in many countries, including Turkey (Table 1) [20].
ECP regimens | Formulation | Application time |
Providing status |
The Yuzpe combined hormonal regimen | 0.05 mg etinil estradiol and 0.25 mg, 2 times, every 12 hours | Within 72 hours after unprotected intercourse | By prescription |
Levonorgestrel (LNG) regimen | 0.75 mg (Levonorgestrel, 2 |
Within 72 hours after unprotected intercourse | |
SPRM | 30 mg Ulipristal acetate (1 dose) | Within 120 hours after unprotected intercourse | By prescription |
Mifepristone | 10, 25, 50 mg (1 dose) | Within 120 hours after unprotected intercourse | Not in Turkey |
Copper intrauterine device (cu-IUD) |
The health institution should be consulted | ||
COC pills, obtained via primary health care (PHC), may be obtained at no cost. Moreover, they can be purchased from pharmacies without a prescription. UPA is available on prescription from pharmacies. IUD may be applied free of charge to married women as PHC. At present, however, IUD may not be provided when applied to health institutions for PHC. PHC was the most important source of contraceptive method procurement, provided free of charge by the government. However, the procurement rate of this method decreased from 35.6% in 2008 to 24% in 2018 [21]. This may be due to support of pro-natalist policies in the last 15 years and a family planning service approach that has changed within Health Reform [22, 23]. Insofar as other obstacles against access to services include stigma, embarrassment, prejudice and parental fear, the group benefitting the least from PHC in sexual health-related situations is the youth [24]. Another major problem with EC is its relative lack of recognition [13, 17, 25]. The most common information sources are reported as peers, school and media [26]. Healthcare personnel are expected to provide non-judgmental, objective and professional sexual counselling. In the Youth Counseling and Health Service Center, established within the scope of the European Union Turkey Reproductive Health Program between 2004 and 2007, the SHRH training, consultancy and service activities carried out by competent personnel were interrupted by the reform [27]. No service delivery or model has been developed to fill the gap, exposing a critical, unmet need for young people who comprise roughly one quarter of the population.
The payment for work done by the health workers is based on performance; with the reform, there have been disruptions in services such as contraceptive counseling that are not based on performance. Recent research shows that contraceptive services are limited to those who demand them, while no effort is made in outreach due to the new pricing system, increased workload of healthcare workers, and lack of support and supervision of PHC in terms of contraception provisions [23, 27]. Indeed, research indicates that young people get the most information about sexual health and EC from friends and the Internet [26]. The Internet increases availability of health information, but it requires an ability to access reliable information. In this regard, e-Health Literacy (e-HL), an ability to search, find, understand, evaluate, and apply health information from electronic sources to address and/or solve health problems, is an important skill [28]. Accordingly, determining EC knowledge and e-health literacy levels will serve as a guide in developing and planning education, guidance, and counselling programs. e-HL should be investigated to better understand factors that can affect EC information awareness in university students. The aim of this study is to determine university students’ emergency contraception knowledge, the factors affecting it, and the relationship between e-health literacy and knowledge level. Research questions:
(1) What is the level of EC knowledge in university students?
(2) What is the level of e-health literacy in university students?
(3) What factors are associated with the EC knowledge level of university students?
(4) Is there a relationship between e-health literacy levels of university students and their level of EC knowledge?
This cross-sectional study was conducted at a state university in a province in
Western Turkey between February and June 2017. The university has 11 faculties,
four institutes, four colleges and 13 vocational schools. It has a total of
36,339 students, 828 of whom are foreign nationals. The educational language is
Turkish. Population of the research consisted of 3390 enrolled seniors. The
sample size was aimed to reach at least 821 students with 50% unknown
prevalence, 5% absolute deviation and 99.9% confidence level (n =
[DEFF
The Personal Information Form, designed by researchers upon conducting a literature review, consists of questions to determine the socio-demographic characteristics of students [13, 14, 15, 17, 19].
