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Psychology, Health & Medicine


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Ambivalence, communication and past use: Understanding what influences women's intentions to use contraceptives
Shelly Campo Losch
a d a b

, Natoshia M. Askelson , Erica L. Spies & Mary

Department of Community and Behavioral Health, Center for Health Communication and Social Marketing, University of Iowa, Iowa City, IA, USA
b

Department of Communication Studies, University of Iowa, Iowa City, IA, USA


c

Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA
d

Department of Psychology, Center for Social and Behavioral Research, University of Northern Iowa, Cedar Falls, IA, USA Version of record first published: 07 Sep 2011

To cite this article: Shelly Campo, Natoshia M. Askelson, Erica L. Spies & Mary Losch (2012): Ambivalence, communication and past use: Understanding what influences women's intentions to use contraceptives, Psychology, Health & Medicine, 17:3, 356-365 To link to this article: http://dx.doi.org/10.1080/13548506.2011.608432

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Psychology, Health & Medicine Vol. 17, No. 3, May 2012, 356365

Ambivalence, communication and past use: Understanding what inuences womens intentions to use contraceptives
Shelly Campoa,b, Natoshia M. Askelsona, Erica L. Spiesc* and Mary Loschd
a Department of Community and Behavioral Health, Center for Health Communication and Social Marketing, University of Iowa, Iowa City, IA, USA; bDepartment of Communication Studies, University of Iowa, Iowa City, IA, USA; cDepartment of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA; dDepartment of Psychology, Center for Social and Behavioral Research, University of Northern Iowa, Cedar Falls, IA, USA

(Received 9 September 2009; nal version received 25 July 2011)

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Unintended pregnancy among women in the 1830 age group is a public health concern. The Extended Parallel Process Model (EPPM) provides a framework for exploring how womens perceptions of threat, ecacy, and fear inuence intentions to use contraceptives. Past use and communication with best friends and partners were also considered. A telephone survey of 1830year-old women (N 599) was completed. After univariate and bivariate analyses were conducted, the variables were entered into a hierarchal, multivariate linear regression with three steps consistent with the EPPM to predict behavioral intention. The rst step included the demographic variables of relationship status and income. The constructs for the EPPM were entered into step 2. Step 3 contained the fear measure. The model for the third step was signicant, F(10,471) 36.40, p 5 0.001 and the variance explained by this complete model was 0.42. Results suggest that perceived severity of the consequences of an unintended pregnancy (p 5 0.01), communication with friends (p 5 0.01) and last sexual partner (p 5 0.05), relationship status (p 5 0.01), and past use (p 5 0.001) were associated with womens intentions to use contraceptives. A womans perception of the severity was related to her intention to use contraceptives. Half of the women (50.3%) reported ambivalence about the severity of an unintended pregnancy. In our study, talking with their last sexual partner had a positive eect on intentions to use contraceptives, while talking with friends inuenced intentions in a negative direction. These results reconrm the need for public health practitioners and health care providers to consider level of ambivalence toward unintended pregnancy, communication with partner, and relationship status when trying to improve womens contraceptive behaviors. Implications for eective communication interventions are discussed. Keywords: unintended pregnancy; extended parallel process model; contraceptive use

*Corresponding author. Email: erica-spies@uiowa.edu


ISSN 1354-8506 print/ISSN 1465-3966 online 2012 Taylor & Francis http://dx.doi.org/10.1080/13548506.2011.608432 http://www.tandfonline.com

