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Current knowledge, attitude, and patterns of oral contraceptives utilization among women in Jordan
© Bardaweel et al. 2015
Received: 13 July 2014
Accepted: 3 December 2015
Published: 14 December 2015
Studies exploring the knowledge, attitude and patterns of OCs use among women in Jordan are lacking. The aim of this study was to assess knowledge, attitude, and patterns of oral contraceptives (OCs) utilization among women in Jordan.
A face-to-face questionnaire inquiring demographic information and issues related to knowledge and use of OCs was completed by women (n = 1571), who have had used OCs at least once in their lifetime. A model was created to assess the effects of knowledge, attitude and previous experience on the patterns of OCs utilization.
Jordanian women exhibited positive attitudes towards OCs efficacy and safety. This positive attitude was approvingly associated with the patterns of use. However, only half of participating women reported that they knew how to use OCs. About 60 % of women received recommendations for OCs use from a physician. Moreover, women’s knowledge about OCs mechanism of action was obtained namely from physician (29.9 %). Side effects were reported in 75.1 % of participating women. Reported side effects were headache (41.2 %), mood swings (35.5 %), irritability (33.5 %) and weight gain (28.7 %). Interestingly, the occurrence of side effects was the main reason for OCs discontinuation.
The study showed that women who have positive attitude toward OCs tend to utilize them more appropriately. However, there is still need for educational programs to enhance knowledge about OCs utilization in Jordan.
Contraception, the deliberate prevention of pregnancy, can be achieved via several approaches. Some contraceptive methods prevent the release of secondary oocytes and sperms from gonads, others limit sperm access to the mature egg to prevent fertilization, whereas certain contraceptive methods allow fertilization to occur before, ultimately, preventing implantation of an embryo. Except for complete abstinence from sexual intercourse, the incidence of unwanted pregnancies might occur with any of the contraception methods [1–3].
Demographic studies in Jordan indicate that the annual fertility rate is 4.4 per woman , with fertility rate being defined as the average number of live births or children per woman . While 1 in 4 women, worldwide, recommence to have a fourth child after three consecutive pregnancies, 50 % of Jordanian women who have had three births would try to get pregnant again within 2 years . The relatively high fertility rate in Jordan with the allied short birth interval between births can be attributed to the lack of knowledge available on possible contraception methods [7, 8]. In addition, several demographic and non-demographic factors have been shown to influence Jordanian women’s beliefs about contraception [6, 9]. Indeed, religion, education, employment and gender of children were among the most prominent factors that influence Jordanian women’s beliefs and behavior towards contraception [10–13].
Oral contraceptives (OCs), are one of the most prevalent forms of reversible contraceptive methods used among women of reproductive age worldwide [14, 15]. In Jordan, OCs are the second most popular method of contraception preceded by the intrauterine devices . Unfortunately, Jordan Pharmacy law has no regulations to restrict prescription medications use, hence, OCs can be obtained from community pharmacies without prescription. In spite of their widespread utilization in Jordan, several misconceptions dominate common knowledge of Jordanian women regarding OCs. In 1996, Farsoun et al. identified decisive hurdles to the use of modern contraceptive methods in Jordan. Serious side effects due to OCs, such as cancer, back pain, headaches, dizziness, hair loss, weight gain, and infertility, were all linked to Jordanian women’s beliefs about OCs.
During the last decade, augmented emphasis on the use of OCs to prevent pregnancy has been practiced by media to promote their utilization among Jordanian women. The later also comes along with education to enhance their awareness of safe and effective use of OCs. In spite of that, no studies have taken place since the last two decades to address this issue. Studies exploring the knowledge, attitude and patterns of OCs use among women in Jordan are, therefore, needed. In fact, Jordanian women could potentially benefit from increased information and advice on OCs to ensure better and regulated use that is compatible with their therapeutic purpose. Hence, the aim of this study was to describe four different aspects of OCs utilization among women in Jordan; patterns of use, attitude toward use, knowledge and previous experience. The study also aimed to determine where women acquire advice and whom they consult regarding their OCs utilization.
