Contraceptive knowledge and practice among undergraduates at a Canadian university DIANE
MUNZ,
STEPHEN
B.A.
CARSON,
BARRY
BROCK,
LORRAINE
B.Sc. B.ENG.
BELL,
IRWIN
KLEINMAN,
MARIE
ROBERT,
JANINE
SIMON,
B.Sc. B.Sc. B.Sc. B.A.
Montreal, Quebec, Canada
A total of 509 undergraduate
students, aged 17 to 23 years, were tested to assessthe adequacy of their knowledge of methods of birth control. A level of adequate knowledge was arbitrarily defined a priori as one standard deuiationbelow the mean score of a random sampk of second-year ~d~~al students, who were assumed to have more then ~eq~te knowledge on the basis of prior courses in re~rod~ti~e ~h~sio~a~ and hu~n sexuality. Of the u~der~~~te popu~tion sampled, 34 per cent were found to have i~~~e~uat~ knowledge. This ~~~~atio~ is in need of birth control ~nfo~t~on. Qf ~onvir~‘ns in the sampLe, 20.2 per cent risk unwanted regency, the rn~io~‘t~(78.3 per cent) in spite of adequate knowledge. This suggests that lack of motivation, rather than purely lack of information, is an important factor contributing to the unwanted pregnancy rate of the college student population.
THREE TYPE s of studies suggest that lack of information about birth control is a serious problem among young people in general and among college students in particular: the unwanted pregnancy rates, surveys of birth contra1 use, and surveys of birth control knowledge. To the extent that illegitimate is equivalent to unwanted or unplanned, current illegitimacy rates may be taken as evidence of lack of use of contraceptives, which may be due to lack of knowledge. Fujita and associates1 estimated that one of every 11 children are illegitimate (this figure agrees well with Canadian 1971
D.B.S. results,* and that one out of six women gives birth within 8 months after her first marriage. When the mother is in the 15 to 17 or 18 to 19 year age range, the proportion of illegitimate children rises to two fifths and one fifth, respectively; over half the firstborn children of girls aged 15 to 19 were conceived prior to marriage.3 Among unmarried female college students, Iv4cCance and Hall4 found that 10 per cent of nonvirgins had had an unwanted pregnancy.4 Coe and Blum,’ in fact, showed that the rate of pregnancies to unmarried college students not only stopped rising but actually declined after a program providing information and counselling on birth control was established by the university. Others point to the abortion rates of teenagers and young adults as an indication that sexual education and contraceptive counselling are urgently required.’ Reports on use of birth control among college students suggest that a disturbingly high percentage of students risk unwanted pregnancy. In Lundy’s’ study of unmarried female college students, only 45 per cent of sexually active subjects said that they used a method of birth control. Fujita and associates found, among
From the Department of Obstetrics and Gynecotogy, McGill University. Project carried out in the autumn of 1973 at McGill University,
Montreal.
for publication December 18, 1974. Revised March 27, 1975. Accepted March 28, 1975. Repriti requests: Dr. R. A. H. Kinck, Depa&nent of Obstetrics and Gynaew@y, McGill Univers~y, Montreal Received
General
Hospital,
1630
Cedar he.,
Montreal,
Quebec
H3G, IA4, Canada.
499
500
Munz
et al.
unmarried undergraduates, that 54 per cent of males and 46 per cent of females failed to use some form of contraception on every occasion of intercourse. Of those who did attempt birth control, 14 per cent of males and 40 per cent of females depended on withdrawal (which has a clinical failure rate of 20 to 30 per 100 woman-years of exposure,s and 13 per cent of males and 31 per cent of females used rhythm (which has a failure rate of 15 to 30 per 100 woman-years of exposure*.’ Studies by McCance” and Baumar? revealed a similar extent of exposure to unwanted pregnancy, and emphasize the first occasion of sexual intercourse as being particularly likely to occur without use of contraception. To what extent is this ineffective contraceptive behavior due to inadequate knowledge? Direct assessments of the state of undergraduates’ sexual knowledge range from rhe impression of Sarrel and Sarrel,” based on clinical experience, of “widespread ignorance about sex” To Fujita’s’ report of “over-all understanding of the facts,” based on the results of a written questionnaire on basic sexual physiology ancl contraception. Even the more favorable reports, however, found striking gaps in the extent of sexual knowledge, e.g., students had unrealistic perceptions of pregnancy risk’ and half or less of sexually active young people were aware of the correct relationship of greatest risk of pregnancy to the menstrual cycle.“-‘” The aims of the present study were to survey the contraceptive knowledge and practices of undergraduate students at a large Canadian university. In general, we were interested in obtaining a Canadian perspective on sexual activity of college students and on the problems of contraceptive negligence and its sequelae. In particular, we wished to answer the following questions: (1) Do people who have engaged in sexual intercourse have what we consider to be adequate knowledge of contraception? (2) Do those whom we consider adequately informed tend in practice to risk unwanted pregnancy in spite of sufficient knowledge? (3) What sources are most effective in providing adequate knowledge about birth control? Focus on knowledge as a major determinant of birth control use does not exclude consideration of the contributions of motivation and accessibility factors, but rather helps to clarify the relative importance of these factors.
The study The sample. Two groups of students were involved in the study, the pretest sample group and the study sample group itself. The data collected from the
March 1. 19th Am. J. Obstet. Gywol.
