Emergency Contraception Knowledge, Attitudes, and Barriers Among Men: A Cross-Sectional Study

Background Emergency contraception (EC) plays a pivotal role in the prevention of unintended pregnancies following unprotected sexual intercourse. Men's awareness regarding emergency contraception is pivotal for informed decision-making and for enhancing reproductive health in this context. This study investigated Syrian men's awareness and perspectives on emergency contraception to inform diverse reproductive health initiatives. Methods We conducted a cross-sectional study in Syria, from June 2022 and April 2023. Our study included male participants aged 18 years or older who held Syrian nationality and volunteered to participate. The data collection involved administering a questionnaire comprising three sections (knowledge, attitude, and barrier assessment), encompassing a total of 30 questions. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY). Results Most participants were aged 18-25 (65.7%) and single (75.4%) and held a university degree (79.3%). The knowledge of emergency contraception was low (36.1%), with the Internet and social media (77.5%) being the primary sources of information. While 89% held positive attitudes toward emergency contraception, only 37.3% supported nonprescription availability. Age, income, and desire for children were associated with knowledge, attitudes, and the use of emergency contraception. Men aged 26-35 exhibited the highest positive attitude (8.11±1.83). Those desiring no children showed higher attitude scores (7.42±2.04). Income was positively associated with knowledge (adjusted odds ratio {AOR}=1.75 and confidence interval {CI}=1.02-2.99) and emergency contraception use (AOR=2.87 and CI=1.27-6.48). Conclusion This study underscores the knowledge gap regarding emergency contraception in Syrian men. Despite positive attitudes, awareness remains limited, particularly among those of childbearing age. Targeted education and improved accessibility to emergency contraception can enhance its use among men, particularly in those with low socioeconomic status and younger age groups.

Unintended pregnancies, marked by their occurrence without deliberate planning regarding timing or conception, are a significant global concern.They have substantial implications, contributing to both physical and mental health challenges for both mothers and infants [1].Furthermore, they often lead to an increase in abortion rates, accompanied by associated medical complications, and are a known risk factor for postpartum depression in developing countries.Notably, in 2017, roughly half of all pregnancies worldwide were classified as unwanted [2,3].
Family planning, defined as the capacity to regulate the number of children and spacing between childbirths [4], plays a pivotal role in curbing unintended pregnancies.Contraceptives encompass a wide array of methods, including condoms that prevent sperm from reaching the ovum and fertilization, hormonal approaches (pills or injections) that alter the ovulatory cycle, intrauterine devices (IUDs), and surgical interventions, such as tubal ligation for women and vasectomy for men.Contraceptive methods vary in terms of administration mode, timing, efficacy, and regional prevalence [5].For instance, injectable contraceptives are commonly used in Africa, whereas they are less frequently used in developed countries [6].
Emergency contraception (EC) is a critical component of family planning, defined as the use of a device or medication within the first 72 hours after unprotected sexual intercourse to prevent conception [7].
Although no contraceptive method is 100% foolproof, emergency contraception has proven to be significantly effective.It comprises two primary methods: oral contraceptive pills and copper intrauterine devices (IUDs), with IUD implantation feasible within five days of unprotected intercourse.Oral contraceptive pills include various options, such as levonorgestrel, mifepristone, and ulipristal acetate [7].
Despite the importance of contraception, there remains a knowledge gap, particularly evident in Africa, where only 29.4% of women aged 15-49 years use these methods [8].Research indicates that women with a higher education and economic background are more receptive to emergency contraception.However, educating men about EC is equally vital, as their support can significantly impact positive reproductive healthcare outcomes for families.Equipping men with accurate information empowers them to actively participate in decision-making and facilitates accessibility to EC [9].
In some regions, such as Turkey and Saudi Arabia, there is limited knowledge and awareness of EC among men, as emergency contraceptive usage is often perceived as a female-specific health concern [10,11].In Muslim-majority countries such as Syria, cultural and religious challenges surrounding termination of pregnancy (TOP) exist due to strong religious condemnation in Islam, the predominant religion in the region.Consequently, EC has emerged as one of the primary options for preventing unwanted pregnancies and TOP [12].
Furthermore, we identified a significant gap in the literature, specifically in the Syrian population, regarding EC awareness.This study aimed to address this knowledge deficiency and offer fresh insights into the role of men in family reproductive decision-making.These findings can inform future strategies to increase awareness among the population and shape healthcare policies aimed at improving reproductive health outcomes.