For the EC Knowledge Test, a total of 13 questions were asked to determine students’ EC usage knowledge. The questions are as follows: “EC should be used before the desired pregnancy”; “Using EC positively affects physical and psychological health of people by preventing unwanted pregnancies”; “Using EC method is the responsibility of only women”; “It is a sin to use EC methods”; “Only married couples should use EC methods”; “Every individual should have knowledge about EC”; “EC is a family planning method”; “It makes having children more difficult in the future”; “It may harm the baby when it is not effective”; “This method should be expensive”; “Defining EC”; “Time to use pills used for EC purposes”; “Time of use of the intrauterine device used for EC purposes”. Correct answers were calculated as 1; incorrect and undecided answers were calculated as 0 and were evaluated over the total score. Scores of negative expressions were reversed to calculate EC knowledge scores (min = 0; max = 13) [13, 14, 15, 17, 19, 20, 25].
The e-Health Literacy Scale, containing 10 questions in total, was developed by Norman and Skinner and adapted into Turkish by Coşkun and Bebiş. The scale Cronbach’s alpha score is 0.78 and for this study, 0.80. The Turkish version of the scale, reported to be used validly and reliably, was developed to measure overall literacy, health literacy, skills for obtaining knowledge, scientific research, media literacy and computing literacy. Scale items included the following options: 1 = strongly disagree to 5 = strongly agree. Scale score ranged between 8 and 40 points, where higher scores indicate higher levels of e-HL [29].
A Kolmogorov-Smirnov test was done to control whether the data had normal
distribution. Data were analyzed using mean, standard deviation, minimum and
maximum values, frequencies, and percentages. Independent t-tests and
ANOVA test were performed to determine differences between socio-demographic
variables and EC knowledge scores of participants. Spearman correlation test was
performed to determine correlation between EC knowledge score and e-HL.
Characteristics associated with the EC knowledge score were analyzed by linear
regression analysis. p value was taken as
The mean age of students was 21.42
Characteristics | n | % | |
Gender | |||
Female | 716 | 74.6 | |
Male | 287 | 28.4 | |
Marital status | |||
Married | 45 | 4.5 | |
Not Married | 958 | 95.5 | |
Longest living place | |||
Provincial Center | 545 | 54.3 | |
District | 339 | 33.8 | |
Village | 119 | 11.9 | |
Place of residence | |||
With Family | 178 | 17.7 | |
In a Dormitory | 455 | 45.4 | |
Alone | 123 | 12.3 | |
With Roommates | 247 | 24.6 | |
How do you get income? | |||
I am not working | 126 | 4.7 | |
I am working | 121 | 39.8 | |
Credit/Scholarship | 412 | 23.2 | |
Family Sending Money | 331 | 23.6 | |
Other | 13 | 8.7 |
Other features are included in Table 1: 57.6% of the students stated that they
did not take a course on reproductive health, 40.1% did not hear the concept of
EC, and 70.4% did not know about EC (706). EC knowledge score mean of students
who said they heard about EC (n = 402) was 5.37
About emergency contraception | n | % | |
Hearing of emergency contraception (n = 1003) | |||
Yes | 402 | 59.9 | |
No | 601 | 40.1 | |
Having knowledge about EC (n = 1003) | |||
Yes | 297 | 29.6 | |
No | 706 | 70.4 | |
EC information resources (n = 402) | |||
Family | 19 | 4.7 | |
From friend | 98 | 24.4 | |
Internet | 122 | 30.3 | |
Health personnel | 52 | 12.9 | |
Consultant/Instructor | 111 | 27.6 | |
Received reproductive health education (n = 1003) | |||
Yes | 425 | 42.4 | |
No | 578 | 57.6 | |
Knowing where to get EC methods (n = 402) | |||
Pharmacy | 281 | 69.9 | |
Family Medicine | 96 | 23.9 | |
Other | 25 | 6.2 | |
Thinks EC is effective in preventing pregnancy (n = 402) | |||
Yes | 337 | 83.8 | |
No | 65 | 16.2 | |
You/your sexual partner using one of the EC methods (n = 378) | |||
Yes | 77 | 20.37 | |
No | 301 | 79.63 | |
How many times have you used EC methods? (n = 77) | |||