pretest group were used in the evaluation of the grading system and in the formulation of a definition of adequate knowledge. The pretest sample consisted of 100 medical students randomly selected from the second-year class. Ot these. 99 responded to our questionnaire. We chose the second-year medical class on the assumption that these students would have more than adequate knowledge about contraception since, at this particular university, they have been exposed to considerable information about birth control in the course of lectures on reproductive physiology and on obstetrics and gynecology, and seminars on human sexuality; unlike their British counterparts. they have also had 4 or 5 years of prior university experience. Arbitrarily, the level of adequate knowledge was defined beforehand as one standard deviation below the mean score of the pretest sample. Since the mean score of the pretest sample was 35.6 (25.9 SD.) out of a possible score of 43, adequate knowledge was defined as a score of 29.7 or above. The study sample consisted of 509 students aged 17 to 23 studying Child Psychology or Psychology Statistics. These classes were chosen because they were large in size and contained students with diversified college backgrounds (i.e., arts, science, commerce, engineering, and religion). Questionnaires were distributed at the beginning of the lecture and were collected 15 minutes later (before the lecture started). Of the 616 responses, 107 were rejected. Seventy were deleted because the answer cards were filled out incorrectly (e.g., two responses for one question); the remainder did not fall into the predefined age distribution (17 to 23). The questionnaire. The knowledge questions were restricted to concepts directly applicable to the prevention of pregnancy and were graded according to difficulty and saliency of information. There were five items on basic knowledge of human reproductive physiology (graded at 3 points each), three items on the relative effectiveness of different methods of birth control (graded at 6 points each for a correct answer and 2 points for a partially correct answer), and five items dealing with information essential to the successful contraceptive use of specific methods (graded at 2 points each). A point biserial correlation between total score and the responses to individual questions showed all of the questions to be valid discriminators between knowledgeable and unknowledgeable subjects. Eight remaining items dealt with the sample characteristics in which we were interesttd: age, sex, major source of information about birth control, subject’s assessment of his own knowledge, whether the subject
Volume Number
Contraceptive knowledge and practice among undergraduates
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501
5
had ever tion used whether unwanted
had sexual intercourse, method of contracepmost frequently by subject or coital partner, subject or coital partner had ever had an pregnancy, and prevalence of “risk-taking.”
Table I. Complete sample, major information on contraception
source of
Results Characteristics of the sample population. The sample consisted of 509 undergraduates; 24.2 per cent of these were male and 75.8 per cent were female. Ages ranged from 17 to 23 years inclusive, with mean age being 19.4. There were 228 students (44.8 per cent of the sample) who were sexually active, i.e., had experienced sexual intercourse at one time or another; 57.7 per cent of males were nonvirgins, compared to 40.7 per cent of females. Virgins were in the majority in each of the age groups 17, 18, and 19 years; nonvirgins were in the majority in each of the older age groups (except among the small population of 22-year-olds, where virgins are in a slight majority). Findings in knowledge and score. The mean score of the study group was 31.4 (t 0.3 SE. = standard error), which is lower than that of the pretest students (as expected) but above the predefined level of adequate knowledge. No marked differences in knowledge emerged between males and females: similar proportions of each had adequate knowledge (66.7 per cent of males, 65.8 per cent of females), and their mean scores were virtually identical (31.5 ? 0.5 SE. and 31.4 & 0.4 SE., respectively). Every age group had adequate knowledge but, surprisingly, there was no improvement in score with age. Of sexually active students, 79.8 per cent were found to have adequate knowledge, compared to only 54.8 per cent of virgins, which suggests that the people who most need contraceptive information (i.e., sexually active students) are more likely to actually have it. Female nonvirgins had the highest mean score (34.4 % 0.5 SE.) probably because they have the greatest incentive to acquire adequate knowledge and avoid pregnancy, followed by male nonvirgins (32.7 -+ 0.7 SE.) and male virgins (29.8 & 0.9 SE.). The mean score of female virgins (29.4 f 0.5 S.E.) puts this group into the inadequate knowledge category; for this group, the incentive to acquire contraceptive information may be outweighed by the social sanctions against expressing interest in premarital sex
1, 4, 9, 14
There were 240 students who thought their knowledge of contraception was inadequate; in 52.1 per cent of cases this agreed with our evaluation of their knowledge
(they
scored
below
29.7
on
the
question-
Printed matter (booklets, pamphlets, etc.) Parents Friends and lovers Sex education course, school, or other educational institution Doctor
Table
II. Trends
Rhythm Postcoital douche Pill Condom IUD Diaphragm and jelly Vaginal spermicides Vasectomv or tubal ligation’ Coitus interruptus Pot luck
373
73.3
67.6
12 68
2.4 13.4
66.7 48.5
31
6.1
80.6
in contraceptive
use
5 1 143 54 4 5 1 0
2.2 0.4 62.7 23.7 1.8 2.2 0.4 0.0
2.8 0.0 62.0 25.4 0.0 0.0 0.0 0.0
1.9 0.6 63.1 22.9 2.5 3.2 0.6 0.0
12 3
5.3 1.3
7.0 2.8
4.5 0.6
naire). Another 269 students thought they had adequate knowledge of contraception; of these, 82.2 per cent did have adequate knowledge by our standards and the 17.8 per cent who did not have adequate knowledge but thought they did are presumably at high risk for inadvertently causing an unwanted pregnancy.* Trends in source of information about contraception are shown in Table I. Each source-except “friends and lovers”-provided adequate information to the majority of students using that source. *Proportionately, more students underestimated than overestimated their knowledge by our standards. This suggests two interesting considerations: (1) our standards were too low or did not test some essential areas of knowledge, or (2) people are unwilling to admit to knowing a lot about contraception, perhaps because it would suggest that they are interested in premarital sexual activity of which peers, parents, and society in general are thought to disapprove and because it would imply that they know enough to take responsible birth control action in sexual encounters, a conclusion that some students may wish to avoid. In this latter regard, it is interesting to note that a higher percentage of the males than of the females underestimated their level of knowledge!
502
Munz et al.
Findings in risk-taking and its consequences. Table II shows trends in use of birth control. Only 1.3 per cent of sexually active students said that they regular11 used no method of contraception. However, 20.2 per cent of nonvirgins currently risk unwanted pregnancy. Risk taking was assessed by asking, “Currently, do you CZVYengage in sexual intercourse without using a,z~ OM’ of the following contraceptive techniques-thepill, intrauterine device, the condom, diaphragm and jelly?” A “yes” response to this question was defined as risking unwanred pregnancy. The methods listed were chosen because they are reported to have a clinical failure rate of 20 or less per 100 woman-years of exposure.R Of the nonvirgin sample, 9.6 per cent reported that they had been involved with an unwanted pregnancy. Since 11.5 per cent of women students but only 5.6 per cent of males reported involvement with unwanted pregnancies, one might suspect under-reporting b! males due to lack of awareness or belief in the pregnancies of girlfriends whom they had not continued to see. Interestingly, the mean score of the unwanted pregnancy group was 32.6 (t 1.4 S.E.), well above the adequacy level. However, 27.3 per cent of these students still had inadequate knowledge of birth control, and 27.3 per cent still took risks.