Study design and setting
A cross-sectional study was conducted in Syria between June 2022 and April 2023 to assess the knowledge, attitudes, and barriers related to emergency contraception (EC) among Syrian men.The participants who met the inclusion criteria were males aged 18 years or older with Syrian nationality who willingly participated in the study.The exclusion criteria included individuals under the age of 18 years, females, non-Syrian nationals, those who declined participation, and those who had limited mental or language capacity.All participants were informed of the study's objectives, their right to abstain from participation, the protection of their privacy and data, and the inclusion of only fully completed surveys for analysis.The questionnaire employed in this study was adapted from prior research and included a comprehensive and validated scale [11].The scale was translated into Arabic to ensure complete comprehension by the participants.The translated questionnaire was subjected to rigorous scrutiny by language experts and culturally adept individuals to ensure that the intended meaning was preserved.To reach a diverse cross section of the Syrian male population, a robust strategy for survey dissemination was devised.A meticulously designed Google Forms (Google, Inc., Mountain View, CA) survey was used to ensure that the participants could easily access and complete the survey.The survey was shared across various social media platforms including Facebook, WhatsApp, and Telegram.

Measures
The evaluation was conducted using a questionnaire divided into three parts consisting of 30 questions/statements.

Sociodemographic Variables
This section comprised seven questions concerning the participants' sociodemographic information, including age, level of education, economic status, work status, marital status, number of children, and recent willingness to have children.

Knowledge Assessment
The participants' knowledge of emergency contraception was evaluated using a series of questions and statements.These questions aimed to determine whether the participants were aware of EC, whether they understood its use within three days of unprotected intercourse, and the depth of their knowledge of EC.If the participants answered affirmatively to being aware of EC, additional questions were asked to assess their knowledge in more detail.These questions covered topics such as when women can use EC, what actions can be taken to prevent pregnancy, the correct timing for its use, its availability, prerequisites for its use, and the sources from which they acquired knowledge about EC.

Attitude Assessment
The participants' attitudes toward emergency contraception were assessed through a series of statements and questions.They were asked to respond with "yes," "no," or "do not know" to these statements, with each statement reflecting a different aspect of attitudes toward EC.A higher score (>5) was considered indicative of a positive or favorable attitude toward EC use, whereas a lower score (≤5) indicated a less favorable or negative attitude.

Barriers Assessment
The study also examined the perceived barriers to the use of emergency contraception.The participants were asked about various factors that might discourage them from using EC, including religious or cultural factors, difficulties in access, concerns about drug side effects, and cost-related issues.

Pilot study
A random sample of 50 men from the general population participated in a pilot study to assess the effectiveness and clarity of the survey.Based on these responses, the questionnaire was revised and improved accordingly.Subsequently, a pilot test was conducted with an additional 50 participants to assess the survey's validity.This pilot study demonstrated high levels of internal consistency, with Cronbach's alpha values ranging from 0.712 to 0.861.Following the successful pilot study, the survey was finalized for publication.

Ethical consideration
Ethical approval for this study was obtained from the University of Aleppo Ethics Committee (approval number: J/55-34).The participants were provided with a link to the survey, and informed consent was obtained before they completed the questionnaire.Detailed research materials were made available to the participants on the following page, and they completed the questionnaire at their own pace.The survey typically took between five and 12 minutes to complete, and all responses were securely stored in an online database.

Statistically analysis
Data analysis was conducted using the Statistical Package for Social Sciences (SPSS) version 23 (IBM SPSS Statistics, Armonk, NY).We calculated descriptive statistics, including frequencies and percentages, sociodemographic data, sources of education on emergency contraceptive pills (ECP), and responses related to ECP knowledge.The chi-squared test was used to examine associations and determine statistical significance.Univariate analyses were performed using descriptive statistics.To identify factors potentially linked to EC awareness and usage, we conducted a multivariable logistic regression.When analyzing factors influencing EC usage, we considered the number of participants with accurate information regarding contraceptive use within three days of unprotected intercourse.Statistical significance was set at P<0.05.

