Contraception knowledge and attitudes among Hispanic women

Purpose: Unintended pregnancies are among the most troubling public health concerns and a major reproductive health issue in women's health (Yazdkhasti, Pourreza, Pirak & Abdi, 2015). Nearly half of all pregnancies in the United States are unintended, with the highest rates among Blacks, Hispanics, and teenagers between the ages of 15 to 19 years of age (Craig, Dehlendorf, Borrero, Harper & Rocca, 2014). Unintended pregnancies mainly result from not using contraception and inconsistent or incorrect use of effective contraceptive methods (Tonlaar & Ayoola, 2014). In order to decrease rates of unintended pregnancies, we need to better understand the social and cultural influences, level of awareness and education, and barriers to access among all women (particularly those at higher-risk) about the use of contraception. Greater efforts to comprehend the reasons women experience unintended pregnancies will ultimately lower disparities and improve quality of life for all women. The purpose of this project was to better understand the facilitators and barriers of the use of contraception among a group of reproductive-age Hispanic women. Methods: A semi-structured interview guide was developed and administered to eight primiparous Hispanic women, ages eighteen and older. The interview guide included questions about their use of contraception, awareness of various methods, level of education about birth control and the social/cultural, familial, and religious influences regarding their decision to use contraception. Interviews were audio recorded and transcribed for data analysis. Recurrent codes and themes were identified by the bilingual, bicultural investigator and faculty mentor. Results: Four main themes were identified including; family influence, education provided vs. needed, religious influence, and the women's role related to birth control. Hispanic women in this study reported that these factors influenced their decision to use or not use contraception. Conclusion: This pilot study highlighted the important factors that affect contraception use and decision making among Hispanic women of reproductive-age. Although the findings from this small sample cannot be generalized for the whole population of Hispanic women in Utah, they shed light on important factors that should be considered by healthcare professionals in women's health. Exploring women's contraceptive knowledge and attitudes will allow clinicians to better educate and empower women with the necessary information for them to make the best informed choices and decrease the number of unintended pregnancies. These findings also contribute to the gaps in research in this critical area of women's health and help to inform efforts aimed at increasing health equity and decreasing health disparities.

CONTRACEPTION KNOWLEDGE AND ATTITUDES AMONG HISPANIC WOMEN by Laura Sofía Ortega-Flores A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirements for the Honors Degree in Bachelor of Science In Nursing Approved: ________________________________ Ana C. Sanchez-Birkhead, PhD, WHNPBC, APRN Thesis Faculty Supervisor _____________________________ Connie Madden, PhD, RN Assistant Dean for the Baccalaureate Program and Student Services College of Nursing _______________________________ Lauri Linder PhD, APRN, CPON Honors Faculty Advisor _____________________________ Sylvia D. Torti, PhD Dean, Honors College December 2019 Copyright © 2019 All Rights Reserved ABSTRACT Purpose: Unintended pregnancies are among the most troubling public health concerns and a major reproductive health issue in women’s health (Yazdkhasti, Pourreza, Pirak & Abdi, 2015). Nearly half of all pregnancies in the United States are unintended, with the highest rates among Blacks, Hispanics, and teenagers between the ages of 15 to 19 years of age (Craig, Dehlendorf, Borrero, Harper & Rocca, 2014). Unintended pregnancies mainly result from not using contraception and inconsistent or incorrect use of effective contraceptive methods (Tonlaar & Ayoola, 2014). In order to decrease rates of unintended pregnancies, we need to better understand the social and cultural influences, level of awareness and education, and barriers to access among all women (particularly those at higher-risk) about the use of contraception. Greater efforts to comprehend the reasons women experience unintended pregnancies will ultimately lower disparities and improve quality of life for all women. The purpose of this project was to better understand the facilitators and barriers of the use of contraception among a group of reproductive-age Hispanic women. Methods: A semi-structured interview guide was developed and administered to eight primiparous Hispanic women, ages eighteen and older. The interview guide included questions about their use of contraception, awareness of various methods, level of education about birth control and the social/cultural, familial, and religious influences regarding their decision to use contraception. Interviews were audio recorded and transcribed for data analysis. Recurrent codes and themes were identified by the bilingual, bicultural investigator and faculty mentor. ii Results: Four main themes were identified including; family influence, education provided vs. needed, religious influence, and the women’s role related to birth control. Hispanic women in this study reported that these factors influenced their decision to use or not use contraception. Conclusion: This pilot study highlighted the important factors that affect contraception use and decision making among Hispanic women of reproductive-age. Although the findings from this small sample cannot be generalized for the whole population of Hispanic women in Utah, they shed light on important factors that should be considered by healthcare professionals in women’s health. Exploring women’s contraceptive knowledge and attitudes will allow