Comment Of those students who have engaged in sexual intercourse, 20.2 per cent have inadequate knowledge of contraception by our criteria and a similar proportion (20.2 per cent) risk unwanted pregnancy by failing to use an effective method of birth control. Are these the same people? While the mean score of risk takers (33.5 +- 0.8 SE.) was lower than that of non-risk takers (34.0 2 0.5 SE.), it was nonetheless well above the level of adequate knowledge. In fact, 78.3 per cent of risk takers scored above the level of adequate knowledge. This suggests that adequate contraceptive knowledge does not necessarily give rise to adequate contraceptive behavior; intervening factors such as motivation and accessibility play an important part in the risk taking and subsequent unwanted pregnancies of young adults. Some students may use a very effective method of contraception but be abysmally ignorant in terms of their score on the questionnaire. This may reflect the occurrence of social compliance, where a person ignorant about contraception accepts and acts upon the advice of a person (e.g., a physician) designated by society as an expert in this field. Our study was not intended to discover whether students were socially compliant. but rather to determine whether students
possessed the basis for cognitive consensus, i.e.. whether they themselves knew enough about differences in contraceptive effectiveness to be able to accept (or reject) expert advice on the basis of their own knowledge. How does our Canadian student population compare with United States college populations? The percentages of sexually active male (57.7 per cent) and female (40.7 per cent) students are very- similar to U. S. estimates, which range from 45 per cent to 60 per cent’” for males and from 30.5 per cent’ to 47 per cent’ for females. The age at which the population changes from virgin to nonvirgin ma.jority (between ages 19 and 20) agrees well with the findings of Kantner and Zelnick.‘3 In twv areas however. our findings differ markedly from those of U. S. studies. The incidence of risk taking was much lower in our student sample: 90.4 per cent of sexually active students usualI\ used an effective method of contraception and 79.8 per cent always used an effective method of contraception. This contrasts sharply with the findings of Lundy7 and Fujita and associates’ cited earlier, in which half or more of students failed to use any form of contraception. effective or otherwise. Second, a striking 73.3 per cent of our Canadian sample said that printed matter was their chief source of information m birth control, with only 13.4 per cent of students relying on peers. Thornburg, I5 in agreement with earlier li. S. studies b) Ramsey and Bell, found peers to be the most popular chief source of information, used by 37.9 per cent of his sample, with literature accounting for onI) 20.6 per cent (barely ahead of mothers, 19.3 per cent, and schools, 14.8 per cent). Even for sophomore medical students in the United States, peers \qcr-e the main source of information for a majority (57.-l per cent of students.‘” The popularity of printed matter ma! reflect the particular situation at this univeristy, where a comprehensive and detailed birth control handbook has been widely distributed. Nonetheless, it is a little disappointing to note that only 67.6 per cent of students using printed matter have adequate knowledge, parents being just as effective a source of information. This may suggest the need for a more simple and direct guide to rhe essentials of birth control, perhaps a summary of the very thorough birth control handbook. An alternative interpretation, however, and one that is less easily remedied. must also be considered: regardless of the free availability of excellent printed materials on birth control, if people are not motivated to retain or use this information the impact of such materials on their knowledge and usage
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Contraceptive knowledge and practice among undergraduates
of contraception is bound to be minimal. For this group of students, the decision to have intercourse without effective contraception (similar perhaps to the decision to continue smoking or to drive without using automobile seat belts) may be based on factors other than rational or objective considerations. The “unexpected,” unplanned nature of intercourse, and the overwhelming desires of the moment, conflict with the requirement of considerable forethought for use of most methods of birth control.4* s The results of Table II further suggest that the doctor, when used, is a highly effective source of adequate knowledge, emphasizing the need for the physician, especially the campus physician, to take a more active role in birth control education. A university campus of over 15,000 people may be likened to a small city with the important difference that virtually all of its citizens are of a potentially fertile and sexually active age. A more visible univeristy involvement in
503
contraception, e.g., the establishment of a central, easily accessible, and emotionally supportive birth control clinic (as at Yale”) might go far toward improving student willingness to use contraception, as well as providing reliable information and advice. To summarize the chief findings of the study, 34 per cent of the undergraduates sampled were found to have inadequate knowledge. This segment of the population does need more information about birth control but, by far the majority of the students who risk unwanted pregnancy did so in spite of adequate knowledge. This emphasizes that motivation, rather than purely lack of information, plays an important role in the unwanted pregnancy rate of the college student population. We are indebted to Drs. J. G. Lohrenz and R. A. Kinch for advice and encouragement, and to Drs. S. Shapiro, I. Simon, B. Kaplan, and R. Hutcheon for critical reviews.
REFERENCES
Fujita, B. N., Wagner, N. N., and Pion, R. J.: Contraccptive use among single college students, AM. J. OBSTET. GYNECOL. 109: 787-793, 1971. 2. Dominion Bureau of Statistics, Dept. of Health and 1.
3. 4.
5.
6.
7.
8.
Welfare, Canada: Summary of Vital Statistics, Ottawa, 1971. Menken. J.: The health and social consequences of teenage child-bearing, Fam. Plann. Perspect. 4: 45, 1972. McCance, C., and Hall, D. J.: Sexual behaviour and contraceptive practices of unmarried female undergraduates at Aberdeen University, Br. Med. J. 2: 694, 1972. Coe, B., and Blum, M.: The out of wedlock pregnancy: Six year’s experience with a univeristy population, Obstet. Gynecol. 40: 807, 1972. Weisman, A. I.: Open legal abortion “on request” is working in New York City; but is it the answer’, AM. J, OBSTET. GYNECOL. 112: 138. 1972. Lundy, J. R.: Some personality correlates of contraceptive use among unmarried female college students, J. Psychol. 80: 9, 1972. Cherniak, D., and Feingold, A.: McGill Birth Control Handbook, ed. 10, Montreal, 1973, Montreal Health Press, Inc.
