Natural Family Planning Use Among Hispanic and African

Natural Family Planning Use Among Hispanic and African American Young Adult Women: Qualitative and Quantitative Approaches January 14, 2008 Jennifer Manlove, Ph. D Lina Guzman, Ph. D

Background • Overall NFP use is low: - 1 -4% of all women use NFP each year • Higher ever use of NFP: - 12% of young adult women (18 -29) • Higher use among minorities - Especially Hispanics and African Americans • Failure rates: - 3 -5% with consistent and correct use - 25% with typical use (user failure)

Gaps in Research • Little is known about the who, why and when of NFP use in the US - Current measures may underestimate NFP use - Little research has examined factors associated with NFP use - Information about NFP users’ knowledge, attitudes and perceived benefits of NFP use is also limited • Incomplete understanding of the effectiveness of NFP use for preventing unintended pregnancy

Key Questions and Potential Problems • Preliminary findings from Hispanic unmarried parents suggests that many women equate “birth control” with hormonal methods and underreport NFP use: I: What about the withdrawal method? Did that come to mind when you were thinking about birth control in this question? R: No, I was thinking about something like, specific, like medicines or something. I: And why would you say that those two methods [rhythm method and withdrawal] you don’t really consider as much as the others? R: Cause we’re not really doing anything really to prevent, the fertilization of an egg. I mean when I think of birth control, I think of like something, a product. I: So when you heard the phrase birth control, what kind of methods did you think of? R: Um, the first one I thought of was the depo-provera shot. When I think of birth control I think of something permanent.

Key contributions • We build on previous research by: - Identifying multiple domains of influence on NFP (family, individual, partner/couple and community) - Examining knowledge, attitudes and perceptions about NFP among young adult women and family planning staff - Assessing the effectiveness of NFP use compared with no method and with other methods

Conceptual framework: Behavioral model of health service use Predisposing Characteristics Demographics Age Race/ethnicity Immigrant Relationship status Previous children Social Structure Family structure Parent education Individual education Attitudes/Beliefs/Knowledge Cultural/religious beliefs Knowledgere: family planning Perceivedbarriers/facilitators to NFP, hormonal methods Family, peer, & partner belief s Enabling Resources Family/Individual Insurance Poverty status Funding for services & prescriptions Community Resources Presence ofaccessible/ affordable family planning services Culturally appropriate programstaff Awareness ofprograms Perceived Need for Services Perceived/ Evaluated Need Sexual activity Perceptions of pregnancy, STD risk Partner risk-taking Condom use Hormonal method use Use of natural family planning

Study’s Three Stages • Stage 1: 3 waves of one-on-one semistructured cognitive interviews • Stage 2: Focus groups with program staff and service providers • Stage 3: Quantitative analysis

Qualitative Components: Stages 1 & 2

Stage 1: Key Research Questions • What are the factors associated with the use of NFP? • How is knowledge about and perceptions of NFP associated with use? • What are predictors of successful NFP use and factors associated with discontinuation in use?

Stage 1: Qualitative Interviews Study Design Baseline Interviews • Collect data on predisposing characteristics, enabling resources and perceived need 6 -Month Follow-Up Interviews • Focus on short-term changes in contraception methods, relationship and pregnancy status and sexual activity. 12 -Month Interviews • Focus on predictors of contraceptive success, (the avoidance of an unplanned pregnancy)

Stage 1: Sample Design • Target sample: - Hispanic and African-American women using Title X funded clinics in DC - EVER used NFP - Ages 18 -29

Stage 1: Recruitment & Screening • Recruitment: - Building from current local contacts Work with 2 -3 local clinics Anticipate recruitment will take at least 6 months Key to success will be establishing strong partnerships and buy in from program at all levels - • Offering stipend to clinics; Communicate potential benefits of study to clinics Screening - High levels of screening to identify target population Brief interview, easily administered by staff or research staff Questions designed to identify the methods women are currently using and those that have ever used NFP Questions will seek to ensure that: - Target population is identified Underreporting of NFP is minimized