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Unintended pregnancies, both mistimed and unwanted, are a serious public health concern and result in negative outcomes such as infant death, low birth weight babies, lower breastfeeding rates, and depression and unemployment for mothers (Gipson, Koenig, & Hindin, 2008). Unintended pregnancies among 1830 year olds have been reported to be as high as 43% nationally (Ahluwalia, Whitehead, & Bensyl, 2007), and 52.5% in the state where this research was conducted, a rate virtually unchanged over the past 10 years (Losch, 2006). The cause may be contraceptive failures or inconsistent, incorrect, or non-use of contraception (Trussell, 2004). Despite the prevalence, little attention has been given to this issue in ages other than teens. Although family planning literature discusses contraceptive eectiveness, womens use of contraceptives, and factors aecting contraceptive use, the literature is limited in its ability to inform message design and campaign development (Kirby, 2008). The majority of the literature is atheoretical. The Extended Parallel Process Model (EPPM) (Witte, 1994) has been used as a framework to understand how messages could be crafted to encourage women to take action to prevent unintended pregnancies. This article presents research conducted to ascertain which constructs of the EPPM, as well as communication and past behavior, predicted behavioral intention to use contraception during the next sexual encounter. Extended Parallel Process Model The EPPM has shown that threat and ecacy motivate behavior (Witte & Allen, 2000). Threat includes two components: (1) perceived severity of the outcome, and (2) perceived susceptibility to the outcome. Ecacy comprises self-ecacy, or condence to perform the behavior, and response ecacy, an assessment of whether the recommended response would prevent the negative outcome. Witte (1992) argues that when both perceived threat and perceived ecacy are high, people will be motivated to act in order to control the danger they sense. When the threat is low, people will take no action. When the threat is high and ecacy is low, people will become fearful and disregard the message because they perceive that they are unable to mitigate the threat either because there are no eective responses or they are unable to respond. EPPM has been used to investigate numerous womens health concerns, including teen pregnancy (Witte, 1997), breast cancer (Hubbell, 2006), and genital warts (Witte, Berkowitz, Cameron, & McKeon, 1998). Due to past success of this theoretical framework (Witte & Allen, 2000), this studys goal was to determine if EPPM constructs predict womens intention to use contraceptives (a danger control process). The following research question was examined:
RQ1: How are the EPPM constructs of fear, susceptibility, severity, response ecacy, and self-ecacy related to young adult womens intention to use contraceptives?

Although the correlation between behavioral intention and behavior is not perfect, behavioral intention has been found to be a signicant predictor of actual behavior (Ajzen, 1985, 1991; Kim & Hunter, 1993) and is the outcome of interest. Moreover, past behavior has been recognized as a predictor of future intention

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(Conner & Armitage, 1998); therefore, we wished to determine if past contraceptive behavior would inuence intention to use contraceptives in the future.
H1: Past contraceptive use will be positively associated with intention to use contraceptives.

Communication with friends (DiIorio, Kelley, & Hockenberry-Eaton, 1999; Lefkowitz & Espinosa-Hernandez, 2007) and partners (DiIorio, Dudley, Lehr, & Soet, 2000; Lefkowtiz & Espinosa-Hernandez, 2007) is included because it is vital to examine how communication impacts 1830-year-olds behavioral intentions. Therefore, the following hypotheses were investigated:
H2: Communication with friends will be positively associated with intention to use contraceptives. H3: Communication with last sexual partner will be positively associated with intention to use contraceptives.

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Method This data collection was a part of a larger, formative research project to guide development of messages for a statewide, multi-pronged intervention to encourage contraceptive use and to decrease unintended pregnancies. The sample frame for the survey consisted of all residential telephone numbers for adult women in Iowa ages 1830. Respondents were contacted by telephone using targeted listed household samples provided by a sample frame vendor. The listed household sample was generated by identifying the universe of listed residential telephone numbers within the state and supplemented with additional data sources (e.g. drivers license). All data were collected via Computer Assisted Telephone Interviewing system. The interview took approximately 20 min to complete and included 79 items assessing knowledge, attitudes, and general behaviors related to reproductive health, and demographic items. The study was reviewed and approved by an Institutional Review Board, and participants were consented. A total of 929 interviews were completed. The response rate (RR4; American Association for Public Opinion Research, 2008) was 30% with a cooperation rate of 68% (COOP4; American Association for Public Opinion Research, 2008). The analysis only included those women who had reported already having sexual intercourse, and who were not trying to conceive (N 599). Measures The women were asked a number of socio-demographic questions including participants relationship status, age, level of education, household income, and race and ethnicity. EPPM To ascertain whether or not women felt susceptible to pregnancy, they were asked to imagine that, Sometime soon you were to have sexual intercourse with someone just once, you were able to become pregnant, but were unable to use any method of birth control for some reason. What is the chance that you would get pregnant? and report their perceived probability as a percent (M 56.97%, SD 30.85; range 0 100%). Severity was measured by asking women to pick a statement that best