Sociodemographic characteristics of the study participants
A total of 826 men participated in the study.Most participants (65.7%, n=537) were within the age range of 18-25 years, and a significant portion (75.4%, n=623) were single.Notably, 79.3% (n=655) of the participants held a university degree, while only 0.8% had completed primary school.Furthermore, the majority (n=651, 78.8%) of the participants reported having no children.In terms of income, 49.5% of the participants fell into the moderate-income category, and the largest subgroup (n=376, 45.5%) indicated that they were not currently employed.For a more comprehensive overview of the demographic characteristics, please refer to Table 1.

TABLE 1: Sociodemographic characteristics of the study population
The data has been represented as N and %

Knowledge of the participants about emergency contraception among men
In assessing the participants' familiarity with contraceptive methods, it is notable that male condoms and oral contraceptives emerged as the most recognized among male respondents, with 97% and 95.2%, respectively (n=801 and n=786), acknowledging the awareness of these methods (refer to

TABLE 2: Knowledge of the participants about EC among men
The data has been represented as N and % EC: emergency contraception Among those who demonstrated awareness of EC, the primary source of information was digital platforms, such as the Internet and social media, as indicated by 77.5% (n=213) of the respondents.Subsequently, healthcare professionals, including physicians and family planning specialists, constituted the next most commonly cited source, as acknowledged by 60.4% (n=166) of the participants.In contrast, only 8.5% of the men reported newspapers as a source of information.It is pertinent to highlight that a significant majority (83.3%, n=229) correctly identified the critical timeframe for EC administration, recognizing its efficacy within a 72-hour window following unprotected sexual intercourse.
Moreover, more than half of the male respondents (52%, n=143) revealed that they advocated their partners to consider EC as a means of pregnancy prevention.A noteworthy percentage of the participants (74.2%, n=204) emphasized the importance of consulting a medical professional prior to EC use, while a substantial majority (59.6%, n=164) correctly asserted that a pre-administration pregnancy test was unnecessary.Intriguingly, most participants (85.5%, n=235) had not previously utilized EC (Table 3).

TABLE 3: Men's knowledge about different methods of contraception
The data has been represented as N and %

Participants' attitudes and beliefs regarding emergency contraception
Inquiries concerning the decision-making process for emergency contraception (EC) use revealed that the majority of the participants (88.4%, n=730) advocated for shared decision-making involving both partners.However, it is noteworthy that only 37.3% expressed agreement with the concept of making EC available without a prescription, whereas 87.8% (n=725) believed that men should have the ability to purchase EC.
Exploring men's behaviors regarding EC, 68.9% (n=569) indicated their willingness to procure EC for emergency situations in order to keep it readily available at home.Additionally, a substantial majority (82.3%, n=680) expressed their readiness to recommend EC to men facing the risk of an unplanned pregnancy.
When exploring their beliefs concerning EC, it emerged that more than one-third of the men (33.5%, n=277) reported feeling embarrassed about purchasing EC.Furthermore, the side effects of EC were identified as the most frequently cited factor (66.6%, n=550) influencing the decision to use it (see Table 4).

Affective (feelings)
The decision to use ECP is ultimately the decision of:

TABLE 4: Participants' attitudes and beliefs regarding emergency contraception (EC)
The data has been represented as N and % ECP: emergency contraceptive pills

The differences between attitudes scores regarding emergency contraception based on sociodemographic characteristics of the study population
In terms of attitudes toward emergency contraception (EC), a substantial 89% of men exhibited a satisfactory outcome, as indicated by a mean attitude score of 7.35±2.04(see Figure 1 and Table 5).Notably, eight variables demonstrated statistically significant association with attitudes toward EC (P<0.05).

TABLE 5: The mean of attitude score regarding emergency contraception based on sociodemographic characteristics of the study population
The data has been represented as mean and standard deviation (SD) (minimum and maximum) The participants within the age group of 26-35 exhibited the highest mean attitude score, standing at 8.11±1.83.Additionally, men who did not express a desire for children exhibited a higher attitude score compared to those desiring children, with scores of 7.42±2.04and 7.06±2.04,respectively.Furthermore, individuals with educational qualifications beyond a university degree displayed the highest attitude scores when compared to their counterparts with varying educational backgrounds, recording a mean score of 8.04±1.86.
Men who did not identify religion as a barrier to EC reported a higher mean attitude score (7.61±1.87).Moreover, those who reported experiencing difficulty accessing EC also presented a higher mean attitude score (7.76±1.82) in contrast to men who did not encounter such access barriers (refer to