clinicians to better educate and empower women with the necessary information for them to make the best informed choices and decrease the number of unintended pregnancies. These findings also contribute to the gaps in research in this critical area of women’s health and help to inform efforts aimed at increasing health equity and decreasing health disparities. iii TABLE OF CONTENTS ABSTRACT ii-iii INTRODUCTION 1 METHODS 4 RESULTS 6 DISCUSSION 15 REFERENCES 18 APPENDIX A 21 APPENDIX B 22 APPENDIX C 23 APPENDIX D 24 iv 1 INTRODUCTION Unintended pregnancies are among the most troubling public health concerns and a major reproductive health issue in women’s health (Yazdkhasti, Pourreza, Pirak, & Abdi, 2015). When a pregnancy is unplanned it places socioeconomic burden on individuals and society. Unintended preganices cost an estimated $9.6 to $12.6 billion dollars a year to U.S. taxpayers (Trussell, Henry, Hassan, Prezioso, Law & Filonenko, 2013). Children who are born as a result of an unintended pregnancy are more likely to “live in poverty, experience adverse physical and psychological outcomes during childhood, and achieve lower educational attainment” (Pickle, Wu & Burbank-Schmitt, 2014, pg. 240). Unintended pregnancies mainly result from not using contraception and/or inconsistent or incorrect use of effective contraceptive methods (Tonlaar & Ayoola, 2014). Nearly half of all pregnancies in the United States are unintended, with the highest rates among Blacks, Hispanics, and teenagers between the ages of 15 to 19 years of age (Craig, Dehlendorf, Borrero, Harper & Rocca, 2014). Ensuring that family planning interventions are tailored to the communities they serve is imperative in order to improve health outcomes and eliminate health disparities among these populations. Growth in the Hispanic population is expected to triple over the next 40 years nationwide (World Health Review, 2019). The United States Census Bureau predicts that the Hispanic population will reach 111 milliion by 2060 (United States Census Bureau, 2018) Figure 1 illustrates the growth measurement of this projection. Utah’s population is also becoming more diverse and the “state’s changing demographic profile [will] place new demands on Utah’s health care system as different population groups have different health care needs and access to [our] health care system” (Summers, 2019, pg. 6). 2 Figure 1. National Hispanic Population growth A study published by the University of Utah’s Kem C. Gardner Policy Institute explains that half of Utah’s population growth from 2015 to 2065 will come from minority populations (Hollingshaus, Harris and Perlich, 2019). Among minority populations, Hispanics show the largest numerical increase with approximately 850,000 new Utah residents from 2015 to 2065, reaching 1.3 million. Figure 2 shows the increase of minority groups in Utah, where the greatest growth is in the Hispanic population. Figure 2. Utah’s population growth (Davidson, 2019) 3 This tremendous growth is a concern for healthcare providers as many Hispanics do not have access to health insurance and have the highest uninsured rates of any racial or ethnic group in the United States (Center for Disease Control and Prevention, 2015). Acccording to a 2018 United States Census Bureau report, Hispanics had the highest uninsured rate at 16.1 percent (Berchick, Hood and Barnett, 2018). If the Hispanic population continues to have a high uninsured rate, many individuals will not have access to effective contraceptive methods. Examining the awareness, education, social/cultural factors, and use of contraception among the Hispanic population may alleviate the burdens of an unintended pregnancy. One study explained that Hispanic women expressed a desire to not become pregnant, but were then more likely to have sexual intercourse without the use of contraception due to improper use and/or lack of awareness regarding available contraceptive methods (Tonlaar & Ayoola, 2014). Craig and associates also reported that foreign-born Hispanic women had less knowledge regarding contraceptive methods than U.S.-born Hispanics (Craig, Dehlendorf, Borrero, Harper & Rocca, 2014). Analyzing the contraceptive knowlegde of the Hispanic population will improve delivery of culturally competent care among health care professionals. Understanding common cultural values may also help with family planning interventions with populations who are at high risk for an unintended pregancy. It will also give guidance to focus policy that reflects differences in social, cultural, structural, economic and political contexts (Guttmacher Institute, 2019). 4 Aim and Hypothesis The aim of this study was to better understand the use of contraception among a group of eight primiparous Hispanic women and how social/cultural, familial, and religious influences affect their decision in choosing a birth control method. The literature reports that Hispanics have higher rates of unintended pregnancies, due to decreased awareness, education, and unproper usage of contraceptive methods (Tonlaar & Ayoola, 2014). The hypothesis was that the experiences of these eight primiparous Hispanic women would reflect what is found in the literature regarding Hispanics having higher rates of unintended pregnancies due to less contraceptive knowledge and use. Other factors revealed in participants’interviews about what influenced their decisionmaking regarding their use of birth control were also included in the anaylsis of this pilot study. METHODS Study This qualitative study included three phases. The first phase was to create a short semi-structured interview guide that explored the awareness and education of contraceptive methods, as well as the social-cultural factors and use of contraception among a group of eight primiparous Hispanic women. The second phase was to interview these women and assess their use and understanding of contraception. The third and final phase was to analyze their responses and create recurrent codes and themes to gain an increased understanding of their contraceptive perspectives. 