Ethical approval to perform the study was obtained from the Scientific Committee at the Deanship of Scientific Research at The University of Jordan. Participants’ information remained confidential and within the institution. Verbal informed consent to participate in the study was obtained based on a standard written statement.
Jordanian women who, were married, able to give informed consent, and used OCs at least once in their lifetime, were asked to participate in the study. Many misconceptions, like fear of side effects, especially among unmarried females are strongly dominant among Jordanian women towards the use of contraceptives. Indeed, very small percentages of OCs users are unmarried females and thus this sample criterion was designed to suit the sociocultural characteristics of the Jordanian community.
Data were collected from women living in different districts of Jordan. Selection was performed via a convenient non-random sampling technique from women who visit community pharmacies, fertility, obstetrics and gynecology outpatient clinics in the capital city of Jordan, Amman. The study took place between March 2013 and December 2013.
The study questionnaire was structured based on initial discussions with women, using OCs, and health professionals (Additional file 1). Furthermore, the questionnaire was validated by a committee whose members were health professionals, consisting of three family medicine physicians, a pharmacist, and a nurse. The questionnaire was written in English and then translated into Arabic. Both versions of the questionnaire were checked by three members of the public with no medical background.
The questionnaire was administered by well-trained administrators on each site. The principle investigator coordinated the logistic aspects of questionnaire distribution, data collection, and following responses. The questionnaire gathered data about four aspects of OCs use; patterns of use, attitude toward use, knowledge and previous experience. This was based on the hypothesis that three predictor variables, knowledge, attitude and previous experience, can influence the patterns of use of OCs. Knowledge was measured through direct questions inquiring whether participants know how OCs manifest their action in the body, how to self-administer OCs, how to maintain the efficacy of OCs, and if OCs have potential drug-drug interactions. Secondly, attitude was assessed by asking the participants if they prefer to use OCs, if they think OCs are effective, or safe, or if they fear side effects. Previous experience was measured via asking whether OCs were successful in preventing pregnancy, or if side effects ensue that women had to stop their pill use (refer to Table 2 for detailed description of items). Patterns of use, which is the outcome variable, was evaluated by examining the purpose of pill use, and whether or not women had received doctor’s consultation or prescription before using the pill.
Data were coded, entered and analyzed using Statistical Package for Social Sciences program (SPSS) database for Windows, version 17 (SAS Institute, Cary, NC). The analysis of answers involved descriptive quantitative statistics e.g. frequency and percentage. Chi-square and Fisher exact tests were used to test for significant association between groups.
A pattern of use, i.e. the outcome variable, was converted into a categorical variable: the sum of three variables was obtained (pill used for birth control purposes, doctor consultation obtained, and pill was prescribed). Those who scored < two were defined as inappropriate users, while those who scored > two were considered as appropriate users. In the same way, the predictors were decoded into categorical variables. Attitudes were considered positive if a score of more than 3 out of 5 was achieved, good knowledge and experience is defined as a score more than 3 out of 5 and 4 out of 6; respectively. To assess the relationship between knowledge, attitude, previous experience and the patterns of use, logistic regression was utilized. All hypothesis testing was two-sided, with a probability value of 0.05 deemed as significant.
