Exploring African-American and Latino Teens' Perceptions of Contraception and Access to Reproductive Health Care Services.

PURPOSE: Reducing disparities in teen pregnancy and birth rates among African American and Latina teens is a central focus of a community-wide teen pregnancy prevention initiative implemented by the South Carolina Campaign to Prevent Teen Pregnancy. Disparities in teen pregnancy and birth rates are driven, in part, by differential access to contraception and reproductive health care services. The purpose of this qualitative study was to understand African American and Latino teens' 1) preferences for finding health information, 2) perceptions of accessing reproductive health services, and 3) beliefs about contraception.
METHODS: As a part of this community-wide initiative, eight focus groups were conducted in the Fall of 2012 with African American and Latino male and female youth from two communities in South Carolina. Among eight focus groups of youth, teens most often reported parents, other trusted relatives, and the Internet as sources of health information.
RESULTS: Participants discussed the value of social media and television advertisements for reaching young people and emphasized the importance of privacy, a desire for a teen-only clinic, and the need for friendly clinical staff. Participants' comments often reflected inaccurate beliefs about the reliability and correct usage of contraceptive methods. Female participants also reported side effects of birth control as a potential barrier to use.
CONCLUSIONS: Ensuring that teens' beliefs and perceptions are taken into account when developing, marketing, and implementing culturally competent reproductive health care services is important to improve access to care for all teens in Horry and Spartanburg Counties.

Teen pregnancy affects all racial/ethnic groups, but African-American and Latina teens share a disproportionate burden [1]. African-American and Latina teens’ pregnancy and birth rates are well over those of their white counterparts [2,3]. African-American and Latina females aged 15–19 years are more likely to report ever having sex than white females [4]. Among those who report having sex, a higher percentage of African-American and Latina youth as compared with white youth report not using contraception at the first sex and the last time they had sex [4]. Disparities in teen pregnancy and birth rates are driven in part by differential access to contraception and reproductive health care services, as well as a host of complex social determinants [5-8]. Research has also found that African-American and Latina youth are less likely to have insurance and to access routine primary health care services [6]. As a result, promising teen pregnancy prevention programs have focused on increasing access to contraception for sexually active youth [9]. Understanding adolescents’ perceptions of contraception and access to reproductive health care can potentially influence the quality of care that medical providers deliver and whether adolescents access these services. [10].

The unique needs of African-American and Latina youth must be fully considered to successfully increase their access to and utilization of contraception [11]. As an example, contraception misinformation, stemming from culturally based health myths, and unequal access to health care information may be more common among African-American women [12,13]. Research is needed to understand African-American and Latino adolescents’ perceptions of accessing contraception and to find practical ways to communicate the importance of accessing these services [5,11]. Communities can build effective interventions to reduce teen pregnancy in part by developing an understanding of African-American and Latino youth’s perceptions about contraception and reproductive health services [14].

When African-American and Latina youth access services, they are more likely than white youth to receive inadequate care [10]. Negative experiences not only affect the teen directly receiving services but also impact social norms surrounding reproductive health care services and may contribute to teens’ reluctance to access services [10,15]. Therefore, African-American and Latino youth’s perceptions of health care services and contraception must be taken into account when developing teen-friendly guidelines for reproductive health care services [16].

In 2010, the Centers for Disease Control and Prevention (CDC) in partnership with the Office of Adolescent Health released the funding opportunity, teenage pregnancy prevention: integrating services, programs, and strategies through community-wide initiatives. The goal of the community-wide initiatives was to reduce teen pregnancy and birth rates in communities with rates above the national average, with specific focus on reaching African-American and Latino youth aged 15–19 years. Each funded community-wide initiatives utilizes a model with five key components: (1) mobilizing the community in support of teen pregnancy prevention; (2) implementing evidence-based teen pregnancy prevention programs; (3) increasing youth access to contraceptive and reproductive health care services; (4) educating stakeholders about evidence-based strategies to reduce teen pregnancy; and (5) working with diverse communities to ensure priority populations are effectively reached. The South Carolina Campaign to Prevent Teen Pregnancy (SC Campaign) received an award to implement community-wide teen pregnancy prevention initiatives in Horry and Spartanburg counties.

This article focuses on two components of the CDC community-wide initiatives model. Increasing youth access to contraceptive and reproductive health care services emphasizes efforts to ensure that health center partners provide teen-friendly, culturally competent reproductive health care services that are easily accessible to all youth in the community. Working with diverse communities focuses on raising awareness of community partners about the link between teen pregnancy and social determinants of health, and supporting the availability of culturally and linguistically appropriate programs, and reproductive health care services for youth. The intersection of these components is critical for the provision of reproductive health services that effectively meet the needs of African-American and Latino youth from these communities. The SC Campaign conducted focus groups to learn about local African-American and Latino teens’ preferences for finding health information, beliefs about contraception, barriers to accessing reproductive health services, and ways to address those barriers. This article describes findings from the focus groups with youth in two counties in South Carolina, and how findings were used to enhance efforts of the community-wide initiative to increase youth access to reproductive health care.

