Atitudes Surrounding Contraceptive Responsibility: Do Latino Youth Difer from Other Groups?

Introduction

Recent estimates demonstrate that more than 75% of young women and men ages 15 to 19 used contraception at first sex and their most recent intercourse.[1] However, there are notable disparities in contraceptive use by race/ethnicity. Female and male Latino adolescents are less likely than African American and white teens to report contraceptive use at first sex.[2] In addition, Latino adolescents are less likely to report using condoms at last intercourse (54.9%) compared to African Americans (62.4%) and whites (63.3%) and were also less likely than whites to state they used hormonal methods (14.0% compared to 29.3% among whites).[3]

These lower rates of contraceptive use may be due, in part, to differences in attitudes about contraceptive decision-making. Several studies have noted that Latinos report that women are primarily responsible for contraception and preventing pregnancy,[4-8] which is associated with less effective method use compared to when both partners are responsible for deciding on contraception.[6,9-12] However, it is not clear whether attitudes placing responsibility for contraceptive use on women are more widely endorsed among Latinos compared to other racial/ethnic groups. Some of these studies have only included Latinos,[4,7] and others that assessed attitudes across racial/ethnic groups found few differences.[13] Additionally, little is known about the underlying beliefs and values that shape ideas about which partner or partners have responsibility for contraception and how these might vary by race/ethnicity. Such information is important in order to identify target areas for interventions that promote shared decision-making, and therefore increase effective use of contraception.

In this study, we explore youths' attitudes toward contraceptive responsibility. The specific questions we address are: Which partner is usually responsible for contraception and why? How do these attitudes and beliefs vary, if at all, across racial/ethnic groups and gender? To answer these questions we used data collected from focus groups with Latino, African American and white young women and men. Focus groups are particularly well-suited for the study of this topic because they highlight values and norms within groups sharing similar characteristics, as well as identify beliefs underlying attitudes and behaviors.[14]

Methods

Study design and recruitment

The data from this study come from the Texas Teen Opportunity Project, which investigated norms surrounding factors that put teens at risk for pregnancy. Between June and October 2009, we conducted 36 gender-and race/ethnicity-specific focus groups with young women and men in four of the largest cities in Texas. Specifically, we conducted 18 focus groups with young women aged 15 to 21 years and 18 groups with young men aged 18 to 24 years. The age range for young men was somewhat older than that for women due to the identified pattern of age discordance between young mothers and fathers in Texas.[15] Of these 36 groups, 12 each were with Latino, African American and white youth, resulting in six groups for every race/ethnicity-gender combination. Since youth who have had children may have different values surrounding future goals, experiences with parent-child communication about sex, attitudes about contraceptive responsibility, and other factors associated with pregnancy during the teen years, we also stratified the groups according to whether or not youth had already become parents (18 parenting and 18 non-parenting groups).

We recruited participants through community organizations that primarily served clients whose sociodemographic characteristics were similar to those of the target population (eg, a Latino community organization to recruit Latino youth). Since poor and low-income youth have higher rates of unintended pregnancy,[16] we focused on organizations serving low-income clients, such as community assistance and advocacy organizations and those offering at-risk teen programs or work force training. Once we identified an interested organization, a member of the research team explained the study objectives to their staff and provided a written description of participant eligibility criteria and recruitment flyers describing the study; flyers were available in English and Spanish. Given the diverse types of programs and services offered at the community organizations, staff had flexibility in their approaches used to recruit clients. Research staff was in regular contact with organizations to check on how recruitment was proceeding and ensure organizations had confirmed a sufficient number of eligible participants to conduct the groups. On the day of the focus group, the research staff confirmed participant eligibility.

Community organizations hosted the focus groups and provided on-site childcare when needed. Organizations were paid for hosting the groups and recruiting participants. A total of 214 young women and men participated in the 36 focus groups.

Focus group discussions

Moderators who had extensive experience conducting qualitative research with youth facilitated the focus groups. African American women moderated all the African American groups. A Latina woman moderated nine of the Latino groups; a Latino man and African American women moderated the remaining three Latino groups.* African American and Latino moderators facilitated white groups. Because of their experience working with youth, the moderators were able to successfully develop rapport with participants, even in groups where the moderator and participants were of the opposite sex or a different race/ethnicity.