1 time | 32 | 41.56 | |
2 and more Times | 45 | 58.44 | |
Requesting information about EC methods | |||
Yes | 621 | 61.9 | |
No | 382 | 38.1 | |
Wants a reproductive health counseling unit to be established in university (n = 1003) | |||
Yes | 555 | 55.3 | |
No | 184 | 18.3 | |
Undecided | 264 | 26.3 | |
The reason for not wanting to establish a counseling and service unit in sexuality and reproductive health at the university (n = 265)* | |||
Let People Learn on Their Own | 102 | 38.49 | |
Cs/Base Information Can Promote Sexuality | 163 | 61.51 | |
* Answer given by “No” and Undecided. 113 blank answers. |
The e-HL score mean of students was 25.68
Characteristics | Mean score on knowledge of EC | p | |
n = 399 | |||
Gender* | |||
Female | 5.77 |
0.00 | |
Male | 4.38 |
||
Marital status* | |||
Married | 4.39 |
0.09 | |
Not married | 5.43 |
||
Place of residence** | |||
With family | 5.98 |
0.12 | |
In a dormitory | 5.50 |
||
Alone | 4.73 |
||
With roommates | 5.18 |
||
Received reproductive health education* | |||
Yes | 5.84 |
0.00 | |
No | 4.85 |
||
Have knowledge of EC | |||
Yes | 5.63 |
0.05 | |
No | 4.70 |
||
Information source** | |||
Family |
4.78 |
0.00 | |
Friends |
4.47 |
4–2 | |
Internet |
5.01 |
5–3 | |
Healthcare Professional |
5.86 |
5–2 | |
Consultant/Instructor |
6.45 |
||
Thinks EC is effective in preventing pregnancy | |||
Yes | 5.65 |
0.08 | |
No | 4.89 |
||
Needs information about EC | |||
Yes | 5.39 |
0.89 | |
No | 5.35 |
||
Would you like to establish a reproductive health advisory unit at the university ** | |||
Yes |
5.90 |
0.00 | |
No |
4.45 |
1–2 | |
Undecided |
4.77 |
1–3 | |
Note: One-way ANOVA test was applied to variables with more than three groups in the table. Variables were symbolized by numbers: * independent t test. ** ANOVA test. Number of people who heard the concept of EC. Post hoc analysis was examined with Bonferroni test. Those with p |
Pearson correlation analysis was made to examine the relationship between students’ EC knowledge scores and e-HL. There is a positive correlation (p = 0.00) between EC knowledge and e-HL scores (Table 5).
Score on knowledge of emergency contraception | Score on e-Health literacy |
r | 0.247** |
p | 0.000 |
r = Pearson correlation test **. Correlation is significant at the 0.01 level (2-tailed). |
We found that 59.1% of surveyed students were unfamiliar with the concept of EC, roughly two thirds had no knowledge about EC, while for those who had some knowledge, it was at lower levels. Gölbaşı et al. (2012) [17] determined that 71% of students had not heard of the concept of EC and 38.7% stated that they had no information about the methods used for EC. Another study conducted in Turkey determined that 67.4% of students stated they were unaware of contraceptive methods for use after unprotected sexual intercourse [13]. Research on adolescents found that 8.7% of them had not heard anything about EC, while 38.6% knew of its effectiveness; however, 12.7% did not know the exact periods of EC [30]. In research from Korea, 88.2% of students were aware of EC, while 35% were able to answer the question of usage periods of oral contraceptives; in contrast, 23.1% of university students in South India were reported to have heard of EC [31]. Research conducted with female students in Ethiopia reported that the knowledge score of 49.8% of students was “moderate” [32]. Among young people aged 13–25 in San Francisco, women had a higher rate of EC familiarity than men (86% vs. 70%), while 44% reported the time of use incorrectly [33]. Looking at the literature, prevalence of EC awareness and knowledge is higher in developed countries, though there are important knowledge gaps in EC usage periods, access and correct use of EC pills [17, 33]. In research conducted in Turkey, the rate of EC awareness and knowledge is very low. Variance in results of the research may be due to differences in culture, time, region, sexual lifestyles and provision of reproductive health services.