9. Bauman,
K. E.: Selected aspects of the contraceptive of unmarried univeristy students, AM. J. OBSTET.GYNECOL. 108~ 203,197O. 10. Sarrel, P. M., and Sarrel, L. J.: Birth control services and practices
sex counselling at Yale, Fam. Plann. Perspect. 3: 33, 1971. 11. Furstenburg, F. F., Marsnick, G. S., and Ricketts, S. A.: How can family planning programs delay repeat teenage pregnancies? Fam. Plann. Perspect. 4: 54, 1972. 12. Goldsmith, S., Gabrielson, M. O., Gabrielson, I., Mathews, V., and Potts, L.: Teenagers, sex and contraception, Fam. Plann. Perspect. 4: 32, 1972. 13. Kantner, J. F., and Zelnick, M’.: Sexual experience of young unmarried women in the United States, Fam. Plann. Perspect. 4: 9, 1972. 14. Kaats, G. R, and Davis, K. E.: The dynamics and sexual behaviour of collesre students. 1. Marr. Fam. 32: 390. 1970. 15. Thornburg, H. D.: A comparative study of sex information sources, J. Sch. Health 42: 88, 1972. 16. Gottheil, E., and Freedman, A.: Sexual beliefs and behaviour of single male medical students, J. A. M. A. 212: 1327, 1970. ”
.,
Appendix: The questionnaire The Medical Students at McGill University would like your assistance by answering the following questions on contraception. The success of this project depends highly on the integrity of your responses, so please follow
the instructions
SAMPLE
1. The sky is:
(1) blue (2) black (3) red (4) grey (5) blue during a clear day, black at night, red with the sunset, grey when it is cloudy.
carefully.
DO NOT PUT YOUR NAME, STUDENT NUMBER, OR ANY OTHER FORM OF IDENTIFICATION ON YOUR IBM CARD. We are not interested, nor will we be able, or try to trace your answers back to you.
QUESTION
-answer panying
the most appropriate IBM card-only
answer with
the
on the accomspecial
pencil
504
Munz et al.
prozri&d-fill in the space completely outside the boundaries. -best
answer
(1) [II
to sample question PI 131 [41 n
without
going
is [5]
(2) (3) (4) etc.
gasm) (5) hot bath preceding
-if you must erase, erase completely so that only ONE answer remains-please do not bend or mutilate your computer card. PLEASE FILL IN ONE ANSWER ON THE IBM CARD PROVIDED FOR THE FOLLOWING QUESTIONS (WITHOUT HELP FROM OTHER SOURCES) Your age as of September 1, 1973 is (choose one from numbers 1 or 2) 1. (1) 15 or under (2) 16 (3) 17 (3) 18 (5) 19 2. (1) (2) (3) (4) (5)
(1) the condom (safe) (2) spermicidal foam or jelly (spermicidal means “kills sperm”) (3) postcoital douche (postcoital = after intercourse. douche = washing) (-I) coitus interruptus (withdrawal before or-
20 21 22 23 24 or more
Your sex is:
(1) male (2) female
4. A woman who has intercourse, is most likrlq become pregnant if intercourse occurs: (1) Just before menstruation (2) during menstruation (3) right after menstruation (4) 2 weeks before menstruation 5. Before which fluid, (1) (2) (3)
to
orgasm there can be a few drops of semen escape (orgasm) = climax; semen = seminal fluid containing sperm) true false don’t know
6. Orle drop containing (i.e., cause (1) true (2) false (3) don’t
of semen (seminal fluid, i.e., fluid sperm) is enough to fertilize an ovum pregnancy):
know
7. For the incidental sexual encounter, of contraception is:
the best form
intercourse
8. Which of the following arrangements represents modes of contraception from nzo.rl to Ircts/ effective in preventing pregnancy? (1) condom (safe), pill, rhythm (2) rhythm, pill, condom (3) condom, rhythm, pill (4) pill, condom, rhythm (5) pill, rhythm, condom 9. For a woman on oral contraceptives to become pregnant, the IPUS! number of‘ days she would have to miss taking rhe pill is: (1) for 2 consecutive days in a normal menstrual cvcle (2) for 7 consecutive days in a normal menstrual cycle (3) for 14 consecutive days in a normal menstrual cycle (4) for more than half the days of a normal menstrual cycle regardless of which days (5) for the whole length of a normal menstrual cycle 10. Vaseline is a good lubricant (1) true (2) false (3) don’t know
for condoms:
1 1. Condoms tend to tear more easily if kept in hot, moist places, like wallets and pockets: (1) true (2) false (3) don’t know 12. The diaphragm can be removed 2 hours following intercourse and still give very good contraceptive protection: (1) true (2) false (3) don’t know 13. Sperm cells, if deposited between the labia majora (vaginal lips), can result in pregnancy, even in a virgin with an intact hymen (protective membrane over vaginal orifice): (1) true (2) false (3) don’t know
Volume 124 Number
Contraceptive knowledge and practice among undergraduates
505
5
14. A woman can avoid becoming not achieve an orgasm: (1) true (2) false (3) don’t know
pregnant
if she does
15. Which of the following arrangements represents the modes of contraception from most to bu.st efficient? (1) IUD (intrauterine device), diaphragm, Coitus interruptus (withdrawal) (2) IUD, coitus interruptus, diaphragm, (3) diaphragm, coitus interruptus, IUD (5) coitus interruptus, IUD, diaphragm 16. The postcoital douche is an effective means of contraception (postcoital = after intercourse, douche = washing): (1) true (2) false (3) don’t know 17. Do you consider that you have adequate edge of birth control? (1) yes (2) no
knowl-
18. Which of the following categories represents your nzujor source of information on contraception? (1) printed, information (e.g., booklets, magazines, etc.) (2) parents (3) friends and lovers (4) a sex education course, school or other educational institution (5) your doctor 19. Have you engaged (1) yes (21 no
in sexual intercourse?
IF YOUR ANSWER WAS “YES” TO OUS QUESTION, THEN PLEASE NUMBERS 20 TO 23.
THE PREVIREPLY TO
IF YOUR ANSWER WAS “NO,” THEN LEAVE THE REMAINING QUESTIONS BLANK. Choose only one method of contraception (from Numbers 20,2 1, and 22) that you, or your partner use most frequently. 20. (1) rhythm method (2) postcoital douche (3) the pill (4) condom (safe) technique listed in No. 2 1 (5) I use a contraceptive and No. 22 most frequently device) 21. (1) IUD (intrauterine and jelly (2) diaphragm (3) vaginal spermicides (4) vasectomy or tubal ligation (5) I use a contraceptive technique and No. 22 rn~stfT~q~nt~~ 22. (1) coitus interruptus (withdrawal) (2) pot-luck technique (3) I use a contraceptive and No. 21 mostfrequently
listed in No. 20
listed in No. 20
23. Have you or a partner in sexual intercourse had an unwanted pregnancy? (1) yes (2) no
ever
24. Currently, do you ever engage in sexual intercourse without using any one of the following contraceptive techniques? -the pill -intra-uterine device -the condom -diaphragm and jelly (1) yes (2) no ANSWERS WILL BE POSTED TOMORROW THOSE WHO ARE INTERESTED. THANK FOR YOUR COOPERATION.
