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Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United StatesDepartment of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA United States
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United StatesDepartment of Family Medicine and Community Health, University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, United States
We sought to systematically review the literature on values and preferences for contraception among adolescents and young adults globally.
Study design
We searched ten electronic databases for articles from January 1, 2005 through July 27, 2020 regarding end-users' values and preferences for contraception. We included studies that report specifically on people up to 25 years old.
Results
Fifty-five studies out of 7,846 met our inclusion criteria. These studies included participants aged 10-25 years and were conducted in 16 countries. Through open coding, we identified 18 content areas. The five most commonly discussed content areas were: (1) general preferences regarding contraception, (2) contraceptive method benefits, (3) contraceptive method drawbacks, (4) the influence of the social context, and (5) the influence of myths and misconceptions, including safety and side effects, on contraceptive choice. Privacy and autonomy were important overarching themes, along with safety of the method. These considerations affected participants’ access to and use of contraception.
Conclusion
Various social, cultural, and method-specific factors influence a young person's values and preferences around contraceptive methods. Understanding their values and preferences can help providers and programs improve contraceptive care for young people.
The importance of access to sexual and reproductive health care has been recognized by the World Health Organization (WHO) to be fundamental to peoples’ rights, health and well-being [
]. Ensuring access to contraception is a key component of efforts to support sexual and reproductive health, and also reduce both unintended pregnancy and maternal mortality [
]. Adolescence is a time of psychological, social, and physical development and transitions. Unintended pregnancies may be associated with poor maternal and infant outcomes [
]. Decreasing unmet need for contraception and unintended pregnancies among adolescents and young adults requires understanding their values and preferences around contraception. Access to and effective use of contraception in this population can be influenced by a variety of factors, such as health literacy, patient-clinician interactions, cost, issues with confidentiality, and parental consent [
In order to better meet the sexual and reproductive needs of young people and to be able to provide more patient-centered family planning care for young people, providers and health systems need to better understand factors that influence contraceptive decision-making and use. Thus, we sought to systematically review the literature on values and preferences for contraception among adolescents and young adults.
2. Methods
This review is part of a larger set of reviews on values and preferences related to contraception globally; a detailed description of the methods for the larger review is available elsewhere [
]. The objective of this review is to describe from the available literature the values and preferences of adolescents and young adults related to contraception.
We report this review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for quantitative studies [
]. We included primary qualitative and quantitative studies that report values and preferences specifically among reproductive-aged people up to 25 years old, encompassing the age range covering “young people” as defined by the World Health Organization [
]. We included studies related to any combination of the following methods: low-dose (≤ 35 mcg ethinyl estradiol) combined oral contraceptive pills, progestogen-only pills, combined patch, combined vaginal ring, progesterone vaginal ring, combined injectable contraceptives, depot medroxyprogesterone acetate (DMPA), injectable norethisterone enanthate, levonorgestrel and etonogestrel implants, emergency contraceptive pills, copper-bearing intrauterine devices (IUDs), levonorgestrel intrauterine device (LNG IUD), copper-IUD for emergency contraception, physical and chemical barrier methods, fertility awareness-based methods, lactational amenorrhea, coitus interruptus, and female and male sterilization. We excluded case series, review articles, editorials, letters, and conference abstracts or posters. Studies had to describe some aspect of values and preferences, defined as “goals, expectations, predispositions and beliefs that individuals have for certain decisions and their potential outcomes” [
] related to contraception. We excluded studies that solely reported knowledge, contraceptive prevalence, user characteristics, demographic factors associated with use or discontinuation, or contraceptive effectiveness. We included studies from any country or setting and in any language. For studies published in a language other than English, we identified proficient speakers to abstract data.
Ten electronic databases were included in the search: PubMed, PsycINFO, Sociological Abstracts, CINAHL, Scopus, LILACS, WHO Global Health Libraries, Ovid Global Health, Embase, and POPLINE. We also conducted a secondary search of references of relevant review articles. To account for secular changes in values and preferences over time, we included studies that were published between January 1, 2005 and July 27, 2020. Specific search terms are reported elsewhere [
]. For this review, AT screened studies which reported on young people for those that pertained to our research question. AT, KS, AD, and TR extracted data on pertinent study information, including author, year, funding source, study location, study design, study population, contraceptive method(s), and a coded summary of key results. Two authors independently abstracted data for each study, and differences were resolved through discussion and consensus. Using descriptive content analysis [
], AT and KS reviewed the coding across all studies to facilitate comparisons across heterogeneous studies and capture relevant content areas. Meta-analysis was not possible given the wide variety of study designs and outcomes of interest.