Focus group discussions addressed the following topics: (1) future goals and planning for education and training, employment and other life goals; (2) parent-child communication about sex and attitudes about sexual debut; (3) contraception, including attitudes toward contraceptive responsibility and barriers and enablers of consistent contraceptive use; and (4) knowledge about the risk of conception and attitudes about teen pregnancy. The focus groups lasted an average of 90 minutes, with a five-minute break halfway through the discussion to minimize participant fatigue. All groups were digitally recorded, and an assistant moderator took field notes during the group. After the discussion, participants filled out a short, anonymous sociodemographic survey that included questions about their educational attainment and that of their parents, language spoken at home, and whether the participant and his/her parents were born outside the US. Participant characteristics are presented in Table 1.

Table 1

Distribution of focus groups and sociodemographic characteristics of Texas Teen Opportunity Project participants by race/ethnicity and sex

	Latinos		African Americans		Whites
	Women	Men	Women	Men	Women	Men
Total groups (range of participants/group)	6 (2-10)	6 (4-8)	6 (5-10)	6 (3-11)	6 (2-6)	6 (4-12)
	(n=32)	(n=42)	(n=42)	(n=39)	(n=21)	(n=38)
Mean age, years	17.1	19.8	18.2	19.9	18.8	20.3
Has children, n (%)	13 (41)	19 (45)	13 (32)	16 (41)	9 (43)	12 (32)
Born outside US, n (%)	7 (22)	3 (7)	1 (2)	0 (0)	1 (5)	0 (0)
Speaks Spanish at home, n (%)	4 (13)	10 (24)	0 (0)	0 (0)	0 (0)	0 (0)
Parents born outside US, n (%)	13 (41)	24 (57)	6 (14)	3 (8)	2 (10)	6 (16)
Mother did not receive a high school diploma, n (%)	16 (50)	13 (31)	4 (10)	2 (5)	2 (10)	1 (3)

Before beginning the group, young women and men ages 18 and older gave their verbal consent to take part in the study. Parents of girls ages 15 to 17 years provided written consent. Participants received $40 for taking part in the group.[†] The Institutional Review Boards at the appropriate institutions approved this study.

Data management and analysis

We transcribed the focus group recordings and then reviewed the transcripts for accuracy against the original recordings and corrected any omissions and errors.

We used thematic analysis[17] to code and analyze the transcripts, and our coding scheme was developed based on previously defined themes drawn from the literature and focus group guide, as well as new themes that emerged from the data. As a first step in the analysis, two research assistants, under the guidance of a consultant with extensive qualitative data-coding experience, independently coded two transcripts. The three coders then reviewed these transcripts for consistency, discussing discrepancies and assigning codes to text once they reached a consensus. Next, they independently coded four additional transcripts, and again reviewed the transcripts to solidify their inter-coding reliability and finalize the coding scheme. The two research assistants then divided the remaining transcripts into two groups, which each coded exclusively; when they were unsure of the most appropriate code, the research assistants met to discuss the relevant transcript segments and agree on the coding. We used NVivo 8 to manage and code the transcript data.

This analysis is primarily derived from participants' responses to the question, “Whose responsibility is it to use contraception?” In addition, we analyzed relevant transcript segments that addressed emerging themes of contraceptive responsibility in response to the following questions: “What makes it harder (easier) for young people to use contraception all the time?,” and “If teens know they do not want to get pregnant, why do you think they do not use anything to prevent it?” Using the coded transcript segments, we then compared similarities and differences by race/ethnicity and gender (and the intersection of these) in the common themes that emerged in youths' attitudes toward contraceptive responsibility. We also compared themes across parenting and non-parenting youth focus groups, but identified few differences; therefore, the presentation of our results focuses on racial/ethnic and gender differences, our primary areas of interest.

Results

In response to the question “Whose responsibility is it to use contraception?” youth most frequently said that both partners or just women are responsible for contraception; participants talked about men having primary responsibility far less often. In further discussions, several main themes emerged which demonstrated that beliefs about the consequences of unprotected sex, norms about maturity and self-control in sexual relationships, and perceptions of respect and trust in one's sexual partner shaped youths' ideas about which partner(s) had greater responsibility for contraception. Table 2 presents an overview of these themes and the interrelationship between these beliefs and gender norms and expectations surrounding contraceptive responsibility. We discuss these findings in more detail below.