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matched their reaction if they were to have an unintended pregnancy now (Condelli, 1998). The women could select from seven options: (1) It would be the best thing that could happen to me, (2) It would be very good, (3) It would be good, (4) It would be both good and bad, (5) It would be bad, (6) It would be very bad, and (7) It would be the worst thing that could happen to me (M 2.99, SD 0.93). Questions assessing womens perceptions of response ecacy and selfecacy were based on items from Kyes (1998). Women were asked how much they agreed or disagreed on a ve-point Likert scale with the statement Using birth control consistently and appropriately every time you have sexual intercourse will prevent pregnancies, to evaluate womens response ecacy of contraceptive use (M 3.63, SD 1.10). The majority of women (67.4%) agreed or strongly agreed with this statement. Womens self-ecacy about contraceptive use was measured by two statements. Women reported how much they agreed or disagreed on a ve-point point scale with the statements (1 strong disagree): I feel condent that I can use birth control consistently and appropriately every time I have sex (M 4.36, SD 0.74) and I am able to use birth control consistently and appropriately every time I have sex (M 4.26, SD 0.85). The majority of women (93.9% and 90.3%, respectively) agreed or strongly agreed with these statements. The mean of these two variables was used as the nal measure of self-ecacy (a 0.718, M 4.32, SD 0.68). Fear was measured by asking the women how much they agreed or disagreed with the statement I fear having an unintended pregnancy on a vepoint scale (M 2.84, SD 1.35). Communication We adapted Fishers (1998) Weighted Topics Measure of Family Sexual Communication to measure communication with their last sexual partner or best friend about reproductive health. Women were asked Would you say you have talked with your last sexual partner about birth control never, once, or several times? and Would you say you have talked with your best friend about birth control never, once, or several times? We dichotomized participants responses into two categories, those who had and those who had not talked about birth control, because there were very few respondents who said that they had only spoken to their friend or partner about birth control once. Most women reported talking about contraceptives with their partner (94.5%) and their best friend (96.0%). Past use and behavioral intention Women were asked, Were you or your partner using any kind of birth control method at the time of the most recent intercourse (81.6% used contraceptives last time). Future intentions were assessed by asking, How likely are you to use birth control the next time you have sexual intercourse? Responses were on a four-point scale from highly unlikely to highly likely (M 3.56, SD 1.00). The vast majority (82.3%) reported they were highly likely to use contraceptives. Analysis Univariate and bivariate analyses were conducted. The variables of interest were entered into a hierarchal, multi-variate linear regression with three steps consistent