5 Sample Eight primiparous Hispanic women, ages eighteen and older, were recruited from a list of 26 prior study participants who had given permission to be recontacted for future studies. Interviewed participants included six native/bilingual English speakers and two native monolingual Spanish speakers. Participants were recruited and interviewed by telephone using the semi-structured interview guide developed for this study. Consent Process This study was approved by the University of Utah’s Institutional Review Board (IRB_00120991). The research was deemed as presenting no more than minimal risk to the participants. Only women who previously consented to be contacted in the larger “The cultural context of motherhood and pelvic floor health” (CC-MAP) study were approached. Participants were given a complete description of the study and invited to participate. Informed consent form was then read to the women and those who agreed to participate gave verbal consent over the phone. Refer to APPENDIX A for English Informed Consent and APPENDIX B for Spanish Informed Consent. Participants at this point where asked a series of questions concerning their contraceptive knowledge and attitudes. Refer to APPENDIX C for English semi-structured interview guide and APPENDIX D for the Spanish semi-structured interview guide. Participants who chose not to participate were thanked for their time and the phone call ended. For those who were willing to participate, all of the questions in the interview guide were asked and all interviews were recorded for purposes of accuracy and data analysis. 6 Data Collection Procedures Telephone interviews were on average 15-20 minutes in length and were audiorecorded for data analysis. Recorded interviews were transcribed and analyzed by the Honors undergraduate student and Dr. Ana Sanchez Birkhead, Associate Professor at the University of Utah, College of Nursing. A thematic analysis process was conducted. Responses to each question were read and re-read by both members of the research team and recurrent codes and themes were identified and further developed. All data were kept on an encrypted laptop in a secure and private location. Personal information gathered for this study was kept private. Information from this study that will be published or presented at scientific meetings will not include any personal identifying information of the participants. Findings are summarized in this thesis and results were also written, reported and disseminated to research team members of the larger study. Audiotapes were destroyed at the end of the study. RESULTS Eight primiparous Hispanic women, ages eighteen and older, were recruited and interviewed. Participants included six native/bilingual English speakers and two native monolingual Spanish speakers. Four main themes were identified including; family influence, education provided vs. needed, religious influence, and the women’s role related to birth control. Hispanic women in this study reported that these factors influenced their decision to use or not use contraception. The more commonly reported contraceptive methods used among this sample was the intrauterine device and the birth control pill as shown in Table 1. 7 TABLE 1. Reported Birth Control use among Participants IUD (Kyleena/Mirena/Copper) 6 Birth Control Pill 5 Pull out Method 1 Abstinence 1 Condom 2 Ring 1 Nexplanon 1 Depo Shot 2 (Please note that one participant reported to have used more than one method) Theme 1. Family Influence Family influence was a major factor that affected the choice of birth control for the participants. Refer to Table 2 for participant responses. Four out of eight participants mentioned that their sisters impacted their final decision of what they chose to use. Four participants explained that their mothers influenced their final choice by making them “nervous” about a particular method, convincing them not to use a specific method, or by not explaining all contraceptive options that were best for the participant. Two participants had other members of the family who influenced their final decision. For example, participant #1 had uncles, aunts, and cousins, who advocated for safety and protection against sexually transmitted infections. Participant #5’s grandmother informed her not to use contraception because of her belief that it prevents the opportunity to become pregnant later. Overall, each participant in this study mentioned that at least one member of their family influenced their final decision in choosing a birth control method. The most commonly used birth control method reported by participants was the Intrauterine Device. 8 TABLE 2. Family Influence Responses Participant # 1 2 3 4 5 6 7 8 Quotes of Family Influence “…very much so… aunts and uncles, cousins, are like; Make sure you are being safe, like you know, if you end up doing it, be protected and all that stuff. So, I think [family] does play a huge role…” “My mom made me a bit worries about it, she actually did some litigation work on the Dalkon Shield back when it was in practice, and just from her understanding, and kind of her work, and talk with other women who had other IUD, she was very concerned that it was going to be a lot of pain in the insertion… I was a bit nervous, like she was all panicked about it.” “[Porque mi hermana también] tuvo el IUD, tambien [yo] lo tuve.” “speaking with my sister [who] has a lot more [experience with] many birth controls, I believe she used the Depo and the Mirena, when I tried the Depo, it was because my sister suggested it…she helped me and whom I talked to about that kind of stuff” “este solamente lo aprendí en la escuela, mi mama fue muy penosa y no hablaba estos como de estos temas conmigo.” “Mi abuelita me dijo que no usara anticonceptivos porque uno no se puede embarazar luego…cuando