Can youth get the contraception they want? Results of a pilot study in the province of Quebec

Abstract

Objectives

Canadian contraceptive providers report many barriers to access to contraception, and perceive youth as particularly vulnerable to these barriers. This study explores Quebec youth’s experience of obtaining contraception.

Methods

A convenience sample of Quebec youth (aged 14 to 21 years) participated in an online anonymous survey of their experiences obtaining contraception. Data were collected between June 1, 2016 and December 31, 2016.

Results

One hundred and five youth were eligible to participate. Of these, 95 had used at least one form of contraception. Twelve (13%) reported not being able to obtain their preferred method of contraception, with cost being the most common barrier (N=10). Eleven participants (12%) stopped using their preferred contraceptive method: cost was a factor in four cases, and difficulty with access to the clinic/prescription in seven. Youth who required confidential access experienced more difficulty obtaining contraception (P<0.01).

Conclusion

Despite benefitting from universal pharmacare and a network of youth sexual and reproductive health clinics, Quebec youth still experience barriers to obtaining and continuing their preferred contraceptive. Youth who desire confidential care are more likely to experience difficulty obtaining contraception.

In Canada, in 2014, almost 20,000 young women under 20 became pregnant (Vital Statistics), of which 83% were unintended (1). Yet in a survey of sexually active Canadian women not desiring pregnancy, up to 14% of youth ‘never’ or only ‘sometimes’ used contraception (2). Additionally, only 1% was using intrauterine contraceptives (IUCs), the recommended first-line method for all adolescents (3).

Both individual and systemic factors contribute to the failure to use contraception and to do so consistently, despite not desiring pregnancy. While individual factors such as contraceptive knowledge and contraceptive self-efficacy (4) are of significant importance, this paper focuses on the systemic barriers to access to contraception experienced by Canadian youth. A qualitative study of Canadian contraception providers reveals many barriers to accessing contraceptive care: access to health care providers, inadequate reproductive health knowledge and skills of health care providers, negative attitudes of health care providers toward contraception, and difficulty obtaining confidential services. These professionals identify cost as the single most important barrier to access to contraceptives, with adolescents being the most vulnerable to this barrier (5).

The use of IUCs is particularly sensitive to cost as a barrier, even in Canada where insertion of the device is covered by provincial health insurance. Amortized over the device’s duration of effectiveness, it is no more expensive than any other method, and in fact is less expensive than short-acting hormonal methods, but it has a substantial upfront cost (6). One Canadian study of adult women who had undergone a second trimester abortion found that more than half of women opted for an IUC as their contraceptive method when it was offered at no cost (7). This is in contrast to 11% in a similar cohort who obtained it with their usual source of pharmaceutical care (provincial insurance, private insurance, or out-of-pocket) (8), and to 4% in the general population (2).

Universal health care facilitates the delivery of confidential contraceptive care in Canada. All provinces recognize the right to confidential care of an adolescent provided she has capacity to comprehend and consent to her care (and is over age 14 if living in Quebec). However, two prominent issues remain: in small communities, youth (and adults) may not be able to access that care without being seen entering the premises thus indirectly affecting the ability to receive confidential services; and youth who have private pharmaceutical insurance cannot access it confidentially since the primary insured person is always informed of the benefits that have been provided to dependents.

Contraceptive services are delivered to youth through a patchwork of strategies across Canada: free-standing family planning clinics; school-based clinics; expanded scope of practice agreements allowing nurses and/or pharmacists to prescribe contraceptives. The province of Quebec provides a network of Youth Health Clinics situated in the local community service (CLSCs), and focused on sexual and reproductive health services. In many instances, these clinics also provide outreach to local high schools. Additionally, all Quebec residents are mandated to have pharmacare. This is provided through the provincial health plan at no cost to those receiving social assistance benefits; through private insurance provided by an employer; or from the provincial health plan on a sliding scale to the remaining residents. Youth are covered under their parent’s plan until age 25 if they are in school full time. The combination of Youth Health Clinics, and universal pharmacare is perceived to provide excellent access for Quebec youth (5).