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with the EPPM to predict behavioral intention. The rst step included the demographic variables. Susceptibility, severity, response ecacy, self-ecacy, talk with a partner, talk with a best friend, and past use were entered into step 2. Step 3 contained the fear measure. Models were assessed for signicance at the 0.05 level, and changes in R2 were evaluated. Results Demographics The mean age of the sample was 24.84 years (SD 4.02). Nearly half (47.7%) of the women reported either being married or currently living with their partner, whereas almost half (48.6%) of the women had some education after high school graduation. Over half (59.6%) were employed, and 20.5% were students. Only 11.2% of the women had no insurance. Approximately 40% of the women reported household incomes of $50,000 or more. Consistent with the state population, only 2.2% reported being Hispanic and 2.5% African American. Of the women who reported having had a pregnancy (n 329), 72.2% of them said it had been unintended and 50.9% (n 305) of them had at least one child. Table 1 shows the correlations between all the variables in the regression models. EPPM The model for the rst step was signicant, F(2,481) 16.56, p 5 0.001, and the eect of relationship status was signicant (see Table 2). The model for the second step showed signicant improvement in prediction, with a DR2 0.37, and this model was also signicant, F(9,472) 40.26, p 5 0.001. Severity, talking with partner about contraceptives, talking with best friend about contraceptives, and contraceptive use the last time a woman had sexual intercourse were signicant predictors of intention to use contraceptives the next time a woman has sexual intercourse. The model for the third step was also signicant, F(10, 471) 36.40, p 5 0.001, but oered no improvement in the predictive value. The nal variance explained by this complete model was 0.42 (see Table 2). RQ1 looked at the eect EPPM constructs have on womens intention to use contraceptives. After examining the results of the regression models, perceptions of severity (b 0.10, p 5 0.001) was the only EPPM construct that was a signicant predictor of intention; the more severe a woman thinks an unintended pregnancy would be, the more likely she was to intend to use contraceptives the next time she has sexual intercourse. It is important to note that half of the women answered It would be both good and bad to the severity question, suggesting that many women were ambivalent about the severity of an unintended pregnancy.
H1 predicted that past contraceptive use would be positively associated with womens intentions to use contraceptives. H1 was supported. Past use (b 0.59, p 5 0.001) was the most powerful predictor of behavioral intention. H2 and H3 looked at how communication with friends and partners are related to womens intentions to use contraceptives, respectively. Talk with partner (b 0.07 p 5 0.05) and talk with best friend (b 70.11, p 5 0.01) were predictors of behavioral intention. There was no support for H2 because talking with a best friend

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Table 1. 3 70.09* 70.38** 0.13** 0.12** 70.01 0.03 0.12** 0.09* 0.03 0.07 70.01 0.23** 0.07 0.01 0.06 0.01 0.07 0.21** 0.02 70.01 0.03 70.02 0.05 0.08 0.21** 4 5 6 7 8 9 70.02 70.17** 0.09* 0.15** 0.20** 0.35** 0.28** 0.15**

Correlation matrix (N 599). 10 70.10* 70.17** 0.01 0.30** 0.06 0.06 0.03 0.05 0.10* 11 70.12** 70.25** 0.05 0.23** 0.11** 0.22** 0.22** 0.04 0.69** 0.13**

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Income Relationship status Susceptibility Severity Response ecacy Self-ecacy Talk partner Talk best friend Past use Fear Intention

0.33**

70.02 70.09*

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Note: *p 5 0.05, **p 5 0.01, ***p 5 0.001.

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Table 2. Results for hierarchical regression analysis predicting intention to use contraceptives (N 599). Variable Step 1 Income Relationship status Step 2 Susceptibility Severity Response ecacy Self-ecacy Talk partner Talk best friend Past use Step 3 Fear B 0.002 70.44 0.00 0.92 70.02 0.01 0.32 70.55 1.44 70.002 SE B 0.01 0.08 0.00 0.04 0.03 0.05 0.16 0.19 0.09 0.02 B 0.01 70.26** 0.01 0.10** 70.03 0.01 0.07* 70.11** 0.59*** 70.003 R2 0.06

0.42

0.42

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Note: *p 5 0.05, **p 5 0.01, ***p 5 0.001.

about contraceptives was negatively related to intention, so that women who reported talking with a best friend were less likely to intend to use contraceptives. Conversely, women who reported talking with a partner about contraceptives were more likely to intend to use contraceptives, which was consistent with H3.

Additionally, relationship status (b 70.26, p 5 0.01) was a signicant predictor of intention. If a woman is married or living with a partner, she would be less likely to intend to use contraceptives the next time she has sexual intercourse. Discussion Based on the model tested in this study, past use, communicating with a best friend, communicating with a partner, perceptions of severity, and relationship status inuence womens intentions to use contraception the next time they have sexual intercourse. This study provides evidence to guide the development of interventions to encourage contraceptive use and points to areas requiring further research. Threat Women who perceive an unintended pregnancy as more severe are more likely to intend to use contraceptives. Half of the women reported ambivalence about unintended pregnancy, consistent with previous research that identied it as a risk factor for not using contraceptives (Frost, Singh, & Finer, 2007; Schwarz, Lohr, Gold, & Gerbert, 2007). While past contraceptive decision-making models have considered a dichotomy of costs and benets around pregnancy (Luker, 1977; Weisman et al., 1991), none have considered womens ambivalence, or the tension between costs and benets of pregnancy. Our ndings, coupled with previous research, suggest that researchers should focus on unintended pregnancies being perceived as both positive and negative. Consistent with EPPM, women who are ambivalent about unintended pregnancy will need to be convinced of the severity of an unintended pregnancy.