Of the female students, EC knowledge scores were higher for those who took reproductive health lessons, received EC information at school, and who wished to be informed about EC and the opening of any reproductive health counselling unit. While more EC awareness in female students was demonstrated in some research, other reports found no significant difference [13, 25, 31, 34]. This disparity may be due to differing regional and cultural characteristics. About 57.6% of the students received no lessons about reproductive health, while top sources of knowledge about EC included the Internet, consultant/educator and friends, respectively. According to the studies, 55.6% to 88.3% of the students do not receive sexual education [24]. EC knowledge scores of those who have taken reproductive health courses were found to be higher in this research. Another study reported that 97.2% of the nursing students accessed information at school, while only 7.1% of the students in the social services department accessed it at school [13]. Some research suggests that education given to students had positive effects on EC knowledge, attitude and intentions [32]. Gölbaşı et al. (2012) [17] reported the sources as magazines (61.2%), friends (46.1%) school (39%), and Internet/TV (66.2%); Arslan (2014) reported the primary source of knowledge for reproductive health as the Internet [17, 24]. Joaquim et al. (2018) [35] reported sources of knowledge for EC as school, friends and Internet; Doving et al. (2014) [36] as friends (67%), TV (47%) and school. There exists no sexual health educational program in the national education syllabus in Turkey [24]. Research shows that support is not received from professional information sources. In this case, it suggests that the information sources used may be unreliable areas with uncontrolled information. As a result, young people face greater reproductive health risks.
In this study, a majority of the students (88.1%) stated that they knew of centers where they could obtain ECP methods, 78.9% stated that EC could prevent pregnancy effectively, 20.3% used the EC method, 41.5% of those who used it did so only once, while 58.4% used it twice or more. Other research found that 72.2% of university students knew they could get ECP from pharmacies, 88.4% from public health clinics, while 49% were unaware they could obtain ECP from school health centers [37]. Research conducted for the ECP knowledge and practices of young men in Turkey reports that 8.1% of them stated that their girlfriends used ECP [25]. Another study reported that 5.4% of female students used EC [38]. Research from Italy reported that 31.1% of university students used ECP and the rate of female students using it was 21.8% [39]. Research with female university students by Najafi et al. [40] reported quite different findings: only 1% of them stated that they used this method. Not knowing where to obtain ECP also reduces the possibility of using it when needed. In this context, it is important for young people to be informed about the possibilities of obtaining ECP. The results of the research show that less EC is used than stated in the literature. This situation arises from different social and cultural characteristics. In addition, there may be a lack of data due to the lack of studies on this subject in Turkey. In developing countries with a predominantly Muslim population such as Turkey, the concept of honor values the absence of premarital and extramarital sexual intercourse for women, and virginity is of great importance. While sexual intercourse before marriage translates to women being accused, condemned or even killed, it may be accepted as an experience for men and there may be difference between genders [5]. However, with a younger population in our country, sexual intercourse before marriage has increased compared to previous years [16]. As such, cultural structure, societal pressure, and sexuality being forced into secrecy carry a great risk for unwanted consequences.