yo decidí tener un babe, y deje de cuidarme, me tarde bastante tiempo en embarazar me. Pues tengo que tener la duda que al mejor me abuelita tuvo razón y eran malos los anticonceptivos.” “my mom was actually the one who told me to get…the IUD” “I wish they told me not to get it…” “[My sister didn’t like the Nexplanon]… It was quite uncomfortable for her. For like, she would see it. And then how she would kind of explain it to me, she would kind of break out a lot more. I don’t know if it was because of that or she mentioned that from having that she would break out a lot more… it was kind of like I was leaning towards that one, you it is in your arm, you don’t have to worry about taking it out every so often. So that was another one I was thinking. So from what she was telling me I don’t think I should try that one then. “ “I went to Planned Parenthood and that is where I got some more information about it. Because my mom, throughout high school never really talked me about sex, or anything like that… being Catholic they did just kind of say you’re not supposed to have sex until you are married. You know it is a sin if you do. That is just one thing she did tell us growing up, but she never really talked to us about it. Like if you do end up having sex like this is what you have to do to protect yourself, something. But she really didn’t do any of that.” “I have a sister, she was on a ton of different birth control, for her she is more, I guess affected to more of them. So, it was hard to even go with her, because with one of them, it was an issue, you know, so I 9 guess it was more of my own. I didn’t really have any family talk to me about it or anything.” Theme 2. Education Provided vs. Needed All participants mentioned that they learned something regarding birth control during middle school, but the major focus of discussion with participants dealt with education from their providers. Refer to Table 3 for participant responses. Two participants mentioned that providers gave visual resources with the different types of methods and the effectiveness of each, which participants stated enhanced their learning. All participants did some form of research when choosing a birth control method, whether it was talking with their provider or reaching out to their family members. However, three participants sought more in depth information regarding birth control and accessed resources such as Planned Parenthood, PubMed, UptoDate, Google, and the library. Three participants expressed a lack of birth control education. For instance, participant #2 focused on how she would like to see her provider have a more in depth conversation concerning the potential symptoms/side affects one may have with the IUD. Participant #3 focused not so much on the education regarding birth control itself, but more on the education of the number of children a family can support. Lastly, participant #8 explained that her first provider did not give much education about birth control, but that her second provider presented more information of various methods. She also expressed that there is an increase need for education in schools regarding birth control. Out of all the participants, participant #4 explained that her provider did give her good information, but she did not investigate more information about birth control 10 methods. She mentioned, “I didn’t really follow through.” Even when asked, she gave no explicit reason why during the interview. Overall, each participant in this study mentioned how their experiences of birth control education influenced their contraceptive knowledge and decision in choosing a specific method. TABLE 3. Education Provided vs. Needed Responses Participant # 1 2 3 4 5 6 7 Quotes of Education Provided vs. Needed “there was always like a graph of different types of contraceptives. I think like you could like, see the percentage of how effective they are. I remember doing that which was great.” “Learned about it in school (Illinois) …through my sex ed class [in high school].” “I looked at the pamphlet that I was given in clinic, I uhh, PubMed…Planned Parenthood, Uptodate.” “I would go back to my provider and say, you know um, I guess just sort of understanding, the symptoms, the potential symptoms, you can have with an IUD…” “se de esto, ya más en forma, y tenía unos doce o trece años como chica cuando lo escuches de tu casa. Como, te hablan de los condones, te hablan de las pastillas, cosas hace.” “al mejor un poquito más de educación, de la gente puede tener, que la cantidad de hijos.” “You know, I did ask my provider and she gave good information but I really didn’t follow through. I really didn’t do my own, to be quite honest. Umm, I kind of just left it at that.” ““Me recuerdo que me dijeron una hoja, una hoja que tenía los diferentes anticonceptivos. Es lo que recuerdo [en la clínica]” “I pretty much went to google, and googled everything. And then I actually did a whole research about it. I went to the library and I printed all of these kinds of papers and that is how I actually pretty much learned about it.” “I [went] with the depo shot, and so at the time I didn’t really know about it. I preferred that one since you know I don’t have to remember taking it every single day and so I did that, but then a year after umm, I did kind of regret it because my hormones were all different. Like I wouldn’t get my period every month, like I would get it every other month. Or you know every four months. Like it was just bad and so when I had to go in to get my shot and I found out that I was pregnant with my daughter, I was like “okay, I don’t think I should be doing that one” 11 8 “After my daughter I did get more education about [different contraceptive methods]. So I went back to Planned Parenthood and they gave me more information.” “[My first provider] really didn’t talk about birth control, I mean she kind of did, but once I switched doctors that really pushed it, because I