We are interested in understanding Canadian youths’ contraceptive experience with specific attention to the systemic barriers that prevent them from initiating or continuing a desired method. In order to test our survey questions and our survey dissemination strategy, we elected to pilot the survey in the province of Quebec. This paper presents the results of the pilot study. To our knowledge, this is the first Canadian study directly examining adolescents’ experience of barriers to obtaining their contraceptive of choice.

METHODS

Participants aged 14 to 21 years were invited to complete an anonymous self-administered online survey on the topic of contraception. The survey was open to both male and female participants and worded in such a way as to refer to the contraceptive behaviour of the couple rather than the respondent. The survey was tailored to a grade 6 reading level (Flesch-Kincaid score 70 and higher).

Advertisement for the study was posted in clinic spaces, public spaces (e.g., malls), and schools. Youth could either scan a QR code that would connect to the survey or could access the link through a Facebook page created for this purpose. At completion of the survey, youth could access a separate, unique link that would allow them to enter a draw for a $50 prepaid credit card. Survey responses could not be linked to the identifiers provided for the draw.

Recruitment occurred from June 1, 2016 to December 31, 2016. Participants who did not report their age were ineligible.

Study data were collected and managed using Research Electronic Data Capture (REDCap) software (9). Geomapping of respondents’ postal codes was performed using the online tool: Batch Geo (10). Data analysis (Chi square) was performed using IBM SPSS Statistics for MacIntosh, Version 23. The study protocol was approved by the McGill University Health Center’s Research Ethics Board.

RESULTS

One hundred and seventeen respondents accessed the survey, of which 105 met age criteria and consented to participate. Mean age was 18. The demographic characteristics of the sample are reported in Table 1. Eighty-two (78%) respondents provide a partial postal code. Geomapping linked the vast majority (N=70) to the Montreal area, with nine respondents living in two other metropolitan areas and three in rural or remote areas.

Table 1.

Demographic characteristics of respondents

		Mean (SD)	Total (%)
Age		18.0 (1.9)
Gender	Female		92 (88%)
	Male		12 (11%)
	Other		1 (1%)
Language preference	English		72 (69%)
	French		33 (31%)
In school			97 (92%)
Working	Part time		66 (63%)
	Full time		5 (5%)
	Not working		34 (32%)
Source of Survey	Clinic/Hospital Intranet		33 (31%)
	School/Mall		25 (24%)
	Friend		27 (26%)
	Facebook		20 (19%)
Private Insurance			20 (19%)

Table 2 describes the various contraceptives used, and who paid for them. Ten respondents had never used a method of contraception, but had also never attempted to obtain contraception, nor had they experienced vaginal-penile intercourse.

Table 2.

Contraceptive methods ever used and source of payment

		Method # reporting (% of 95 total users)							Total reporting payment source
		Condom 71 (76%)	OCP 58 (62%)	Patch 5 (5%)	Ring 8 (9%)	Depo 5 (5%)	IUD 1 (1%)	IUS 3 (3%)	All methods	Prescription methods
Who pays	Female partner	32	31	2	2	2	1	1	71	39
	Male partner	59	3	0	0	0	0	0	62	3
	Parents	7	20	3	2	2	0	2	36	29
	Free	24	5	0	2	1	0	0	32	8
	RAMQ*	0	8	1	1	1	0	0	7	7
	Private insurance	0	15	1	1	0	0	3	20	20
	I don’t know	2	1	0	0	0	0	0	3	1

*Régie de l’assurance maladie de Québec—the provincial single payer health plan.

OCP oral contraceptive pill; IUD Intrauterine device (copper); IUS Intrauterine system (hormonal)

Of the 95 contraceptive users, 12 could not obtain their desired method and 11 stopped a method they were happy with (Figure 1). Cost was identified as a factor in many of these cases. Of those receiving free prescription contraceptives, the vast majority (71%) depended exclusively on the free supplies (Table 2).

Figure 1.

Youths’ contraceptive experience.