TABLE 6: The differences between attitude scores regarding emergency contraception based on sociodemographic characteristics of the study population
The data has been represented as mean and SD.P-value is significant when <0.05

Binary logistic regression between baseline characteristics of the study population and knowledge of the respondents relating to emergency contraception
Of the 13 variables examined, only age and monthly income demonstrated statistically significant associations with the prediction of knowledge regarding emergency contraception (EC) (P<0.05).
Specifically, men aged between 46 and 55 years were found to be 8.7 times less likely than their counterparts aged between 18 and 25 years to possess knowledge about EC (adjusted odds ratio {AOR}=0.16 and confidence interval {CI}=0.36-0.74).Conversely, the participants with a higher monthly income exhibited a greater likelihood of having knowledge about EC than those with lower income levels (AOR=1.75 and CI=1.02-2.99)(Table 7).

TABLE 7: Binary logistic regression between baseline characteristics of the study population and knowledge of the respondents relating to emergency contraception
The data has been represented as N, %, COR, and AOR.P-value is significant when <0.05 COR, crude odds ratio; AOR, adjusted odds ratio

Binary logistic regression between baseline characteristics of the study population and attitude of the respondents relating to emergency contraception
Four predictors, namely, age, current desire to have children, religion as a barrier, and difficulty in access, demonstrated statistically significant correlations with attitudes toward emergency contraception (EC) (P<0.05).
The participants aged between 26 and 35 years exhibited a noteworthy 5.37-fold increase in the likelihood of holding a positive attitude toward EC compared to those in the 18-25 age bracket (adjusted odds ratio {AOR}=5.37 and confidence interval {CI}=1.76-16.37).Conversely, individuals expressing a desire to have children displayed reduced odds of maintaining a positive attitude toward EC compared to those who did not (AOR=0.47and CI=0.26-0.84).
Furthermore, the participants who identified religion as a barrier to EC were 0.52 times less likely to maintain a positive attitude (AOR=0.52 and CI=0.3-0.87).Conversely, the respondents reporting difficulty in accessing EC demonstrated higher odds of maintaining a positive attitude (AOR=2.76 and CI=1.54-4.96)(see Table 8).

TABLE 8: Binary logistic regression between baseline characteristics of the study population and attitude of the respondents relating to emergency contraception
The data has been represented as N, %, COR, and AOR.P-value is significant when <0.05 COR, crude odds ratio; AOR, adjusted odds ratio

Binary logistic regression between baseline characteristics of the study population and using the emergency contraceptive pill
Out of the 13 variables under consideration, only two demonstrated statistically significant correlations with the prediction of emergency contraceptive pill (ECP) utilization (P<0.05).
Men aged-46-55 years were found to be 0.26 times less likely to use ECP compared to their counterparts in the 18-25 age group (adjusted odds ratio {AOR}=0.26 and confidence interval {CI}=0.08-0.83).Conversely, the participants with an excellent monthly income exhibited a notable 2.87-fold increase in the likelihood of using ECP compared to those with lower income levels (AOR=2.87 and CI=1.27-6.48)(Table 9).Emergency contraception (EC) is a crucial intervention for preventing unintended pregnancies following unprotected sexual intercourse, contraceptive failure, or sexual assault [13,14].Although several studies have focused on women's knowledge of and attitudes toward EC, it is important to acknowledge that male sexual partners also play a significant role in decisions related to EC use [15][16][17][18][19].This study aimed to explore the knowledge, attitudes, and barriers to EC among Syrian men.The results indicate a significant knowledge gap among Syrian men regarding emergency contraceptives, with only 36% of the participants reporting awareness of EC [20].This finding is consistent with those of prior studies that have highlighted lower levels of knowledge among men than among women.One contributing factor may be that contraceptive marketing and counseling predominantly target women, leading to a lack of motivation among men to seek information regarding these methods [21,22].