Most of the students (61.9%) wanted to learn about EC and more than half wanted a counselling service on SRH issues at the university to be founded. Among the undecided students and the ones who did not want a SRH counselling and service center at the university, 61.51% did not find it appropriate to start a counselling center with the idea that sexuality may be encouraged. In a study conducted by Demir and Özsoy (2015) on young men (n = 697), half stated that they wanted to learn about Emergency contraception (EC) [25]. A separate study reported that university students need a “Youth Counseling Unit (YCU)” or a “Reproductive Health Unit” which should be easily accessible and free of charge [41]. In a recent report in which Turkey’s Sexual and Reproductive Health Services were evaluated, a physician working in the health centers of universities stated the following about the SRH situation for young people: “In the past, when the - Youth Counseling Units here was established, the Ministry of Health in Turkey generally established Youth Friendly Health Service Centers (YFHSC) alongside Maternal Child Health and Family Planning Services as a project. I don’t remember the number. YCU was opened in thirteen Universities. But now they don’t know what happened. But we no longer have YCU here. It’s gone back to the past; I guess there is no place for young people to go. They go to family health centers, maybe because everyone has a family doctor. Young people have access to all kinds of information on the Internet. Maybe that’s why they don’t ask anymore. Maybe they don’t know about the services. Special services are no longer offered to them anyway. They hesitate” (50-year-old physician). Another statement in the same report is as follows: “They don’t know about this place, because it wasn’t called a separate SRH Center; there used to be a sign; it doesn’t exist anymore. There is no promotion, it is incomplete; if only more patients would come. First, there is misinformation between each other. ‘I used the pill the next day, you can use it’: the friend factor is very important. Secondly, they will receive information about sexual health, there is a concern whether my family will see these records. This is the question in the minds of the children: there is an unwanted pregnancy, will my mother know if there is a suspicion of pregnancy?” (59-year-old physician) [42]. These results clearly reflect a need for reproductive health and EC counselling services for young people. The need is obvious for an easily accessible, privacy-based system with healthcare professionals serving clients with an unbiased youth-friendly approach. Existence of students who believe that the foundation of a counselling center may encourage sexuality suggests that religious and cultural structure of society is more effective than the enlightenment and knowledge-based perspective of university education.
Findings indicate that there is a significant and positive connection between EC knowledge score and e-HL. Health literacy has been reported as the main behavioral factor in preventing unwanted pregnancy [40]. According to Thongnopakun et al. [43], college students with low health literacy were more likely to engage in inappropriate pregnancy-prevention behaviors. Health literacy is the main behavioral factor when it comes to preventing unintended pregnancy. Our study, in which we found that e-health literacy is positively correlated to EC knowledge, is in line with studies in the literature that reveal the effect of health literacy on the prevention of unwanted pregnancies. The Internet is the most widely accessed source for sexual health information. The fact that the development of e-Health literacy provides an opportunity to obtain the right information and to show appropriate behaviors reveals the potential of preventing high risk situations.
Our research findings reveal a need to increase knowledge and awareness of EC among university students. In addition, the positive correlation between EC knowledge score and e-HL indicates that improving e-HL literacy will contribute to EC knowledge. There is a need for service provision that will contribute to the healthy living of the sexuality experienced in adolescence and young adults while providing solutions to any problems that arise. Counseling and support centers should be founded to meet the SRH needs of young people. Evidence to support the development of good health strategy and action is essential in creating an environment for young people to access SRH information and services. Our study has revealed information that will contribute to this. Our recommendation is for young people to be more enlightened and science-based in their education, as well as in how they search for EC information in online environments, how they make their choices, and how they obtain information.
When EC studies are examined, it is stated that in most of the studies, the taboos of the students on sexuality are directive, and therefore they do not give real and sincere answers to all survey questions. Another limitation is the use of literature-based tests by researchers since there is no standard scale to determine EC knowledge status. All studies on emergency contraception in college students in Turkey were attempted to be surveyed. However, the limited number of studies on this subject limits our own study. The limited number of studies on EC among university students in Turkey is a limitation of the discussion.
FAÖ and MG designed the research study. FAÖ data collected and analyzed. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
In order to conduct the study, written permission was obtained from and the Clinical Research Ethics Committee of Faculty of Medicine at Balikesir University (Decision No.: 2017/15) and the Rectorship of Balikesir University (Date: February 20, 2017, No.: E.2187466).
The authors would like to thank all of the students who participated in the study.
This research received no external funding.
The authors declare no conflict of interest.