Youth were asked to rate the ease of access to contraception on a five-point Likert scale. Of the 61 youth who answered this question, most (54) felt that obtaining contraception was easy (neutral or better). Youth who perceived access as difficult or very difficult had nonetheless still used some form of contraception. Youth who endorsed the statement “I NEVER want my parents to find out that I use birth control,” were more likely to feel that it was difficult to get birth control (Pearson Chi square; data dichotomized to difficult/not difficult; absolutely confidential/OK if parents know; P<0.01). Only 20 respondents indicated that they were covered by their parents’ private pharmaceutical insurance, and 12 of them thought that they could access it confidentially.

Table 3 categorizes free-text suggestions youth had for improving contraceptive access using Bertrand’s classification of factors affecting contraceptive use: Cognitive, Economic, Geographic, Administrative, and Psychosocial (11).

Table 3.

Youth suggestions on ways of reducing barriers to contraceptive access

		Themes	Number of times suggested*
Administrative	28	Condom distributors in schools, hospitals, bars, public bathrooms	1
		Make contraception available in school	7
		Contraception integrated into general health care/don’t refer	5
		Allow nurses to prescribe all methods of contraception	3
		Allow pharmacists to prescribe contraception	2
		More clinics/more appointments/faster appointments	4
		Make prescription renewals easier	2
		Make contraception over the counter	3
		Sell contraceptives in more accessible places	1
Economic	22	Make contraception free for youth	15
		Reduce the cost of contraception for youth	7
Cognitive	1	Educate youth about where to get contraception/all the available methods/and how to get it at low/no cost	1
Psychosocial	5	Decrease the taboo around using contraception	1
		Many girls afraid of having their parents know—make it cheaper, talk about other indications	3
		Parents should give them to kids, even just in case	1

*49/105 respondents made suggestions. Some respondents provided more than one suggestions.

DISCUSSION

Access to comprehensive sexual and reproductive health care, and in particular contraception, empowers women of all ages to define their vision of full potential and achieve it (12). Youth in Quebec are perceived to enjoy privileged access to contraceptive care compared to their Canadian peers (5). However, this study indicates that even Quebec youth experience barriers to obtaining contraception.

Fifteen per cent of the contraceptive users in this study identify cost as a barrier to obtaining (N=10) or continuing (N=4) the contraceptive they desire, and almost half of the youth suggest cost reduction as a means of improving contraceptive access, both indicating gaps in the ‘universality’ of pharmaceutical coverage.

The first gap in ‘universality’ is the co-pay. The provincial pharmaceutical insurance plan covers 100% of the cost of any contraceptive (except for the copper IUD, which is not considered a drug) for all youth under 18, and those under 25 who are engaged in full-time studies. However, youth with private insurers and youth between 18 and 25 who are covered by the public plan but are not in school must pay a portion of the cost of the contraceptive, ranging between 10 and 30% of the total cost. In some cases, youth with private insurers must pay the entire cost up front and be reimbursed later. In this study, four respondents reported not obtaining their desired contraceptive because neither they nor their parents could afford it. This is in line with the adult data that show that out-of-pocket costs can influence the use of contraception and the type of contraception used (13–16). In particular, out-of-pocket costs reduce the use of highly effective IUCs (8).

The second gap in ‘universality’ is that youth who wish to acquire contraception without their parents’ knowledge, and who are covered under private pharmaceutical insurance, must pay for the contraceptive entirely out of pocket. If the pharmacist bills the insurance company, a report is automatically sent to the primary cardholder. Half of the youth who could not obtain the contraceptive method they desired (6/12) were confronted with this situation. This may explain the association between respondents’ preference for confidential use of contraception and their perceived difficulty in accessing contraception (Table 2).

The third gap in ‘universality’ is youths’ lack of knowledge of their pharmaceutical coverage and how it works. Twenty of the 105 respondents reported having private pharmaceutical coverage. This is in contrast to provincial data that indicate that 52% of the population has private pharmaceutical coverage (17). Further, more than half (12/20) of the respondents who report having private pharmaceutical coverage, incorrectly believe that they could access that coverage without their parents knowing. One respondent indicated (free text) that this belief resulted in her parents learning of her sexual activity.