Study rigor was assessed using an 8-item measure developed by the Evidence Project for quantitative studies [
]. Both scales were used for mixed-methods studies. Based on the number of items checked in the relevant scales, study rigor was summarized into categories of low, moderate, or high rigor.
3. Results
The complete search identified 7,846 unique articles, of which 76 included young people in some capacity; 55 of those met our inclusion criteria (Fig. 1). The 55 included studies focused on the values and preferences of a total of 9,693 young people aged 10-25 years and were conducted in 16 countries (Table 1). The majority of studies included only females (N = 41); the remaining included both male and female participants (N = 13) or just male participants (N = 1). Most studies (N = 47) were conducted in high-income countries (Austria [
Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.
[Selected aspects of sexual behaviour and the use of contraceptive methods among students of the faculty of education of Palacký University in Olomouc].
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
]). Thirty of the included studies were qualitative, 23 were quantitative, and 2 were mixed-methods. The included studies described values and preferences around male and/or female condoms (N = 31), oral contraceptive pills (N = 27), vaginal ring (N = 9), patch (N = 10), IUDs (N = 27), implants (N = 20), injectables (N = 18), diaphragm and/or cervical cap (N = 10), male and/or female sterilization (N = 9), fertility-awareness based methods (N = 7), emergency contraception (N = 11), withdrawal (N = 11), microbicides (N = 2), and abstinence (N = 2). Study rigor ranged widely, with 20 studies determined to be of low rigor, seven studies of moderate rigor, and the remaining 28 studies of high rigor.
Fig. 1Contraceptive values and preferences of adolescents and young adults: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of publication screening and selection for study inclusion 2005-2020.
Study rigor as measured by an 8-item scale developed by the Evidence Project [9] in quantitative studies and a 9-item checklist modified from the Critical Appraisal Skills Programme qualitative checklist [10] for qualitative studies, and a combination of both scales for mixed-methods studies. Cu-IUD, copper-containing intrauterine device, EC, emergency contraception; DMPA, depot medroxyprogesterone acetate; FABM, fertility awareness based methods LNG-IUD, levonorgestrel-containing intrauterine device; n, number; OCPs, oral contraceptive pills; RCT, randomized controlled trial; STI, sexually transmitted infection; USA, United States of America; yo, years old.
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
[Selected aspects of sexual behaviour and the use of contraceptive methods among students of the faculty of education of Palacký University in Olomouc].
Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.
Method drawbacks, general preferences, pregnancy, social context, facilitators, non-contraceptive considerations, myths and misconceptions, decision-making
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
for qualitative studies, and a combination of both scales for mixed-methods studies. Cu-IUD, copper-containing intrauterine device, EC, emergency contraception; DMPA, depot medroxyprogesterone acetate; FABM, fertility awareness based methods LNG-IUD, levonorgestrel-containing intrauterine device; n, number; OCPs, oral contraceptive pills; RCT, randomized controlled trial; STI, sexually transmitted infection; USA, United States of America; yo, years old.
Through open coding, we identified eighteen content areas across the included studies (Table 2). The five most commonly discussed content areas were (1) general preferences, (2) method drawbacks, (3) method benefits, (4) the social context, and (5) myths and misconceptions.
Table 2Contraceptivealues and preferences of adolescents and young adults: content areas in included studies 2005-2020
Content area
Number of studies
General preferences for contraception Method benefits Method drawbacks Social context Myths and misconceptions Contraceptive decision-making process Influence of past experiences Sexual activity and method use Prevention of sexually transmitted infections Health concerns Gender roles Comparing contraceptive methods Stigma Risks related to contraception and sexual activity Non-contraceptive considerations Pregnancy concerns or desires Barriers to use or acquisition Facilitators for use or acquisition
We defined general preferences for contraception as descriptions of values and preferences around the use of contraception in general, and not related to values and preferences pertaining to a specific contraceptive method. Twenty-four studies discussed general preferences for contraception. Seven studies (conducted in the UK, US, Czech Republic, and New Zealand) found that female participants generally considered nonmenstrual side effects to be important [
[Selected aspects of sexual behaviour and the use of contraceptive methods among students of the faculty of education of Palacký University in Olomouc].
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
[Selected aspects of sexual behaviour and the use of contraceptive methods among students of the faculty of education of Palacký University in Olomouc].
