Seeing things differently: expert and consumer mental models evaluating combined oral contraceptives

Communication regarding the benefits and risks of combined oral contraceptives (COCs) remains a challenge in view of persistent misconceptions about the 'pill'. The aim of this study was to investigate how women understand the benefits and risks of COCs, comparing their assessments with an expert model created from literature- and guideline-based research and reviewed by a sample of gynaecologists using the mental models approach. Two qualitative studies were conducted in Germany - a questionnaire-based study involving 30 gynaecologists with a mean of 218 COC prescriptions on average per month, and in-depth interviews (plus the use of a questionnaire) with 21 women aged 18-24 years. As expected, women reported only a few concepts of benefits and risks unprompted, but further prompting revealed beliefs of many other associations. The women stated an overall positive valence even if the number of negative concepts predominated indicating a latent cognitive dissonance. The major differences compared with the expert model included: (a) a negative association with weight gain, subfertility and teratogenicity, (b) only a partial association of COC intake with thromboembolic conditions, (c) a confusing, rather negative perception of a COC-related effect on cancer and (d) a partial lack of basic knowledge of the active ingredients, time to excretion and mode of action of COCs. Appropriate COC counselling should cover these discrepancies.