got pregnant right after having my first one, well, not like right after, but umm, pretty close together, I was just worried that it would happen again.” “[With my first provider] I felt like they didn’t really go over what an IUD was, it was more of like the pill, or something” “I mean I probably could have done more research, just talking with friends that had it, umm she (Second provider) did give me a pamphlet that did explain [the IUD] more” “I don’t think it was really mentioned in school. I think especially now a days umm, I would probably think, you know having that be explained in school would be a lot better. Like what is out there and what you can use.” Theme 3. Religious Influence Three out of eight participants mentioned that religion influenced their use of contraception at some point in their lives. Refer to Table 4 for participant responses. Participant #1 mentioned that being raised in a Jehovah Witness family greatly influenced the timing of her exposure to what birth control was, due to her parents teaching her to abstain from sex for marriage. Participant #2 conveyed that as a practicing Christian, she chose a method that was in range with her definition of not ending a life. Participant #7 explained that as a Catholic, one does not use birth control, which did cause her hestitation at first on whether or not to use a contraceptive method. However, she later expressed that she was not ready to have another child and that was the main reason why she chose to use birth control. Participant #3 explained that she is a very active religious member of her community, where it is discouraged to use any birth control method. She asserts that it is a very personal decision whether to use contraception or not. Participants #4 and #6 12 stated that there was no religious influence that affected their decision in choosing a birth control method. Participants #5 and #8 mentioned that the use of birth control was not necessarily influenced by religion. They reported that their decision was based more on the fact that they did not want to become pregnant and therefore needed to use a form of contraception at a specific time in their life. TABLE 4. Religious Influence Responses Participant # 1 2 3 4 5 6 7 Quotes of Religious Influence “I am actually a Jehovah Witness I am actually not a full Jehovah Witness, I am not baptized, but I do believe in their beliefs. I have been in the religion since I was a little girl… a big key…to abstain yourself from sex for marriage. That definitely had a very much impact on my life…as far as like you know getting pregnant and all that stuff.” “I am a practicing Christian…so of course methods that would be, I want to avoid methods that would be, for me, anything that would be considering ending a life…that definition that you define life that would be challenging…I felt that the IUD, [seemed] to fall ethically and morally within my range of what is okay” “no, no…yo soy muy religiosa, [y] voy a la iglesia y todo y dicen que no lo puedes usar para usar lo que Dios te dio, pero es una decisión muy personal” No Religious influence that affected her decision in using a birth control method. “[no influencia religiosa]… la única influencia fue en usar los fue que no quise quedar embarazada” No Religious influence that affected her decision in using a birth control method. “Being Catholic you are not supposed to have any type of birth control…when I told my mom that I was going to be on birth control is was kind of like you know, with our religion you are not supposed to have any type of birth control. You know if you are going to be having sex, you have to be married first. So that was kind of the downside of her like you should have birth control, you know until you are married. Or living with your daughter’s dad.” “I did tell her, it is my body, I know what I want to do. You know, I am sorry you don’t accept that but you know it is my decision and I want to do this. And I don’t see it as like anything bad, you know like being on birth control. You know like sometimes people aren’t 13 8 ready to have kids again…, being Catholic I know a lot of people they aren’t on birth control. And they have kids like every year, every two years. And so, it is kind of like you know like, it’s not like abortion, but I am not going to be on birth control and get pregnant. So that is why I am telling my mom, I am going to do it. I am not ready to have another kid; it is my decision whether or not she agrees.” “It wasn’t more of the religion part it was more of not needing birth control and I guess that is more before getting married, I guess where I could see is more in high school my parents would have been worried about me being on birth control, because that is something that we shouldn’t even be worrying about. So I guess that is where I really never cared about birth control until being married and having kids. So I guess on that side of religion, it was something that I didn’t really need to talk about.” Theme 4. Women’s Role related to Birth Control All participants in this study expressed comments related to the perception of women’s role concerning birth control. Refer to Table 5 for participant responses. Participants expressed concern regarding their fertility and reproductive roles as women and how this might be affected by the use of contraception. Participants #2 and #8 shared how they collaborated with their partners to not have all the responsibility fall on them, regarding protection and prevention of pregnancy. Two participants expressed how birth control had negatively affected them physiologically. For instance, participant #3 shared how she has no period when using the intrauterine device. She stated that “a period is something that must occur with being a female.” Participant #4 reported that she was having a hard time conceiving and how she does not want anything else affecting the possibility of a future pregnancy. However, participant #5 