FOR YOU
MUNZ,
STEPHEN
B.A.
CARSON,
BARRY
BROCK,
LORRAINE
B.Sc. B.ENG.
BELL,
IRWIN
KLEINMAN,
MARIE
ROBERT,
JANINE
SIMON,
B.Sc. B.Sc. B.Sc. B.A.
Montreal, Quebec, Canada
A total of 509 undergraduate
students, aged 17 to 23 years, were tested to assessthe adequacy of their knowledge of methods of birth control. A level of adequate knowledge was arbitrarily defined a priori as one standard deuiationbelow the mean score of a random sampk of second-year ~d~~al students, who were assumed to have more then ~eq~te knowledge on the basis of prior courses in re~rod~ti~e ~h~sio~a~ and hu~n sexuality. Of the u~der~~~te popu~tion sampled, 34 per cent were found to have i~~~e~uat~ knowledge. This ~~~~atio~ is in need of birth control ~nfo~t~on. Qf ~onvir~‘ns in the sampLe, 20.2 per cent risk unwanted regency, the rn~io~‘t~(78.3 per cent) in spite of adequate knowledge. This suggests that lack of motivation, rather than purely lack of information, is an important factor contributing to the unwanted pregnancy rate of the college student population.
THREE TYPE s of studies suggest that lack of information about birth control is a serious problem among young people in general and among college students in particular: the unwanted pregnancy rates, surveys of birth contra1 use, and surveys of birth control knowledge. To the extent that illegitimate is equivalent to unwanted or unplanned, current illegitimacy rates may be taken as evidence of lack of use of contraceptives, which may be due to lack of knowledge. Fujita and associates1 estimated that one of every 11 children are illegitimate (this figure agrees well with Canadian 1971
D.B.S. results,* and that one out of six women gives birth within 8 months after her first marriage. When the mother is in the 15 to 17 or 18 to 19 year age range, the proportion of illegitimate children rises to two fifths and one fifth, respectively; over half the firstborn children of girls aged 15 to 19 were conceived prior to marriage.3 Among unmarried female college students, Iv4cCance and Hall4 found that 10 per cent of nonvirgins had had an unwanted pregnancy.4 Coe and Blum,’ in fact, showed that the rate of pregnancies to unmarried college students not only stopped rising but actually declined after a program providing information and counselling on birth control was established by the university. Others point to the abortion rates of teenagers and young adults as an indication that sexual education and contraceptive counselling are urgently required.’ Reports on use of birth control among college students suggest that a disturbingly high percentage of students risk unwanted pregnancy. In Lundy’s’ study of unmarried female college students, only 45 per cent of sexually active subjects said that they used a method of birth control. Fujita and associates found, among
From the Department of Obstetrics and Gynecotogy, McGill University. Project carried out in the autumn of 1973 at McGill University,
Montreal.
for publication December 18, 1974. Revised March 27, 1975. Accepted March 28, 1975. Repriti requests: Dr. R. A. H. Kinck, Depa&nent of Obstetrics and Gynaew@y, McGill Univers~y, Montreal Received
General
Hospital,
1630
Cedar he.,
Montreal,
Quebec
H3G, IA4, Canada.
499
500
Munz
et al.
unmarried undergraduates, that 54 per cent of males and 46 per cent of females failed to use some form of contraception on every occasion of intercourse. Of those who did attempt birth control, 14 per cent of males and 40 per cent of females depended on withdrawal (which has a clinical failure rate of 20 to 30 per 100 woman-years of exposure,s and 13 per cent of males and 31 per cent of females used rhythm (which has a failure rate of 15 to 30 per 100 woman-years of exposure*.’ Studies by McCance” and Baumar? revealed a similar extent of exposure to unwanted pregnancy, and emphasize the first occasion of sexual intercourse as being particularly likely to occur without use of contraception. To what extent is this ineffective contraceptive behavior due to inadequate knowledge? Direct assessments of the state of undergraduates’ sexual knowledge range from rhe impression of Sarrel and Sarrel,” based on clinical experience, of “widespread ignorance about sex” To Fujita’s’ report of “over-all understanding of the facts,” based on the results of a written questionnaire on basic sexual physiology ancl contraception. Even the more favorable reports, however, found striking gaps in the extent of sexual knowledge, e.g., students had unrealistic perceptions of pregnancy risk’ and half or less of sexually active young people were aware of the correct relationship of greatest risk of pregnancy to the menstrual cycle.“-‘” The aims of the present study were to survey the contraceptive knowledge and practices of undergraduate students at a large Canadian university. In general, we were interested in obtaining a Canadian perspective on sexual activity of college students and on the problems of contraceptive negligence and its sequelae. In particular, we wished to answer the following questions: (1) Do people who have engaged in sexual intercourse have what we consider to be adequate knowledge of contraception? (2) Do those whom we consider adequately informed tend in practice to risk unwanted pregnancy in spite of sufficient knowledge? (3) What sources are most effective in providing adequate knowledge about birth control? Focus on knowledge as a major determinant of birth control use does not exclude consideration of the contributions of motivation and accessibility factors, but rather helps to clarify the relative importance of these factors.
The study The sample. Two groups of students were involved in the study, the pretest sample group and the study sample group itself. The data collected from the
March 1. 19th Am. J. Obstet. Gywol.