Demographic characteristics of women using oral contraceptives in Jordan, 2013
N (VALID PERCENT %)
Age in years (n = 1564)
Education (n = 1543)
Occupation (n = 1530)
Residence city (n = 1538)
Monthly income of the family (n = 1542)
< 1000 JOD
> 1000 JOD
Marriage duration (n = 1462)
< 1 year
More than 5 years
Number of previous pregnancies (n = 1376)
Number of children (n = 1428)
More than four
Number of abortions (n = 1448)
Patterns and attitudes
Oral contraceptives utilization pattern, attitude and knowledge
N (VALID PERCENT %)
PILL UTILIZATION PATTERN
Purpose of Use (n = 1571)a
Doctor consultation before use (n = 1553)
Pills were prescribed (n = 1538)
ATTITUDE TOWARD PILL USE
Prefer use of pills as method of contraception (n = 1519)
Reasons for preferring pills (n = 1571)
Ease of use
Suitability for body
Think pills are safe (n = 1519)
Think pills are effective (n = 1506)
Fear of pills’ side effects
Believe pills can causea
PREVIOUS EXPERIENCE WITH PILLS
Pills were effective (n = 1296)
Ever had side effects (n = 1561)
Ever stopped pills (use alternative method) (n = 1406)
Reason for stopping pillsa
Difficulty of use
Pills recommended bya
How to use pill (n = 1497)
Source of knowledge about mechanism of pills’ action
If medications can counteract the pill efficacy (n = 1494)
Antibiotics can counteract the pill (n = 1492)
Received instructions how to use the pill (n = 1509)
Received instructions to maintain pill efficacy (n = 1490)
Although (82.5 %) of the participating women received consultation from the physician, only half of women knew how to use OCs (Table 2). Surprisingly, very little consultation was obtained from pharmacists (Table 2). Only 15 % of the participating women knew that certain medications could decrease OCs efficacy, and consequently, about the same percentage reported the knowledge that antibiotics may deactivate OCs. Nevertheless, 74.4 % of women got instructions for OCs use from physicians.
Binary logistic regression of knowledge, attitude and previous experience with utilization of oral contraceptives
95 % CI of OR
Pearson correlation of individual characteristics with oral contraceptives utilization
Prefer using pills as a method of contraception
Reason for preference is suitability for body
Reason for preference is effectiveness of pill
Thinks pills are effective
Thinks pills are safe
Thinks pills cause infertility
Pills were effective
Knowledge how pill works
Source of knowledge about mechanism of pills’ action is physician
Source of knowledge about maintenance of pill efficacy is physician/pharmacist
Source of knowledge about use of pill is physician/pharmacist
Pill was recommended by physician
Pill was recommended by pharmacist
Pill was recommended by family
Pill was recommended my neighbors
Pill was recommended by media
Ever suffered from side effects
Side effects as reason for stopping the pill
Ever suffered from headache
Ever suffered from breast swelling
Interestingly, even if women suffered from side effects, the tendency of appropriate use increases (83.9 vs 78.0 %), specifically if the side effect experienced was headache (85.7 % vs 80.1 %) or breast swelling (91.6 % vs 91.8 %). However, the percentage is less if women believe that pills could cause infertility (77 % vs. 83.2 %). This result implicate that the aforementioned side effects would be experienced despite the appropriate use of OCs.
When women are more knowledgeable about the mechanism OCs action, they will have a higher probability of appropriate use (88.5 % vs. 75.4 %); especially if the physician was the source of knowledge (96.7 % vs. 76.2 %) and if the physician/pharmacist informed them how to maintain pill efficacy (91.1 % vs. 75.3 %) and how to use the pill (88.8 % vs. 64.4 %).
This is the first large cross-sectional study to evaluate oral contraceptives (OCs) utilization patterns among Jordanian females of a wide age range (18–50 years). This study used rigorous comprehensive and face-to-face interview. Furthermore, the later was filled in a reliable, valid questionnaire. In addition, this study was designed to unravel the attitude of Jordanian female population specifically towards OCs and, therefore, promote education programs that could preferentially enhance OCs utilization in Jordan.
In this study, Jordanian women showed a good pattern of OCs utilization; the majority of them were using OCs for birth control purposes, and they received prescriptions and consultations from physicians. Interestingly, no significant differences in OCs utilization pattern were found according to demographic variables, i.e. age, education, outcome, etc. In addition, Jordanian women have positive attitudes regarding OCs efficacy and safety. However, only half of women self- reported that they knew how to use OCs, and only few of them are actually aware of medications that can decrease the pill efficacy. Most women received recommendations for OCs use from a physician. Moreover, the physician was the main source of knowledge for OCs. Unfortunately, the contribution of other healthcare professionals, such as pharmacists and nurses, was minor. All items of knowledge were positively correlated with the use patterns.