expressed no thoughts concerning her role as a woman in society when using a birth control method, whereas participants #6 and #7 reported a more feministic position regarding birth control use and education. Participant #6 14 declared that regardless of what others say, “it is her body”and she controls whatever she wants to do concerning birth control use. Participant #7 explained her desire for more contraceptive method education for women to be incorporated in all school programs, instead of just the introduction of the male condom. Participant #1 revealed interesting insight regarding culture. She declared that in the Latina culture it is assumed that Latina/Hispanic women should not have sex prior to marriage. However, if one does, then she explains that the individual in charge of the protection goes “directly to the girl.” She also expressed the increased stress that comes with the choice of what method to choose. She expressed concern that, “is birth control going to make me overweight or am I going to go all crazy because I have postpartum depression...?” TABLE 5. Women’s Role related to Birth Control Participant # 1 2 3 Quotes of Women’s Role Related to Birth Control “Cultural wise like I think it is like as far being a Latina I do feel like a lot of our moms and our Aunts, and it is kind of sad because it kinda goes directly to the girl. But they will always be you know, like “O Cuidate” like you do not want to have kids right now and it is something that I believe, even our Latin culture is like a given don’t do it.” “there is a lot of stress that goes about it that says you know, us being the women that’s like in a society that you have to look a certain way, like my main things, like oh my god is this birth control going to make me overweight or am I going to go all crazy because I have postpartum depression, like it is such a big thing… it worried me.” “[My husband] has certainly offered to be the one of taking the responsibility of protection… he feels like I don’t have to manage this. [We] potentially want something long term, we would like to consider a vasectomy, or something like that, but again, since that is more permanent, we decided to do the IUD.” “Hace me lo voy a quitar. Y por alguna manera con la Mirena yo no rengo. Hace de no tener me periodo, no sé, pero siento que es algo que tiene que salir de tu cuerpo.” 15 4 5 6 7 8 “So, I had a hard time getting pregnant. And when I did it was still kind of hard for me. I don’t know if I want any more kids, or anything. But you know, if I do want more and the time is too short, I do not want to [use birth control], you know.” Expressed no thoughts concerning her role as a woman in society that affected her decision in using a birth control method. “in the end it’s my opinion, it’s my body.” I remember taking one of the health class [in High school] and you know they did tell us like of STD’s, HIV, umm, they told us about tall of that. One thing they did tell us was about Condoms, but I do wish they did tell us that for more men, but I wished that they would have introduced more birth control with/for women. You know to also be protecting themselves. Because I know with condoms you could be protecting yourself [from] STD …But you know, you never know about women, you can still get pregnant. So, I wished they would have explained it a bit more like a women’s perspective…with birth control. “I guess the biggest thing is like with your spouse, umm like mine had a saying in it, like he didn’t want me to be on birth control, because he didn’t want the birth control. Which was the same for me, but after we had our second child it was more like let’s do something so we don’t have another one so soon, you know so, and we weren’t doing anything to prevent it either for because if it happens it happens, but I mean after having the second one it was more like, I can’t have another one so soon. You know I am still trying to heal and stuff like that. So, I guess, maybe when I was first pregnant, being more open minded about it. Because like I said, they kept mentioning it to me, and telling me it is going to be easier to be pregnant after our first one, so I definitely kept saying I don’t need it, So I guess we should be more open about it.” DISCUSSION The findings from this small project highlight that family influence, education provided vs. needed, religious influence, and the women’s role related to birth control were four main factors that affected a Hispanic woman’s choice in choosing a birth control method. As stated above, the aim of this study was to better understand the use of contraception among a group of eight primiparous Hispanic women and how factors such 16 as: social, cultural, familial, and religion influence affect their decision in choosing a birth control method. The experiences shared by these eight primiparous Hispanic women showed that most of the women were knowledgeable concerning birth control. The hypothesis for this study was that the literature regarding Hispanics having higher rates of unintended pregnancies would be due to less contraceptive knowledge and use. Our data collected from participants did not provide a conclusive answer as to whether or not these women had higher rates of unintended pregnancies. Most participants were knowlegdable about contraception, but were not explicitly asked whether or not their past pregnancies were unintended. Nonetheless, the information gathered regarding the decision-making process and potential influencers will greatly contribute to the the literature of women’s health and benefit health care providers and patients. Study Limitations Though this study of eight primiparous Hispanic women provided insightful information regarding what influences affect their decision in using a birth control method, large conclusions about Hispanic women in general are not able to be determined due to the small sample size. In order for findings to be generalized across a specific population, a study sample from a larger number of participants as well as different sites and various ages will be needed. This study provides data from a small sample of primiparous Hispanic women in Utah. Another study limitation may include the willingness of specific participants to being very involved and informed in this topic. Lastly, if the interviews were perhaps on paper/in person, responses that participants may have given could have changed slightly. 