Emergency contraceptive pill
The study also revealed that male condoms and oral contraceptives were the most recognized contraceptive methods among the participants.This aligns with previous research demonstrating that men are more familiar with and prefer condoms and oral contraceptives than other contraceptive options [22][23][24][25].Among those who had heard of EC, the Internet and social media emerged as the primary sources of information, followed by healthcare providers [26,27].This underscores the essential role of healthcare professionals in disseminating accurate information about EC.However, it is worth noting that the study identified room for improvement in healthcare workers' knowledge of EC, highlighting the need for training in this area [28,29].
A positive aspect of the findings was that a substantial proportion of the participants (around 80%) correctly understood that EC should be administered within 72 hours of unprotected intercourse.In addition, the majority (85.5%) believed that consulting a healthcare provider before using the EC was necessary.These results emphasize the crucial role of healthcare providers in promoting EC use and education [30][31][32].Despite limited knowledge, a significant portion of the participants exhibited a positive attitude toward EC.Attitudes were more favorable among middle-aged participants (26-35 years old) and those with university degrees.Education was positively correlated with knowledge levels and, subsequently, attitudes toward EC [33,34].Binary logistic regression analysis revealed that good monthly income, the lack of religious barriers, and desire to have children were factors associated with more positive attitudes toward EC.The participants who identified religion as a barrier tended to have less favorable attitudes.However, those who reported difficulty accessing EC had more positive attitudes, possibly reflecting greater awareness of its importance in such circumstances [35].
Among the barriers reported, concerns about side effects emerged as the most influential factor affecting EC usage, reported by 66% of the participants [36].This is consistent with previous research that highlights women's concerns about side effects as a significant factor influencing their decisions regarding EC [37,38].

Recommendations
The study's findings suggest several recommendations for improving knowledge, attitudes, and barriers related to EC.

Community-Specific Interventions
Conduct further studies involving diverse populations from various cultural and religious backgrounds to identify barriers specific to each community.Tailor educational programs to address these barriers and misconceptions [39].

Healthcare Provider Training
Enhance the education of healthcare providers about different types of emergency contraceptives and their administration.Well-informed providers can offer patient-centered care and play a critical role in promoting EC usage.

Tailored Educational Programs
Develop educational programs tailored to the needs of populations from different cultural and religious backgrounds.These programs should aim to dispel misconceptions, address barriers, and provide accurate information regarding EC.This study is the first of its kind among Syrian men and provides valuable insights into their knowledge, attitudes, and barriers regarding EC.However, this study has limitations, including a relatively small sample size, nonrandom sampling, and its cross-sectional nature, which does not allow for the establishment of causal relationships.

Conclusions
This study sheds light on knowledge gaps, attitudes, and barriers related to emergency contraception among Syrian men.We find an overall significant knowledge gap in Syrian men's knowledge.Male condoms and oral contraceptives were the most recognized contraceptive methods among participants.The Internet and social media were the primary information sources.This study resonates with a call to action, a call to address knowledge gaps, shape positive attitudes, and dismantle barriers surrounding emergency contraception among Syrian men.Through targeted educational interventions, heightened awareness efforts, and improved training for healthcare providers, we have the potential not only to elevate individual awareness and decision-making but also to usher in transformative improvements in reproductive health outcomes for Syrian men and their partners.

Table 2
).Conversely, the awareness of emergency contraception (EC) was less prevalent, with only 36.1% (n=298) of men having prior knowledge of it.2024Alibrahim et al.Cureus 16(1): e51937.DOI 10.7759/cureus.519375 of 16 Is pregnancy test required before ECP pill?Yes 111 40.4%Have you ever used ECP to prevent pregnancy in the past?

TABLE 9 : Binary logistic regression between baseline characteristics of the study population and using the emergency contraceptive pill
COR, crude odds ratio; AOR, adjusted odds ratio Discussion 2024 Alibrahim et al.Cureus 16(1): e51937.DOI 10.7759/cureus.51937 To enhance reproductive health outcomes, Syrian healthcare providers should receive comprehensive training on emergency contraception (EC) to bridge knowledge gaps and offer patient-centered counseling.Encouraging joint decision-making between couples in family planning is crucial, emphasizing open communication and shared responsibility.Culturally competent care that respects religious beliefs should be prioritized.Proactive discussions about the side effects of EC can alleviate concerns, and tailored educational programs should dispel misconceptions and provide culturally sensitive information.Policymakers should consider making EC more accessible without prescription and launch public health campaigns to increase awareness among Syrian men and women.