pretest group were used in the evaluation of the grading system and in the formulation of a definition of adequate knowledge. The pretest sample consisted of 100 medical students randomly selected from the second-year class. Ot these. 99 responded to our questionnaire. We chose the second-year medical class on the assumption that these students would have more than adequate knowledge about contraception since, at this particular university, they have been exposed to considerable information about birth control in the course of lectures on reproductive physiology and on obstetrics and gynecology, and seminars on human sexuality; unlike their British counterparts. they have also had 4 or 5 years of prior university experience. Arbitrarily, the level of adequate knowledge was defined beforehand as one standard deviation below the mean score of the pretest sample. Since the mean score of the pretest sample was 35.6 (25.9 SD.) out of a possible score of 43, adequate knowledge was defined as a score of 29.7 or above. The study sample consisted of 509 students aged 17 to 23 studying Child Psychology or Psychology Statistics. These classes were chosen because they were large in size and contained students with diversified college backgrounds (i.e., arts, science, commerce, engineering, and religion). Questionnaires were distributed at the beginning of the lecture and were collected 15 minutes later (before the lecture started). Of the 616 responses, 107 were rejected. Seventy were deleted because the answer cards were filled out incorrectly (e.g., two responses for one question); the remainder did not fall into the predefined age distribution (17 to 23). The questionnaire. The knowledge questions were restricted to concepts directly applicable to the prevention of pregnancy and were graded according to difficulty and saliency of information. There were five items on basic knowledge of human reproductive physiology (graded at 3 points each), three items on the relative effectiveness of different methods of birth control (graded at 6 points each for a correct answer and 2 points for a partially correct answer), and five items dealing with information essential to the successful contraceptive use of specific methods (graded at 2 points each). A point biserial correlation between total score and the responses to individual questions showed all of the questions to be valid discriminators between knowledgeable and unknowledgeable subjects. Eight remaining items dealt with the sample characteristics in which we were interesttd: age, sex, major source of information about birth control, subject’s assessment of his own knowledge, whether the subject
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5
had ever tion used whether unwanted
had sexual intercourse, method of contracepmost frequently by subject or coital partner, subject or coital partner had ever had an pregnancy, and prevalence of “risk-taking.”
Table I. Complete sample, major information on contraception
source of
Results Characteristics of the sample population. The sample consisted of 509 undergraduates; 24.2 per cent of these were male and 75.8 per cent were female. Ages ranged from 17 to 23 years inclusive, with mean age being 19.4. There were 228 students (44.8 per cent of the sample) who were sexually active, i.e., had experienced sexual intercourse at one time or another; 57.7 per cent of males were nonvirgins, compared to 40.7 per cent of females. Virgins were in the majority in each of the age groups 17, 18, and 19 years; nonvirgins were in the majority in each of the older age groups (except among the small population of 22-year-olds, where virgins are in a slight majority). Findings in knowledge and score. The mean score of the study group was 31.4 (t 0.3 SE. = standard error), which is lower than that of the pretest students (as expected) but above the predefined level of adequate knowledge. No marked differences in knowledge emerged between males and females: similar proportions of each had adequate knowledge (66.7 per cent of males, 65.8 per cent of females), and their mean scores were virtually identical (31.5 ? 0.5 SE. and 31.4 & 0.4 SE., respectively). Every age group had adequate knowledge but, surprisingly, there was no improvement in score with age. Of sexually active students, 79.8 per cent were found to have adequate knowledge, compared to only 54.8 per cent of virgins, which suggests that the people who most need contraceptive information (i.e., sexually active students) are more likely to actually have it. Female nonvirgins had the highest mean score (34.4 % 0.5 SE.) probably because they have the greatest incentive to acquire adequate knowledge and avoid pregnancy, followed by male nonvirgins (32.7 -+ 0.7 SE.) and male virgins (29.8 & 0.9 SE.). The mean score of female virgins (29.4 f 0.5 S.E.) puts this group into the inadequate knowledge category; for this group, the incentive to acquire contraceptive information may be outweighed by the social sanctions against expressing interest in premarital sex
1, 4, 9, 14
There were 240 students who thought their knowledge of contraception was inadequate; in 52.1 per cent of cases this agreed with our evaluation of their knowledge
(they
scored
below
29.7
on
the
question-
Printed matter (booklets, pamphlets, etc.) Parents Friends and lovers Sex education course, school, or other educational institution Doctor
Table
II. Trends
Rhythm Postcoital douche Pill Condom IUD Diaphragm and jelly Vaginal spermicides Vasectomv or tubal ligation’ Coitus interruptus Pot luck
373
73.3
67.6
12 68
2.4 13.4
66.7 48.5
31
6.1
80.6
in contraceptive
use
5 1 143 54 4 5 1 0
2.2 0.4 62.7 23.7 1.8 2.2 0.4 0.0
2.8 0.0 62.0 25.4 0.0 0.0 0.0 0.0
1.9 0.6 63.1 22.9 2.5 3.2 0.6 0.0
12 3
5.3 1.3
7.0 2.8
4.5 0.6
naire). Another 269 students thought they had adequate knowledge of contraception; of these, 82.2 per cent did have adequate knowledge by our standards and the 17.8 per cent who did not have adequate knowledge but thought they did are presumably at high risk for inadvertently causing an unwanted pregnancy.* Trends in source of information about contraception are shown in Table I. Each source-except “friends and lovers”-provided adequate information to the majority of students using that source. *Proportionately, more students underestimated than overestimated their knowledge by our standards. This suggests two interesting considerations: (1) our standards were too low or did not test some essential areas of knowledge, or (2) people are unwilling to admit to knowing a lot about contraception, perhaps because it would suggest that they are interested in premarital sexual activity of which peers, parents, and society in general are thought to disapprove and because it would imply that they know enough to take responsible birth control action in sexual encounters, a conclusion that some students may wish to avoid. In this latter regard, it is interesting to note that a higher percentage of the males than of the females underestimated their level of knowledge!
502
Munz et al.
Findings in risk-taking and its consequences. Table II shows trends in use of birth control. Only 1.3 per cent of sexually active students said that they regular11 used no method of contraception. However, 20.2 per cent of nonvirgins currently risk unwanted pregnancy. Risk taking was assessed by asking, “Currently, do you CZVYengage in sexual intercourse without using a,z~ OM’ of the following contraceptive techniques-thepill, intrauterine device, the condom, diaphragm and jelly?” A “yes” response to this question was defined as risking unwanred pregnancy. The methods listed were chosen because they are reported to have a clinical failure rate of 20 or less per 100 woman-years of exposure.R Of the nonvirgin sample, 9.6 per cent reported that they had been involved with an unwanted pregnancy. Since 11.5 per cent of women students but only 5.6 per cent of males reported involvement with unwanted pregnancies, one might suspect under-reporting b! males due to lack of awareness or belief in the pregnancies of girlfriends whom they had not continued to see. Interestingly, the mean score of the unwanted pregnancy group was 32.6 (t 1.4 S.E.), well above the adequacy level. However, 27.3 per cent of these students still had inadequate knowledge of birth control, and 27.3 per cent still took risks.