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Previous research has indicated that self-ecacy is an important component of contraceptive use (Sable, Libbus, & Chiu, 2000). Surprisingly, self-ecacy did not play a role, which is likely due to ceiling eects. Unlike severity, self-ecacy may not need to be changed. Communication Relationships with partners (DiIorio et al., 2000; Scholly, Katz, Gascoigne, & Holck, 2005) and close friends (Lefkowtiz et al., 2007) have been found to play a signicant role in womens contraceptive use, and interventions should encourage communication between sexual partners about contraceptives. Future research should explore contexts and messages shared in partner communication about contraceptives and the role relationship status plays in communication. In this study, communication with friends was negatively related to behavioral intention. Future research should aim to understand how communication with friends inuences contraceptive use. Perhaps friends are more likely to talk about contraceptive failure or the negatives of contraception, such as side eects. Past research (Campo, Askelson, Spies, & Losch, 2010) indicates that women view friends as valid sources of reproductive health information, so it may be important to reduce the impact of conversations with friends or alter the content. Relationship status and past use Married women and women living with a partner were less likely to intend to use contraceptives than single women not living with partners possibly because they have more favorable life circumstances to support a child. In addition, these data suggest past contraceptive use behavior is the most powerful predictor of future intentions, which is consistent with previous health behavior studies on other topics (Connor & Armitage, 1998). Limitations This study contributes to the understanding of how EPPM can be applied to the issue of unintended pregnancy and how to design interventions to encourage women to use contraceptives; however, it has limitations. Specically, it was beyond the scope of the study to examine the content and frequency of the communication between women and their friends and partners. Additionally, relationship status was dichotomized in this study. Future studies should address dierences that might exist between groups. Due to the limited racial and ethnic diversity and the higher income levels of this study population, future studies should assess the ndings, generalizability to more diverse populations. A nal limitation of this study was the response rate, which was consistent with other recent studies with this age group (Curtin, Presser, & Singer, 2005), such as the National Survey of Fertility Barriers, which had a response rate of 37.2% (Johnson & Johnson, 2009) and another recent telephone survey of young adults, which had a response rate of approximately 20% (RDD, targeted, and cell) (Kaye, Suellentrop, & Sloup, 2009).

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Implications The ndings from this research have implications for designing interventions. Past research has emphasized the importance of tailoring sexual health messages and interventions to increase their eectiveness (Janssen, Wit, Hospers, Stroebe, & Kok, 2004). The EPPM could be used as a theoretical framework in intervention design. First, interventions need to address perceptions of severity of unintended pregnancies by highlighting the negative outcomes to self, child, and society. This would have to be done without stigmatizing women who had unintended pregnancies or demonizing babies. Alternatively, health communicators could work to craft messages to convince women that being ambiguous about pregnancy is not the same as wanting pregnancy, and they should choose to use contraceptives. Second, this study illustrates that health educators should not ignore women who are married or co-habiting with a partner. Women in these relationships are at risk for unintended pregnancies. They may require dierent tailored messages as their motivations for using contraceptives might be dierent. The nding of past behavior as a powerful predictor of intentions has important intervention implications for segmenting women who report contraceptive use versus those who have not. Users need to be encouraged to maintain their behavior, while non-users will require messages that focus on the factors that motivate use. Conclusion This research provides a foundation for understanding contraceptive use and intervention development for adult women that have been neglected in the past. EPPM has the potential to be used as a framework to create messages that will encourage women to take action to use contraceptives and to prevent unintended pregnancies. This study suggests that in addition to the constructs of EPPM, communication with partners and friends needs to be considered as well as womens ambivalent feelings about the severity of an unintended pregnancy. References
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