Table 2

Main themes in youths' beliefs and values and their relationship to attitudes toward contraceptive responsibility

Theme	Partner responsible for contraception
	Both partners	Woman	Man
Beliefs about consequences of unprotected sex Youth primarily emphasized preventing pregnancy. Preventing STIs was a main reason for consistent condom use.	“I mean, if she gets pregnant then that's both your kid. It's gonna be both your responsibility … you guys are gonna have to tackle together.” (African American young man)“You're not gonna have sex by yourself, you can't make a baby by yourself, you can't get an STD by yourself. And it takes another person.” (White young woman)	“[It's more her responsibility] because she's the one getting pregnant, you know what I'm saying?” (Latino young man)“But like, the guy, if he gets you pregnant, he can take off. I mean, it doesn't hurt him. You're the one that's going to get screwed with getting big and having the baby.” (Latina young woman)	“It's my responsibility to make sure someone else doesn't get pregnant. Because … you either have to pay [child support] for the rest of your life… or you're forced to be part of this kid's life.” (White young man)
Norms about maturity and self-control in sexual relationships Using contraception is something one does because they are “grown”; sexually active youth who do not use contraception are “immature” and “irresponsible.” Youth should not get caught up in the “heat of the moment;” if no contraception is available, you should be able to “say no” to sex.	“If you're going to consent to have sex mutually, then you also have to consent to be safe about it.” (White young woman)	“Guys are not in the state of mind that they should be before or during, so you can't really trust them to be like, ‘Oh, need a condom.'… Girls need to be the one to do it.” (White young woman)	Theme not identified
Perceptions of respect and trust in one's sexual partner A sexual partner who uses contraception or is prepared with condoms cares about your health and life goals; a partner who still wants to have sex without contraception is “inconsiderate.”	“If you're in a relationship it's … 50/50, you want to both have your own responsibility to each other, but then know what the other person is feeling”(Latino young man)“If they in their career, and like, ‘Well, if we slip up, we gonna be together, we gonna take care of the child. ’ But if they not in their career and they trying to get there and they really care about themselves, like, ‘you need to take them birth control pills. ’ ” (African American young man)	Not applicable	Not applicable
Partners cannot be trusted to be prepared with condoms or correctly use contraception. Partners will not share the responsibilities of an unplanned pregnancy.	Not applicable	“Sometimes [guys] won't want to wear [a condom]. But if it's up to you and you know that sometimes guys aren't responsible, you have to take care of yourself.” (Latina young woman)	“You know people can say that they're on birth control all the time. Show you the pills and everything, but it don't mean they taking them. …That condom, that's 100%, you know that … condom.” (African American young man)

Both partners share responsibility

Participants viewed both partners as being responsible because they both would be affected by the outcomes of unprotected sex. This attitude was common in groups of both genders and all three race/ethnicities. Some youth even emphasized the importance of each partner using their own method to be “extra safe.” Although this was discussed in the context of preventing STIs as well as pregnancy, “doubling up” on contraception was more often taken as an additional step to prevent pregnancy in case a partner's method failed, as one Latina young woman stated: “What if only the guy's using and then the condom rips like in mine. I don't know. Both of them have to have it.”

More often, however, participants discussed the importance of assuring that just one of the partners used a method. Specifically, they mentioned that since young people make a mature decision to enter into a sexual relationship, they should also be responsible and use a contraceptive method. This sense of responsibility also meant both partners should exercise self-control and say no to sex if there was no contraceptive method available.

In relationships between regular sexual partners, youth also talked about using contraception because they had a sense of responsibility towards their partner and an understanding of a partner's goals, which motivated them to use contraception. Some youth also discussed the importance of deciding together which method they were going to use and how they felt most “comfortable” preventing pregnancy. These conversations were sometimes described as ongoing discussions where couples committed to using contraception evaluated several factors in deciding which method to use. For example, one Latino young man described how he did not want to use condoms and decided to pay for oral contraceptive pills for his girlfriend; after several months of paying $50 a cycle and having sex two or three times a week (which he considered infrequent), they were considering switching to condoms because they were less expensive. Another Latino young man talked about how he and his girlfriend decided not to continue using condoms after discussing that they both did not like how condoms felt:

In my case, the girl was like, “I don't want you to use a condom. I don't want you to use one because it don't feel as good.” I'm like, “Damn, it don't feel as good for me either,” so -- I mean it could go both ways. It might be on the girl but it's on me too.

Although many youth said both partners should share the responsibility for using contraception, their conversations often revealed that this was an ideal, rather than the way in which responsibility for contraception was realized in their own relationships. Some youth mentioned that discussing contraception was “awkward” or just assumed their partner would be prepared with a method. In addition, many youth responded to the dynamics of the group or provided socially desirable responses – agreeing that responsibility was shared by both partners – but within the same statement indicating that one partner was primarily responsible for making sure contraception was used. As indicated below, such conflicting statements often placed greater responsibility for contraception on women:

Equal responsibility, but, like, what he said, a little bit more on the girl's side, they have to be more responsible.