Comment Of those students who have engaged in sexual intercourse, 20.2 per cent have inadequate knowledge of contraception by our criteria and a similar proportion (20.2 per cent) risk unwanted pregnancy by failing to use an effective method of birth control. Are these the same people? While the mean score of risk takers (33.5 +- 0.8 SE.) was lower than that of non-risk takers (34.0 2 0.5 SE.), it was nonetheless well above the level of adequate knowledge. In fact, 78.3 per cent of risk takers scored above the level of adequate knowledge. This suggests that adequate contraceptive knowledge does not necessarily give rise to adequate contraceptive behavior; intervening factors such as motivation and accessibility play an important part in the risk taking and subsequent unwanted pregnancies of young adults. Some students may use a very effective method of contraception but be abysmally ignorant in terms of their score on the questionnaire. This may reflect the occurrence of social compliance, where a person ignorant about contraception accepts and acts upon the advice of a person (e.g., a physician) designated by society as an expert in this field. Our study was not intended to discover whether students were socially compliant. but rather to determine whether students
possessed the basis for cognitive consensus, i.e.. whether they themselves knew enough about differences in contraceptive effectiveness to be able to accept (or reject) expert advice on the basis of their own knowledge. How does our Canadian student population compare with United States college populations? The percentages of sexually active male (57.7 per cent) and female (40.7 per cent) students are very- similar to U. S. estimates, which range from 45 per cent to 60 per cent’” for males and from 30.5 per cent’ to 47 per cent’ for females. The age at which the population changes from virgin to nonvirgin ma.jority (between ages 19 and 20) agrees well with the findings of Kantner and Zelnick.‘3 In twv areas however. our findings differ markedly from those of U. S. studies. The incidence of risk taking was much lower in our student sample: 90.4 per cent of sexually active students usualI\ used an effective method of contraception and 79.8 per cent always used an effective method of contraception. This contrasts sharply with the findings of Lundy7 and Fujita and associates’ cited earlier, in which half or more of students failed to use any form of contraception. effective or otherwise. Second, a striking 73.3 per cent of our Canadian sample said that printed matter was their chief source of information m birth control, with only 13.4 per cent of students relying on peers. Thornburg, I5 in agreement with earlier li. S. studies b) Ramsey and Bell, found peers to be the most popular chief source of information, used by 37.9 per cent of his sample, with literature accounting for onI) 20.6 per cent (barely ahead of mothers, 19.3 per cent, and schools, 14.8 per cent). Even for sophomore medical students in the United States, peers \qcr-e the main source of information for a majority (57.-l per cent of students.‘” The popularity of printed matter ma! reflect the particular situation at this univeristy, where a comprehensive and detailed birth control handbook has been widely distributed. Nonetheless, it is a little disappointing to note that only 67.6 per cent of students using printed matter have adequate knowledge, parents being just as effective a source of information. This may suggest the need for a more simple and direct guide to rhe essentials of birth control, perhaps a summary of the very thorough birth control handbook. An alternative interpretation, however, and one that is less easily remedied. must also be considered: regardless of the free availability of excellent printed materials on birth control, if people are not motivated to retain or use this information the impact of such materials on their knowledge and usage
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Contraceptive knowledge and practice among undergraduates
of contraception is bound to be minimal. For this group of students, the decision to have intercourse without effective contraception (similar perhaps to the decision to continue smoking or to drive without using automobile seat belts) may be based on factors other than rational or objective considerations. The “unexpected,” unplanned nature of intercourse, and the overwhelming desires of the moment, conflict with the requirement of considerable forethought for use of most methods of birth control.4* s The results of Table II further suggest that the doctor, when used, is a highly effective source of adequate knowledge, emphasizing the need for the physician, especially the campus physician, to take a more active role in birth control education. A university campus of over 15,000 people may be likened to a small city with the important difference that virtually all of its citizens are of a potentially fertile and sexually active age. A more visible univeristy involvement in
503
contraception, e.g., the establishment of a central, easily accessible, and emotionally supportive birth control clinic (as at Yale”) might go far toward improving student willingness to use contraception, as well as providing reliable information and advice. To summarize the chief findings of the study, 34 per cent of the undergraduates sampled were found to have inadequate knowledge. This segment of the population does need more information about birth control but, by far the majority of the students who risk unwanted pregnancy did so in spite of adequate knowledge. This emphasizes that motivation, rather than purely lack of information, plays an important role in the unwanted pregnancy rate of the college student population. We are indebted to Drs. J. G. Lohrenz and R. A. Kinch for advice and encouragement, and to Drs. S. Shapiro, I. Simon, B. Kaplan, and R. Hutcheon for critical reviews.
REFERENCES
Fujita, B. N., Wagner, N. N., and Pion, R. J.: Contraccptive use among single college students, AM. J. OBSTET. GYNECOL. 109: 787-793, 1971. 2. Dominion Bureau of Statistics, Dept. of Health and 1.
3. 4.
5.
6.
7.
8.
Welfare, Canada: Summary of Vital Statistics, Ottawa, 1971. Menken. J.: The health and social consequences of teenage child-bearing, Fam. Plann. Perspect. 4: 45, 1972. McCance, C., and Hall, D. J.: Sexual behaviour and contraceptive practices of unmarried female undergraduates at Aberdeen University, Br. Med. J. 2: 694, 1972. Coe, B., and Blum, M.: The out of wedlock pregnancy: Six year’s experience with a univeristy population, Obstet. Gynecol. 40: 807, 1972. Weisman, A. I.: Open legal abortion “on request” is working in New York City; but is it the answer’, AM. J, OBSTET. GYNECOL. 112: 138. 1972. Lundy, J. R.: Some personality correlates of contraceptive use among unmarried female college students, J. Psychol. 80: 9, 1972. Cherniak, D., and Feingold, A.: McGill Birth Control Handbook, ed. 10, Montreal, 1973, Montreal Health Press, Inc.
9. Bauman,
K. E.: Selected aspects of the contraceptive of unmarried univeristy students, AM. J. OBSTET.GYNECOL. 108~ 203,197O. 10. Sarrel, P. M., and Sarrel, L. J.: Birth control services and practices
sex counselling at Yale, Fam. Plann. Perspect. 3: 33, 1971. 11. Furstenburg, F. F., Marsnick, G. S., and Ricketts, S. A.: How can family planning programs delay repeat teenage pregnancies? Fam. Plann. Perspect. 4: 54, 1972. 12. Goldsmith, S., Gabrielson, M. O., Gabrielson, I., Mathews, V., and Potts, L.: Teenagers, sex and contraception, Fam. Plann. Perspect. 4: 32, 1972. 13. Kantner, J. F., and Zelnick, M’.: Sexual experience of young unmarried women in the United States, Fam. Plann. Perspect. 4: 9, 1972. 14. Kaats, G. R, and Davis, K. E.: The dynamics and sexual behaviour of collesre students. 1. Marr. Fam. 32: 390. 1970. 15. Thornburg, H. D.: A comparative study of sex information sources, J. Sch. Health 42: 88, 1972. 16. Gottheil, E., and Freedman, A.: Sexual beliefs and behaviour of single male medical students, J. A. M. A. 212: 1327, 1970. ”
.,
Appendix: The questionnaire The Medical Students at McGill University would like your assistance by answering the following questions on contraception. The success of this project depends highly on the integrity of your responses, so please follow
the instructions
SAMPLE
1. The sky is:
(1) blue (2) black (3) red (4) grey (5) blue during a clear day, black at night, red with the sunset, grey when it is cloudy.
carefully.