Our data also show that, except for condoms, youth generally do not receive no-cost contraception directly from the provider. This is not surprising in view of the fact that the youth community clinics have a limited supply of prescription contraceptives, usually obtained from pharmaceutical companies as marketing samples. This limits the free contraceptives to the newest oral contraceptive pills, the transdermal patch, and the vaginal ring. Youth who depend on marketing sample supplies cannot access long-acting reversible contraception, have limited choices of short-acting reversible contraception, and must change their contraception form or brand when the supply is interrupted. Since contraceptive adherence is higher among adult women who receive a year’s supply of contraception compared to women who receive a year’s prescription, or to women who receive a smaller number of pill packs (18), and since the public system pays for almost half of the costs of prescription contraceptives, administrative solutions should be sought to deliver contraceptives directly to the users in the youth clinics.

The youth clinic system is meant to address administrative barriers to accessing reproductive health services. Such administrative barriers would include the hours of operation; the availability of walk-in services, same day, or next day appointments; the mechanism by which appointments are scheduled, the requirement for frequent renewal of the prescription (e.g., every 3 or 6 months). Yet, the Quebec system does not appear to be a panacea for administrative barriers to contraception. Seven per cent (7 of 95) of the contraceptive users stopped using their preferred method due to administrative barriers (2 ‘could not return to clinic’, 5 ‘prescription expired’). In free-text responses, administrative modifications are the most common improvement to access that youth suggest. In particular, they request having all physicians, including paediatricians, prescribe contraceptives themselves rather than refer the youth to another practitioner (e.g., a family practitioner or gynecologist) for contraception. This is in line with the evidence that integrated care yields better youth health outcomes than problem-based service delivery (19,20), and that youth prefer integrated services (21). It is particularly important in a health care environment such as Quebec’s where physicians are in short supply and the delay to obtaining the consultation can be considerable.

The vast majority of respondents in this survey still use condoms and/or oral contraceptives to prevent pregnancy (Table 2). Intrauterine contraceptives are used by only 4% of the sample, which is slightly better than the 1% reported in 2006, but substantially lower than the 37% of 14 to 19-year olds in the CHOICE study. Much ground must still be covered to optimize the access to contraception for Quebec youth.

Extrapolation of this data must be done with caution: the sample size is small, and it is not representative of Quebec youth with respect to urban versus rural residence, preferred language of communication, gender, age, and school participation. The fact that each province and territory has its own health care and pharmacare landscape, further limits the generalizability of the data to the rest of Canada.

The biased sampling underscores the need for an alternative advertising strategy that would solicit a broader cross-section of the population. Part of our dissemination strategy was snowball sampling—the dissemination of the survey by respondents. This would have been more successful had we had the capacity to reward the participant for a successful referral. It would also require up-to-date knowledge of youth social media use: Facebook was not the preferred social media platform for our demographic in Quebec in 2016. Finally, a technological solution would be required to insure that each response was unique, a condition that was not met in this iteration of the study.

Improving access to contraception has been shown to decrease unintended and mistimed pregnancies in youth. Even in Quebec, with its network of community youth clinics and universal pharmacare, youth continue to experience barriers to accessing contraception. The cost of contraceptives can influence youths’ contraceptive choices: mostly interfering with them starting a method they would like to use, but sometimes causing them to stop that method. Needing confidential access to contraceptives is associated with experiencing more difficulty getting contraception. Youth in this study thought that providing contraception at a much lower cost or at no cost would improve access to contraception. They also suggested administrative interventions to making prescription contraceptives more easily available.

Replication of this study nationally would allow identification of barriers that are experienced by all Canadian youth, barriers that are particular to the health care and pharmacare structure of each particular province and territory, and barriers that are related to urban versus rural or remote living. Understanding the challenges that youth face when accessing contraception is pivotal to ensuring that existing programs are performing as desired, and to identifying the gaps that remain.

Funding: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.