In all fairness, it's both. I never took responsibility for it, but it's both.

I think [it's]… both of them because if you get pregnant then they're going to be saying, ‘Oh, it's your fault for not using it.'

Women have primary responsibility

Women's responsibility was primarily linked to attitudes that an unintended pregnancy has more obvious physical implications for young women compared to young men. Young women also expected to continue to have the majority of the responsibility in caring for the child because a male partner can leave after finding out about a pregnancy, as a white young woman commented: “There are some guys out there, well there are a lot of guys out there, that once you say you're pregnant, they're gone”.

These ideas were mentioned in groups of both sexes, but young women, especially Latina young women, more commonly voiced these attitudes. A small number of female youth from all three racial/ethnic groups expressed their disagreement with and resistance to these norms and reiterated that they felt that both partners were really responsible. Recalling her own experience, a young Latina woman countered, “Like in my case, [my son's] grandma just tells me like—that it's my fault that I got pregnant… And I think it was both our fault.”

Another reason that young women are often held responsible for using contraception is that they are seen as having more self-control, whereas young men are perceived as “naturally more reckless” and willing to accept any opportunity to have sex, regardless of risk. As one white young woman stated, “girls get stuck being … the gatekeepers of sex.” By being perceived as having more self-control, young women are placed in a position to insist that a condom is used or refuse sex if no contraception is available. Some youth also believe that women should be responsible for contraception because methods available to them, like oral contraception, are seen as more convenient and better protect couples who get caught up in the heat of the moment:

Sometimes it's just like you're in the moment and it's like nobody … thinks, “Oh, we need to get this [condom].” But… if the girl is going to be like that, she should use some kind of birth contro l… so she won't have to wait at the last moment.

Young women also said they had to be responsible for contraception because their partners could not be trusted to be prepared with or committed to using condoms or withdrawal, which was echoed in some groups with young men: “But what if you're like, ‘Alright, well, I’m gonna let you do it without a rubber.' But does she really believe that the dude's gonna pull out?”

Men have primary responsibility

There were very few groups with young women in which men were seen as having greater responsibility for contraception; these discussions largely centered around what women perceived as social norms from images of condom use on TV.

In contrast, groups with young men frequently said that men should be responsible for contraception. This attitude often arose from wanting to avoid an unplanned pregnancy and the subsequent financial and legal responsibilities of raising a child. This theme arose more often in groups with African American and white male youth than with Latino young men. As a white young man commented, these obligations also meant having a long-term connection to a woman with whom you did not want a relationship:

I always think the guy in general should always just be prepared. Whether he's in a relationship or not, I mean he should just be prepared. You could get STDs, you could get her pregnant. And if you don't know her that well, why would you want to get her pregnant?

Often interwoven into these discussions were comments that demonstrated men's lack of trust in their partners. Men expressed concerns that their sexual partners were intentionally trying to get pregnant so men would be more committed to the relationship. They also frequently stated that some young women “don't care” about getting pregnant and others may intentionally become pregnant to collect child support in an effort to establish greater financial security, as reflected in this African American young man's statement: “Yeah. I'm not fixing to rule out this, a lot of females put their self in a pregnancy position because they feel like it'll be financial stability too.”

In order to prevent women from “trapping” them with a pregnancy, these young men placed the responsibility for using contraception on themselves. Young men frequently stated that they did not trust that a partner would use other contraceptive methods, like the pill, consistently or did not trust a sexual partner's condoms. For example, an African American young man in one group commented: “I got to see them buy the condom, but they gots they own, they say like poking holes in there and all that, I don't trust that.”

Discussion

Previous research has reported that Latinos often state that women are responsible for contraception and pregnancy,[4,5,7,8] an attitude which may contribute to lower rates of contraceptive use and higher rates of childbirth during Latinas' teen years. While our results also revealed that Latinos believe women are responsible for contraception, we found that these attitudes were not unique to Latinos and were commonly expressed in the majority of groups with African American and white youth.

When we examined underlying reasons for these attitudes, we were able to identify more subtle differences between racial/ethnic groups, which often intersected with gender. Young Latina women more often stated that they were responsible for contraception because women shoulder the majority of the burdens following an unintended pregnancy. Related norms were also found among young Latino men who mentioned concerns about the financial and legal obligations surrounding a pregnancy less often in their groups than African American and white men. By including the perspectives of young Latino men, which has been notably absent in recent studies on teen pregnancy among Latinas, we were able to identify a complimentary set of attitudes that may reinforce Latina women's contraceptive responsibility. Furthermore, our results indicate that norms which place responsibility on women are not universally accepted; some young Latina women (as well as African American and white young women) voiced opposition to these norms, and felt that both partners should be responsible for contraception and an unintended pregnancy.