DO NOT PUT YOUR NAME, STUDENT NUMBER, OR ANY OTHER FORM OF IDENTIFICATION ON YOUR IBM CARD. We are not interested, nor will we be able, or try to trace your answers back to you.
QUESTION
-answer panying
the most appropriate IBM card-only
answer with
the
on the accomspecial
pencil
504
Munz et al.
prozri&d-fill in the space completely outside the boundaries. -best
answer
(1) [II
to sample question PI 131 [41 n
without
going
is [5]
(2) (3) (4) etc.
gasm) (5) hot bath preceding
-if you must erase, erase completely so that only ONE answer remains-please do not bend or mutilate your computer card. PLEASE FILL IN ONE ANSWER ON THE IBM CARD PROVIDED FOR THE FOLLOWING QUESTIONS (WITHOUT HELP FROM OTHER SOURCES) Your age as of September 1, 1973 is (choose one from numbers 1 or 2) 1. (1) 15 or under (2) 16 (3) 17 (3) 18 (5) 19 2. (1) (2) (3) (4) (5)
(1) the condom (safe) (2) spermicidal foam or jelly (spermicidal means “kills sperm”) (3) postcoital douche (postcoital = after intercourse. douche = washing) (-I) coitus interruptus (withdrawal before or-
20 21 22 23 24 or more
Your sex is:
(1) male (2) female
4. A woman who has intercourse, is most likrlq become pregnant if intercourse occurs: (1) Just before menstruation (2) during menstruation (3) right after menstruation (4) 2 weeks before menstruation 5. Before which fluid, (1) (2) (3)
to
orgasm there can be a few drops of semen escape (orgasm) = climax; semen = seminal fluid containing sperm) true false don’t know
6. Orle drop containing (i.e., cause (1) true (2) false (3) don’t
of semen (seminal fluid, i.e., fluid sperm) is enough to fertilize an ovum pregnancy):
know
7. For the incidental sexual encounter, of contraception is:
the best form
intercourse
8. Which of the following arrangements represents modes of contraception from nzo.rl to Ircts/ effective in preventing pregnancy? (1) condom (safe), pill, rhythm (2) rhythm, pill, condom (3) condom, rhythm, pill (4) pill, condom, rhythm (5) pill, rhythm, condom 9. For a woman on oral contraceptives to become pregnant, the IPUS! number of‘ days she would have to miss taking rhe pill is: (1) for 2 consecutive days in a normal menstrual cvcle (2) for 7 consecutive days in a normal menstrual cycle (3) for 14 consecutive days in a normal menstrual cycle (4) for more than half the days of a normal menstrual cycle regardless of which days (5) for the whole length of a normal menstrual cycle 10. Vaseline is a good lubricant (1) true (2) false (3) don’t know
for condoms:
1 1. Condoms tend to tear more easily if kept in hot, moist places, like wallets and pockets: (1) true (2) false (3) don’t know 12. The diaphragm can be removed 2 hours following intercourse and still give very good contraceptive protection: (1) true (2) false (3) don’t know 13. Sperm cells, if deposited between the labia majora (vaginal lips), can result in pregnancy, even in a virgin with an intact hymen (protective membrane over vaginal orifice): (1) true (2) false (3) don’t know
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Contraceptive knowledge and practice among undergraduates
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5
14. A woman can avoid becoming not achieve an orgasm: (1) true (2) false (3) don’t know
pregnant
if she does
15. Which of the following arrangements represents the modes of contraception from most to bu.st efficient? (1) IUD (intrauterine device), diaphragm, Coitus interruptus (withdrawal) (2) IUD, coitus interruptus, diaphragm, (3) diaphragm, coitus interruptus, IUD (5) coitus interruptus, IUD, diaphragm 16. The postcoital douche is an effective means of contraception (postcoital = after intercourse, douche = washing): (1) true (2) false (3) don’t know 17. Do you consider that you have adequate edge of birth control? (1) yes (2) no
knowl-
18. Which of the following categories represents your nzujor source of information on contraception? (1) printed, information (e.g., booklets, magazines, etc.) (2) parents (3) friends and lovers (4) a sex education course, school or other educational institution (5) your doctor 19. Have you engaged (1) yes (21 no
in sexual intercourse?
IF YOUR ANSWER WAS “YES” TO OUS QUESTION, THEN PLEASE NUMBERS 20 TO 23.
THE PREVIREPLY TO
IF YOUR ANSWER WAS “NO,” THEN LEAVE THE REMAINING QUESTIONS BLANK. Choose only one method of contraception (from Numbers 20,2 1, and 22) that you, or your partner use most frequently. 20. (1) rhythm method (2) postcoital douche (3) the pill (4) condom (safe) technique listed in No. 2 1 (5) I use a contraceptive and No. 22 most frequently device) 21. (1) IUD (intrauterine and jelly (2) diaphragm (3) vaginal spermicides (4) vasectomy or tubal ligation (5) I use a contraceptive technique and No. 22 rn~stfT~q~nt~~ 22. (1) coitus interruptus (withdrawal) (2) pot-luck technique (3) I use a contraceptive and No. 21 mostfrequently
listed in No. 20
listed in No. 20
23. Have you or a partner in sexual intercourse had an unwanted pregnancy? (1) yes (2) no
ever
24. Currently, do you ever engage in sexual intercourse without using any one of the following contraceptive techniques? -the pill -intra-uterine device -the condom -diaphragm and jelly (1) yes (2) no ANSWERS WILL BE POSTED TOMORROW THOSE WHO ARE INTERESTED. THANK FOR YOUR COOPERATION.
FOR YOU