17 Implications for Future Research and Practice This pilot study highlighted important factors that affect a Hispanic woman’s decision in choosing a birth control method. Though these eight women do not represent the whole Hispanic female population in Utah nor nationally, exploring their contraceptive knowledge and attitudes does allow the advancement of awareness and understanding to help others further develop the intellectual, professional and personal growth of Hispanic women as well as members of the health science community. These findings may also contribute to the ongoing research regarding health equity and health disparities as we strive to improve our overall healthcare delivery in United States. 18 REFERENCES Berchick, E.R., Hood, E., and Barnett, J.C. (2018) Health Insurance Coverage in the United States: 2017. United States Buearu. Retreived November 18th, 2019 from https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60264.pdf Center for Disease Control and Prevention. (2019) Unintended Pregnancy. CDC. Retrieved October 3, 2019, from https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/inde x.htm Center for Disease Control and Prevention. (2015) Cultural Insights: Communicating with Hispanics/Latinos. CDC. Retrieved June 18th, 2019, from https://www.cdc.gov/healthcommunication/pdf/audience/audienceinsight_cultural insights.pdf Craig, A.D., Dehlendorf, C., Borrero, S., Harper, C.C. & Rocca, C.H. (2014) Exploring Young Adults' Contraceptive Knowledge and Attitudes: Disparities by Race/Ethnicity and Age. Women's Health Issues, 24(3), doi: 10.1016/j.whi.2014.02.003. Davidson. (2019, April 25) Minority population expected to boom in Utah in next 50 years. In 2065, 42% of schoolchildren projected to be minorities.The Salt Lake Tribune. Retrieved November 11th, 2019 from https://www.sltrib.com/news/politics/2019/04/24/minority-population/ 19 Guttmacher Institute. (2019) Unintended Pregnancy in the United States. Guttmacher Institute. Retrieved February 11, 2019, from https://www.guttmacher.org/factsheet/unintended-pregnancy-united-states Hollingshaus, M., Harris, E., Perlich, P.S. (2019, April) Utah’s Increasing Diversity: Population Projections. University of Utah Kem C. Gardner Policy Institute. Retrieved November 11th, 2019 from https://gardner.utah.edu/wp-content/uploads/UtahProjections-Race-Ethnicity-2019.pdf Pickle, S., Wu, J., & Burbank-Schmitt, E. (2014). Prevention of Unintended Pregnancy A Focus on Long-Acting Reversible Contraception. Primary Care, 41(2), 239. Summers, L. (2019, January) Staying Ahead of the Curve: Utah’s Future Health Care Needs. University of Utah Kem C. Gardner Policy Institute. Retrieved November 15th, 2019 from https://gardner.utah.edu/wpcontent/uploads/HealthCareNeedsReportJan2019.pdf Trussell, J., Henry, N., Hassan, F., Prezioso, A., Law, A., & Filonenko, A. (2013). Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception, 87(2), 154– 161. doi:10.1016/j.contraception.2012.07.016 Tonlaar, Y. & Ayoola, A. (2014). Pregnancy Intention and Contraceptive Use Among Low Income Women. Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(S1) doi: 10.1111/1552-6909.12449 World Population Review. (2019) United States Population 2019. WPR. Retrieved June 11, 2019, from http://worldpopulationreview.com/countries/united-statespopulation/ 20 Yazdkhasti, M., Pourreza, A., Pirak, A., & Abdi, F. (2015). Unintended Pregnancy and Its Adverse Social and Economic Consequences on Health System: A Narrative Review Article. Iranian journal of public health, 44(1), 12–21. 21 APPENDIX A Consent Form Contraception knowledge and attitudes among Hispanic women The purpose of this research study is to understand your knowledge and attitudes concerning reproductive life planning. We are doing this study because we want to find the best way to develop culturally sensitive family planning programs. We are asking you to take part in a telephone interview. The information collected in these telephone interviews will include: when you first learned about birth control, knowledge and preferences on birth control, and influences that affect your decision in choosing a birth control method. Some questions may be sensitive and you can choose not to answer them. The telephone interviews will be recorded for data analysis. Recorded interviews will be transcribed and analyzed by an honor’s undergraduate student and Dr. Ana Sanchez Birkhead, Associate Professor at the University of Utah, College of Nursing. We will take a thematic analysis process for conducting the analysis. Responses to each question will be read and re-read by both members of the research team and recurrent codes will be identified and themes will be developed. All data collected including the analysis will be secured on an encrypted laptop. We will do our best to make sure that the personal information gathered for this study is kept private. If information from this study is published or presented at scientific meetings, your name and other personal information will not be used. Audiotapes will be destroyed at the end of the study. The telephone interview should take about 15-30 minutes to complete. Participation in this study is voluntary. You can choose not to take part. You can choose not to finish the interview or not answer any question. By participating in the interview, you are giving your consent to participate. There will not be direct benefit to you from participating this study. However, findings from this interview will contribute to the ongoing research regarding effective family planning programs, health equity and health disparities in women’s health issues as we strive to improve our overall healthcare delivery. If you have specific concerns or feel you have been harmed by this research, please contact Dr. Ana Sanchez-Birkhead, Associate Professor at the University of Utah, College of Nursing at 801-585-5680. Contact the Institutional Review Board (IRB) if you have questions regarding your rights as a research participant. Also, contact the IRB if you have questions, complaints or concerns which you do not feel you can discuss with the investigator. The University of Utah IRB may be reached by phone at [phone] or by e-mail at [e-mail]. Thank you so much for being willing to participate in this study. 