Stage 1: Benefits of Qualitative Interviews • • Sensitive and highly personal topics can best be explored in a one-on-one interview Semi-structured interviews: - • Allow a thorough exploration of the respondent’s thoughts, feelings, attitudes and behaviors Ensure that key topics and issues are addressed similarly for all participants Provide greater flexibility than a structured interview to pursue topics unique to the individual’s situation Cognitive probes helpful in identifying target group and better understanding complex topics (e. g. why and when)

Stage 2: Focus Groups Study Design Research Question: How are reproductive health decisions influenced by enabling resources, in particular programs and services? Target Population: Providers (e. g. , program directors, nurses, doctors) from programs and clinics in Washington, DC

Stage 2: Focus Groups • Sample: - 3 -4 focus groups - 8 to 10 participants per group (total 24 -40) - Group segmented by roles & responsibilities - doctors and nurses - program staff who meet directly with clients about reproductive health - program and clinic directors • Content: - Providers’ perceptions of NFP - How prevalent is it use among its clients? - Should NFP be offered as an option? - Dissemination of information - How often is information about NFP requested? - Do they offer this information? Why or why not? - Do they think it should be offered?

Stage 2: Benefits of Focus Groups • Useful for providing insights based on group interactions and assessing the extent to which there is consensus on an issue • Focus groups are more appropriate settings for identifying barriers and facilitators to NFP use from a program/service perspective • Help identify and receive feedback on recommendations for improving access to NFP information

Quantitative Analysis: Stage 3

Stage 3: Quantitative Analysis Research Questions • How are predisposing, enabling, and perceived need factors are associated with NFP use among young adult women? • Do predictors of NFP use differ by race/ethnicity? • How is NFP use among young adult women associated with unintended childbearing?

Stage 3: Quantitative Analysis Data • NSFG (2002 and forthcoming 2006 -2008) - Cross-sectional Over-samples Hispanics and African Americans Measures of immigration, language status Family planning providers • National Longitudinal Study of Adolescent Health (Add Health) (Wave III and upcoming Wave IV) - Large, longitudinal sample (15, 000+) - Large Hispanic sample - Measures unintended pregnancy

Stage 3: Dependent Variables • NFP use - Ever used NFP (NSFG) - Used NFP in the past year (NSFG, Add Health) - Contraceptive method (NSFG, Add Health) • Unintended birth - Unwanted birth or mistimed birth (Add Health)

Stage 3: Descriptive Information (NSFG) Table 2. Natural Family Planning Use by Young Adult Women (18 -29) in NSFG 2002 Total 12. 0% Race/ethnicity Hispanic 13. 1% Black 13. 4% White 11. 2%

Stage 3: Descriptive Information (NSFG) Table 2 cont. Natural Family Planning Use by Young Adult Women (18 -29) in NSFG 2002 Previous children Has a child 13. 5% Has not had a child 10. 6% Marital/Union status *** Married 15. 2% Cohabiting 7. 3% Outside a Union 10. 8%

Stage 3: Predictors of NFP use • Predisposing factors - Socio-demographics (age, race/ethnicity, immigration) - Family structure / marital/union status - Reproductive health knowledge • Enabling resources - Insurance coverage, poverty level - Publicly-supported family planning provider in county • Perceived need for services - Sexual experience and activity Characteristics of sexual partners and relationships Attitudes about pregnancy, perceived STD risk Other contraceptive methods

Stage 3: Analysis • Bivariate and multivariate analyses - Logistic regression (NFP use vs. no use; unintended birth vs. no birth/intended birth) - Multinomial logistic regression (NFP use vs. other method use vs. no use) - Interactions by race/ethnicity and immigrant status

Conclusion • Three stages will inform each other and provide a better understanding of the use of NFP among young adult women

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