This is the first study to demonstrate an association between perceived competence and current contraceptive method in adolescent girls. Specifically, type of contraceptive use was associated with parental perception of both social and activities competence in their daughters. The DMPA group had lower parental report of activities and social competence scores compared to both the no hormonal contraceptive and the COCs/patch groups. From the adolescent’s perspective, the girls in the DMPA group reported significantly lower social competence scores than either the no hormonal contraceptive or the COCs/patch groups. For YSR activities competence, the only significant difference was between the no hormonal contraceptive and COCs/patch users, with the latter group having a lower mean score. Regarding rule-breaking behavior, our results showed that the parent’s report was significantly different between the contraceptive use groups. Parents reported more rule-breaking behavior for the girls in the DMPA group than for both the no hormonal contraceptive and COCs/patch groups. However, there was no difference in the adolescent’s report of rule-breaking behavior between contraceptive use groups.
The differences in our findings between perceived competence of both parent and adolescent report are interesting. Parents seemed consistent across their assessment of the adolescent in terms of both areas of competence and rule-breaking behaviors. However, the adolescent seemed to discriminate between social competence, activities competence, and rule-breaking behaviors in terms of the associations with contraceptive use. The adolescent’s perspective may be that social competence and activities competence have more to do with hormonal contraceptive use than rule breaking behaviors. Alternatively, the parent’s perspective may be that all three aspects are associated with hormonal contraceptive use. Research from the social domain perspective has examined adolescents’ development of concepts related to personal choice and personal jurisdiction. Areas related to control over one’s body, privacy, and personal preferences and choice are considered by some parents and adolescents to be beyond justifiable social or parental regulation [17
]. Autonomy develops with advancing age [3
], but there is wide variation in the age at which parents and adolescents agree on autonomy regarding decisions of personal choice [1
]. Thus, decisions about hormonal contraceptive methods and use may be either an individual choice, or a shared decision between parents and adolescents. Based on our findings, both parent and adolescent perceived competence are likely relevant to some extent.
Previous studies regarding self-efficacy and contraceptive use have highlighted decreased use of any hormonal method with lower self-efficacy [19
]. Although self-efficacy and competence are different constructs, it could be inferred that adolescent females with lower social and activities competence might have less self-efficacy for contraception. Therefore, these girls might choose a longer acting, and less operator-dependent method for contraception compared to girls with a higher level of competence. Additionally, the parent’s perception of the adolescent’s low competence might exert an independent effect on the adolescent’s perceived self-efficacy. Likewise, the parent may chose to make decisions regarding contraceptive options for the adolescent if they perceive their child to have low competence, and that choice is likely to be one that relies the least on the adolescent’s ability to adhere to regularly prescribed dosing.
Self-esteem is another area that has been previously studied in terms of hormonal contraception during adolescence. High self-esteem has been shown to be related to effective use of contraceptives [9
]. There are many aspects that contribute to global self-esteem, but it is generally thought that among teenagers, physical appearance competence and social acceptance/competence are among the most influential. Other less significant domains include scholastic competence, athletic competence, and conduct [22
]. Thus, although we did not measure global self-esteem, nor all the contributing domains, our findings are consistent with the previous studies evaluating self-esteem and competence. Adolescents with lower perceived social competence may have lower self-esteem. Thus, they may be less likely to use contraceptives effectively, and choose a method of contraception in which it is easier to comply, such as DMPA.
Use of hormonal contraceptives has been described as a complex matter, involving psychological, social and cultural factors. One prior study by Aker et al. [23
], evaluated the effects of temperament and character on the choice of contraceptive method (implant, condoms, intrauterine device, or COCs) among female college students. They noted that subjects who chose COCs had higher mean scores for self-directedness than those choosing intrauterine devices; and higher mean self-transcendence scores were noted among females choosing intrauterine devices as compared to condoms [23
]. Additionally, there are other concerns related to perceived side effects, efficacy, and benefits of each method of hormonal contraception. All of these factors impact choice of contraceptive method. Finally, an adolescent must consider their need for contraception.
Although we controlled for age, SES, race, and gynecologic age, our results should be interpreted with caution because we did not have data regarding sexual activity or sexual intercourse. Additionally, we had low numbers of girls using the patch so we included those adolescents with the girls using COCs, which may have resulted in some degree of bias. This study is cross-sectional, and because we did not randomize girls to categories of contraceptive method, we are not implying that the contraceptive method has a causal effect on competence or behavior problems.
Our findings may have important clinical implications. For example, there may be factors such as competence and rule-breaking behaviors, both parental and adolescent perception, that impact the choice of contraceptive method. Providers, adolescents, and their parents should be aware of the potential influence of these constructs when discussing options for hormonal contraception. We do not recommend measuring competence or behaviors in a clinical setting, but would recommend keeping this concept in mind when there may be a discrepancy between adolescent and parent, or provider and adolescent/parent regarding use or choice of hormonal contraception. For example, a parent may insist their adolescent receive DMPA for hormonal contraception, while the adolescent may either opt for no contraception or an alternative hormonal method. The parent may be incorporating their perception of the adolescent’s competence and behavior in their decision to recommend DMPA. This information may help the provider understand the parent’s perspective and aid in bringing the parent and adolescent towards consensus regarding the decision for hormonal contraception.