Surprisingly, women who suffered from side effects were more likely to be appropriate users. This might be attributed to the fact that the side effects, mostly experienced by these women, were minor in nature, ranging between headache, mood swings and irritability, and consequently women were least concerned about them. On the other side, suffering from side effects was the main reason women to stop OCs and switch to an alternative contraception method. Collectively, the positive attitude toward use was highly correlated with the use patterns.
Historically, there was a negative attitude toward the use of OCs in middle-eastern societies, and Jordan was not an exception [8, 11, 12, 16, 17]. Many misconceptions, like fear of side effects and underestimating efficacy, prevented women from OCs use . In 2004, Kirdli et al. showed that positive attitude and beliefs were among the factors that contributed to Jordanian women’s intention to use OCs, which complies with the results from our study. Since then, many educational programs were implemented to enhance women’s attitudes and knowledge on the rationale use of OCs. Consequently, we expect a leap with regard to these aspects within the last 10 years.
In addition, individual , sociocultural , institutional and political  factors that are substantial in women’s preferences related to OCs use have been investigated in different countries. Among the factors that have specifically captured the attention of healthcare researchers is the attitude of women towards OCs [22, 23]. Unfortunately, most studies were designed to investigate attitudes toward contraceptives in general . Limited number of studies has been designed to study attitudes toward specific contraceptive methods such as OCs. This study was designed to unravel the attitude of Jordanian female population towards OCs and, therefore, promote education programs that could preferentially enhance OCs utilization in Jordan. In addition, no studies have ever described the knowledge of Jordanian population about rationale pill use, and patterns of utilization. The aim of this study was, therefore, to describe four different aspects of pill utilization including patterns of use, attitude toward use, knowledge and previous experience.
Our findings imply that more education programs about OCs use are still warranted. Although more than half of participating women self-reported that they knew how to use OCs, few women could identify medications that interact with OCs, or interfere with their efficacy. Less than 50 % received instructions on how to maintain the efficacy of OCs to prevent pregnancies. For most cases, physicians were the main source of knowledge. Hence, there is a need to increase the contribution of other healthcare professionals such as nurses and pharmacists into the education process, especially about the rationale use of OCs and how to maintain their efficacy. Furthermore, it is essential to enhance the role of other accessible sources of knowledge such as media, workshops, focus groups and internet, in the improvement of women awareness toward OCs use as a critical part of the family planning continuum.
One of the limitations of this study, which is inherent to cross-sectional studies, that it can only assess association between variables at one point of time. In addition, a convenient non-random sampling technique was adopted which, at least in part, explains that most of women in the study resides in Amman, the capital of Jordan. It will be therefore hard to generalize our findings to residents in other cities of Jordan.
In conclusion, this study revealed an improvement of utilization patterns and attitudes towards OCs among Jordanian women over the last 10 years. However, there is still a gap in the knowledge about how to use OCs and how to maintain their efficacy. The study showed that women who has positive attitude toward OCs use tend to utilize them more appropriately. Educational programs provided via various healthcare professionals and other sources can enhance women’s knowledge about the rationale OCs utilization, and thus maximize beneficial effects and reduce side effects. The later will increase the tendency of having positive experience and thus positive attitudes toward OCs usage. It would be crucial for future researchers to investigate attitudes and knowledge of OCs use in women who have never used OCs and compare it to those who have had used them, as well as compare it toward that of using alternative contraceptive methods, such as intrauterine devices, and transdermal batches. Moreover, studying the effect of various educational programs on the appropriate utilization of OCs is warranted.
The authors would like to thank the questionnaire participants who kindly devoted their time to the study. The authors would also like to acknowledge The Deanship of the Scientific Research at The University of Jordan for financial support and the volunteer students who participated in data collection and questionnaire administration.
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