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
]. One qualitative study exploring factors influencing contraceptive decision-making with 51 female participants in the UK specifically described positive non-menstrual side effects (e.g., improvement in acne) [
], and another qualitative study examining reasons for method choices with 30 participants in New Zealand found side effects to be more of a neutral consideration [
]. A qualitative study in Australia examining open-ended survey responses among women who had recently changed a method, and found that method changes happened for beneficial non-contraceptive reasons, such as menstrual suppression, improving acne, or preventing mood swings [
]. One qualitative study exploring contraceptive preferences among people with endometriosis in the UK found that, for some focus group participants, irregular bleeding was a deterrent to contraceptive use in general [
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
Integrating long-acting reversible contraception services into new york city school-based health centers: quality improvement to ensure provision of youth-friendly services.
], participants valued privacy in obtaining services; in the US and New Zealand, participants also described the importance of privacy when using a method [
Twenty-three studies described the perceived benefits of specific contraceptive methods. In a qualitative study using four focus groups to explore contraceptive attitudes with female adolescents in the US, condoms were appealing as they were convenient and easy to obtain, and did not have any side effects [
] found that participants liked cervical barriers because of their ability to control the method and do so privately, to always be prepared, and the overall ease of use. Oral contraceptive pills were seen as safe and familiar by participants in 2 qualitative studies exploring reasons for method use in the UK [
]. In a quantitative study exploring the experiences of adolescents and adults using the contraceptive patch in Austria, adolescents described the patch as convenient and easy to use [
Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.
]. One qualitative study exploring reasons for method choice at an abortion clinic in New Zealand described the potential for lighter periods or amenorrhea with DMPA as a benefit of the method [
] were nearly universally seen as benefits among participants. Views towards the longer durations of these devices were mixed, though some studies found longer durations to be a benefit of IUDs and implants [
More studies (N = 31) described drawbacks of specific methods or types of methods. Side effects from hormonal methods – including weight gain, mood changes, decreased libido, hair loss, or skin irritation (from the contraceptive patch) – were described negatively in 17 studies across seven countries [
Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.
[Selected aspects of sexual behaviour and the use of contraceptive methods among students of the faculty of education of Palacký University in Olomouc].
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
] and sometimes associated with discontinuation. Menstrual changes, either heavy or irregular bleeding or amenorrhea, were described negatively across many studies with regard to implants [
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
]; some participants were concerned about procedural complications or the safety of having a foreign body placed in the uterus, and other concerns were generalized to the safety of hormones. For long-acting reversible contraception, 3 studies found concerns about a lack of control [
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
]. Issues around ease of use of certain methods, such as remembering to take pills or change a patch, having to insert a ring or cervical barrier, or returning to a clinic for injections, were commonly mentioned [
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
]. One qualitative study of 116 young women and men in South Africa exploring condom provision in schools found that some were concerned that condom use would have negative impacts, such as increasing sexual activity or harming academic performance [
Numerous studies (N = 26) described how the social context – specifically societal, religious, community, peer or partner influences – affected contraceptive values and preferences. Ten studies found that the recommendations and experiences of friends had both positive and negative impacts on choice of contraceptive methods [
], while only one qualitative study of young women seeking a new contraceptive method in the US described contraceptive use as a solely personal choice [
]. Two studies mentioned how social goals (e.g., one's sexual identity and life aspirations) and social factors (e.g., maintaining relationships and living according to a moral code) affected contraceptive decision-making [
]. Another qualitative study of attitudes around long-acting contraception among young women in school-based health centers in the US described a social norm that contraceptive use implied sexual activity, a belief held by the participants’ parents, friends, and partners; this deterred some participants from using contraception for non-contraceptive purposes [
]. One qualitative study looking at adolescents’ decision-making process around IUDs in the US mentioned the importance of the participant's mother in choosing a method [
]. Three studies including young men and women in South Africa, Australia, and New Zealand mentioned the importance of privacy, confidentiality, and protecting one's reputation [
Twelve studies looked at the influence of partners or relationships on contraceptive use or choice. Five studies found that relationship status influenced contraceptive choice in a variety of ways [
Evaluation of the contraceptive efficacy, compliance, and satisfaction with the transdermal contraceptive patch system Evra: a comparison between adolescent and adult users.
Fourteen studies described myths or misconceptions related to decision-making around and perceptions of certain contraceptive methods, which tended to influence preferences for certain methods. One qualitative study of condom provision in South African schools identified concerns that availability would increase sexual activity and decrease school performance, leading to a negative perception of condoms [
There were additional concerns related to IUDs and implants, which also tended to discourage their use. With respect to IUDs, a quantitative study conducted in the US found concerns that the amenorrhea associated with the LNG-IUD was unsafe [
]. Another qualitative study in the US found that some teens simply thought they were ineligible for IUDs, even though staff did not hold this misconception [
]. One qualitative study of young women in Scotland found that when shown an implant, some women didn't understand how it could work, leading to mistrust toward the implant [
But you can't reverse a hysterectomy!' Perceptions of long acting reversible contraception (LARC) among young women aged 16-24 years: a qualitative study.