22 APPENDIX B Carta de consentimiento Contracepción conocimiento y actitudes entre las mujeres hispanas El propósito de este estudio de investigación es entender sus conocimientos y actitudes sobre la planificación de la vida reproductiva. Estamos haciendo este estudio porque queremos encontrar la mejor manera de desarrollar programas de planificación familiar culturalmente sensibles. Le pedimos que participe en una entrevista telefónica. La información recopilada en estas entrevistas telefónicas incluirá: la primera vez que aprendió sobre el control de la natalidad, los conocimientos y las preferencias sobre el control de la natalidad, y las influencias que afectan su decisión al elegir un método anticonceptivo. Algunas preguntas pueden ser sensibles y usted puede optar por no responderlas. Las entrevistas telefónicas se grabarán para el análisis de datos. Las entrevistas grabadas serán transcritas y analizadas por un estudiante de pregrado de honor y la Dra. Ana Sánchez Birkhead, profesora asociada de la Universidad de Utah, Facultad de enfermería. Tomaremos un proceso de análisis temático para llevar a cabo el análisis. Las respuestas a cada pregunta serán leídas y releídas por ambos miembros del equipo de investigación y se identificarán los códigos recurrentes y se desarrollarán temas. Todos los datos recogidos incluyendo el análisis serán asegurados en un ordenador portátil encriptado. Haremos nuestro mejor esfuerzo para asegurarnos de que la información personal recopilada para este estudio se mantenga privada. Si la información de este estudio se publica o se presenta en reuniones científicas, su nombre y otra información personal no serán utilizados. Las Audio tapes serán destruidas al final del estudio. La entrevista telefónica debe tardar unos 15-30 minutos en completarse. La participación en este estudio es voluntaria. Puedes elegir no participar. Puedes elegir no terminar la entrevista o no contestar ninguna pregunta. Al participar en la entrevista, usted está dando su consentimiento para participar. No habrá beneficio directo para usted de participar en este estudio. Sin embargo, los hallazgos de esta entrevista contribuirán a la investigación en curso sobre programas efectivos de planificación familiar, equidad en salud y disparidades de salud en los problemas de salud de la mujer, ya que nos esforzamos por mejorar nuestra atención sanitaria general. Si usted tiene inquietudes específicas o siente que ha sido perjudicado por esta investigación, por favor contacte a la Dra. Ana Sánchez-Birkhead, profesora adjunta de la Universidad de Utah, Facultad de enfermería a las 801-585-5680. Comuníquese con la Junta de revisión institucional (IRB) si tiene preguntas sobre sus derechos como participante de la investigación. También, comuníquese con el IRB si tiene preguntas, quejas o inquietudes que no cree que pueda discutir con el investigador. El IRB de la Universidad de Utah se puede llegar por teléfono al [phone] o por correo electrónico a [e-mail]. Muchas gracias por estar dispuestos a participar en este estudio. 23 APPENDIX C English Interview Guide • Tell me of your experience of when you first learned about contraception/birth control? Prompts: How old were you? Where were you living at the time? What was the setting? What contraception did you hear about at that time? • Tell me about what contraceptive/birth control methods you know of? Do you know of any additional methods now? Prompts: How did you hear about these methods? What was the setting; where were you at the time, school, clinic? • Are you currently using a contraceptive/birth control method? a. IF YES; Which method(s) are you using and why did you choose this/these method(s)? i. Do you know the side effects of that/those method(s)? ii. • Is there another method you would rather use? Do any family members influence your decision in using contraception/birth control? • Are there cultural tradition/practice/views that influence your decision about using contraception/birth control? • Are there religious beliefs that influence your decision about using contraception/birth control? 24 APPENDIX D Spanish Interview Guide Preguntas de entrevista telefónica • Cuéntame de tu experiencia de la primera vez que aprendiste acerca de la contracepción/anticonceptivos? Indicaciones: ¿Cuántos años tenías? ¿Dónde vivía en ese momento? ¿Cuál era el escenario? ¿Qué anticonceptivo escuchaste en el momento? • Dígame, ¿qué métodos anticonceptivos y anticonceptivos conoce de no? ¿Sabes de métodos adicionales ahora? Avisos: ¿Cómo te enteraste de estos métodos? ¿Cuál era el escenario? • ¿Está utilizando actualmente un método anticonceptivo/anticonceptivos? a. Si: qué método (s) está utilizando y por qué eligió este/estos método(s)? • i. ¿Conoces los efectos secundarios de ese/esos método(s) ii. ¿Hay otro método que preferirías usar? ¿Algún miembro de la familia influye en su decisión de usar anticonceptivos o métodos anticonceptivo? • ¿Existe una tradición/práctica/opiniones culturales que influyan en su decisión sobre el uso de anticonceptivos? • ¿Hay creencias religiosas que influyan en tu decisión sobre el uso de anticonceptivos?