However, we did not find racial/ethnic differences in other underlying beliefs about why women are responsible for contraception. Similar to earlier studies,[13] we found that participants in all three racial/ethnic groups said that women were responsible because they have greater levels of self-control when it comes to sex. As a result, this largely means that women are supposed to make sure a method is used – even when the method is condoms – or say no to sex because of the belief that men would rather have sex without a method than forego sex entirely.

Given these more nuanced attitudinal differences across race/ethnicity, it does not seem that those we observed would alone lead to the lower rates of contraceptive use among Latinas during their teen years. Rather, these attitudes likely operate in conjunction with other beliefs, as well as structural disadvantages, that make it more difficult for Latina young women to respond to attitudes about women's responsibility for contraception and take steps to use a method and prevent pregnancy. They may be more reluctant to disclose to their parents that they have become sexually active and need contraception due to parental messages about the importance of virginity and admonition of sex and pregnancy outside marriage.[4,18] They may also experience greater barriers to accessing affordable contraceptive services.[18-20]

To address the range of influences on Latino youths' contraceptive use, multi-level culturally relevant interventions are needed. These interventions could include raising awareness among Latino young men of their financial and legal responsibilities for fathering a child. Additionally, engaging Latino parents in youth sexual development education may help Latino youth feel more comfortable seeking out information about sex and contraception, which other studies indicate promote method use and help youth avoid pregnancy.[4,21] In fact, separate focus groups with Latino parents, conducted as part of this study, revealed that programs to assist parents in talking with their teens about sex would be welcomed, particularly among foreign-born Latino parents. Such efforts should be implemented in combination with initiatives to improve access to low-cost confidential reproductive health services to provide Latina teens highly effective methods before they conceive their first pregnancy.

Our results also point to a need to enhance sexual development education for all youth – not just Latinos. Many participants stated that they believed the responsibility for contraception should be shared by both members of the couple but frequently described this as an ideal. Youth of both sexes and in all groups also reported lack of trust in their sexual partners. Therefore, educational approaches should focus on more than just unwanted outcomes (ie, pregnancy and STIs); they should also promote positive sexual development so youth enter into intimate relationships where there is mutual respect rather than mistrust.[22,23] This would enable youth of all races/ethnicities to feel more comfortable discussing and negotiating contraception, which studies indicate is more likely to lead to consistent contraceptive use and use of more effective methods.[9,10,24,25] In addition, this approach could counter gendered norms about male irresponsibility and provide alternative messages and role models for young men that promote self-control, respect and safety as positive characteristics.[23]

This study has several limitations. Although we sought to compare attitudes across several key participant characteristics, it was not possible to explore differences across all categories of youth. For example, we were not able to identify differences between US- and foreign-born Latino youth, as we did not further stratify these groups by nativity and cannot link participants' responses to their country of birth. While other studies have identified differences between foreign- and US-born Latinos with regard to contraceptive use and attitudes,[8,21] we expect these differences are not as strong in our sample, given that youth in these groups were all educated in the US and could participate in English-language groups, which are two key indicators of acculturation. We also do not have information about participants' sexual orientation, which may influence attitudes about contraceptive responsibility due to perceived sexual risks.[26] In addition, the focus groups were conducted in urban areas of Texas, and therefore we cannot assume that the beliefs and norms we identified are generalizable to youth in other settings.

Finally, while not the aim of this qualitative study, we are not able link youths' attitudes to their actual contraceptive practice. Future research should prospectively assess attitudes about contraceptive responsibility and other attitudinal and structural risk factors to better understand how these are associated with subsequent contraceptive use behaviors and differences across racial/ethnic groups.

Despite these limitations, our results suggest that lower rates of contraceptive use among Latina teens may not be due to differences in attitudes surrounding contraceptive responsibility alone. Rather, lower rates of use may be linked to how these attitudes interact with other factors that vary more sharply across race/ethnicity, such as limited access to contraception and socioeconomic disadvantage. They also indicate that basic indicators of which partner is responsible may not adequately assess important differences in contraceptive practice and risk of unintended pregnancy; more nuanced measures that capture underlying beliefs about contraceptive responsibility may be more useful in evaluating these differences. Furthermore, our findings demonstrate a need to promote attitudes and provide skills to youth in all racial/ethnic groups that lead to shared contraceptive decision-making within healthy sexual relationships.