This systemic review set out to examine the values and preferences for contraception among adolescents and young adults. We identified 55 relevant articles that covered 18 content areas across this body of literature. The three most commonly discussed content areas were general contraceptive preferences, contraceptive method benefits, and contraceptive method drawbacks. The importance of method safety, side effects, and effects on menstruation were relevant to both general contraceptive preferences as well as specific method benefits and drawbacks. This review also identified ways that myths and misperceptions about contraception can influence values and preferences. We also found privacy and autonomy and a young person's social context to be influential in their perception of contraception and their comfort with accessing care.
Concerns around hormones, safety, and side effects are not unique to adolescents and young adults; studies exploring the experiences of adults with contraception have highlighted similar concerns [
]. Adolescents and young adults may develop these concerns through a variety of ways, including provider counseling, peer experiences, and their own experiences using various methods. Our review found that young women have diverse and variable preferences for menstrual changes and side effects from contraception and different priorities with regards to safety. Individual preferences and concerns are critical to recognize and address as they can influence contraceptive initiation, continuation, and method-switching.
What may be distinct for this age group is the influence of the social context, which could reflect the unique social and psychological transitions that occur during this time, as well as potential normative cultural values about age and sexuality. This review also found that, across a variety of countries and settings, adolescents and young adults valued privacy and confidentiality with regards to accessing care and the use of the method itself. Privacy of a method was important, as young people did not want their sexual activity or use of contraception to be found out by parents or sometimes peers, though privacy from a partner was not frequently described. Additionally, having autonomy over method choice, use, and discontinuation was also crucial.
These findings are key to understanding how to better approach contraceptive care and structure services for young people globally. Because of the diversity of values and preferences surrounding contraception for young people, counseling must be individualized and responsive to patient priorities. Shared decision-making is a key counseling framework that prioritizes individual values and preferences and recognizes contraceptive choice as a preference-sensitive decision, and this framework should be used to center the needs of adolescents and young adults [
]. While the principles of shared decision-making are universal, special considerations may need to be taken for adolescents and young people with regards to literacy, power dynamics, and legal contexts. Failing to do so risks the imposition of social or provider biases into contraceptive counseling, and providers may ignore or minimize side effects that are important to the young person [
]. Additionally, because the social context is so important for adolescents and young adults, interventions that are guided by conceptual frameworks recognizing the importance of social norms and contexts may be more effective for this age group. A Cochrane review found that social cognitive theory, which frames self-efficacy in the context of individual factors that are influenced by the social environment, may be effective in improving care for adolescents [
], perhaps more so when compared to adults. Finally, as adolescents and young people learn to navigate health systems to obtain sexual and reproductive health care, our findings related to the importance of autonomy and privacy underscore the need for confidential access to care in any organizations that hope to better serve this population.
Strengths of this review include that it is a global assessment of the values and preferences of young people and contraception and that it represents a variety of countries and settings. It also includes diverse methodology, which helps to capture the nuances of describing values and preferences. However, study rigor varied widely, which may limit the quality of this body of literature. Across studies, outcomes were very heterogeneous, which made the overall synthesis of results challenging. While we included any studies exclusively looking at young people as defined by WHO, the included studies used a variety of age ranges which encompassed different subsets of early, middle, and late adolescents as well as early adulthood. These represent distinct developmental stages and may complicate conclusions across this group as a whole. Finally, this body of literature covered the full range of contraceptive methods and a wide scope of countries and settings. However, only two studies were conducted in low-income countries, only one study had only males, and none specified whether they included transgender or gender-diverse participants.
This review highlights the variety of factors that influence a young person's values and preferences around contraceptive methods. Understanding these factors can help providers and programs improve access, counseling, and contraceptive continuation for young people. The values and preferences of adolescents and young adults who live in low-income countries or who identify as transgender or gender-diverse are poorly represented, and represent an important gap in the literature. Future research focusing on the implementation of youth-friendly services should take care to preserve privacy and autonomy, and emphasize shared decision-making to provide care that is tailored to individual concerns and circumstances.
Acknowledgments
This review was supported by the World Health Organization, Department of Reproductive Health and Research. We would like to thank the 2014 WHO MEC Guidelines Development Group for their input and the Johns Hopkins Bloomberg School of Public Health graduate students who contributed to the screening and data abstraction process.
References
World Health Organization
Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations.
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