Methods

Qualitative data were collected through focus groups with youth in two counties (Horry and Spartanburg). Focus group results are not intended to be generalized to a larger population but can provide valuable insights from “information-rich cases” for the development of programs and interventions [17]. A brief description of teen birth rates in the two counties is provided in the following section as context for these cases.

Teen births in Horry and Spartanburg counties

Although the rate of teen births in Horry County has fallen in recent years, at 36.9 births per 1,000 females aged 15–19 years in 2013, it is still well above the national average (26.6 per 1,000 females) and rates are considerably higher among African-American (42.8 per 1,000 females) and Latina females (59.9 per 1,000 females) [18]. African-Americans and Latinas make up 28% of the 15- to 19-year-old female population in Horry County but account for 35% of teen births. The teen birth rate in Spartanburg County is above the national average at 32.9 births per 1,000 females aged 15–19 years in 2013, and rates are highest among African-American and Latina youth (36.1 per 1,000 females for African-American females and 45.7 per 1,000 females for Latina females) [18]. African-Americans and Latinas constitute 32% of the 15- to 19-year-old female population in Spartanburg County, but 38% of teen births occur among these groups. In both counties, approximately 18% of the residents live below the federal poverty level and the unemployment rate hovers around 10% [19].

Participants

Purposive sampling was used to identify participants. Local community-based organizations assisted with the recruitment of participants. Flyers with a description of the study, inclusion criteria, and contact information were shared with each partnering organization of the initiative. Inclusion criteria included (1) African-American or Latino race/ethnicity; (2) age: 15–19 years; (3) if younger than 18 years, parent/guardian was willing to consent for adolescent participation; (4) not currently pregnant or parenting; and (5) willing to engage in a group discussion about contraception and reproductive health care services.

During fall 2012, eight focus groups—two with African-American males, two with African-American females, two with Latino males, and two with Latina females—were conducted. The sample included 63 participants. Approximately, half of the participants were male, and half were female. Participants were between the age of 15 and 18 years; the mean age was 16.6 years (standard deviation = 1.15). Race and ethnicity were Self-identified by participants; 35 participants were identified as African-American, 27 were identified as Latino/a, and one was identified as biracial.

Procedure

Focus groups ranging in length from 90 to 120 minutes were conducted by trained facilitators, and the audio was recorded. Two focus groups with Latino participants were conducted completely or partially in Spanish. Questions were asked according to a focus group guide (available from the corresponding author on request) developed based on findings from surveys of youth in the communities and relevant literature [5,10,11]. Feedback from experts on teen pregnancy prevention from the National Campaign to Prevent Teen and Unplanned Pregnancy, John Snow Institute, and the CDC was used to develop the final guide. Facilitators used probe questions to obtain and clarify responses from participants [20]. Participants were given a $50 gift card for their participation. The study was approved by the Liberty IRB, an independent institutional review board.

Coding and data analysis

Audio files from the focus groups were transcribed verbatim by a professional transcription service, and English translations were provided for the two groups conducted in Spanish. Transcripts of the focus group audiotapes, observer notes, and the demographic surveys were the primary data sources for analysis. Content analysis was used in examination and interpretation of the data. The verbatim transcripts were entered into QSR NVivo v.10.0, a qualitative data management program, for coding, text retrieval, intensive data organization, and content analysis [21].

To develop a codebook, the research team used the focus group guide as an initial framework, and when they encountered an idea or meaning in the transcripts, they manually marked the text segments and assigned a semantic code, which was based on the explicit meaning of the data. The team compared codes to determine if they arrived at similar interpretations of the data. During this “open coding” process, the definition of each code and a list of codes were finalized [22]. A master codebook was drafted by integrating and conceptually organizing the lists of codes. Each transcript was then recoded using this master codebook, and when necessary, new codes were added to the codebook. To obtain intercoder agreement, excerpts from a sample of the focus transcripts were manually coded independently by two of the researchers. Intercoder agreement of .80 was achieved for the transcripts.

By using QSR NVivo’s output function, all the coded data were printed out by code type, reviewed for accuracy, and examined for links to other codes. This “axial coding” process was used to connect code categories and to identify relationships between codes that were suggestive of themes [22]. In addition, comparing and contrasting focus group themes within and across groups (“constant comparison method”), we detected similarities and differences in the data [22]. Verbatim quotes from the focus group participants were used to validate the researchers’ coding, interpretation, and conclusions.

With the limited number of focus groups (two per subgroup), the researchers were restricted in their ability to thematically analyze, compare, and contrast the four subgroups without identifying individuals, particularly with the Latino participants. Therefore, the groups were thematically analyzed by gender but not by participants’ race/ethnicity.

Results

Results from the focus group data are considered by topic. All the emergent themes discussed in the article were expressed in both the male and female focus groups. However, several places where findings applied only to female participants are noted.

Finding health information

Focus group participants were asked “When you have a question about health, where do you go for answers?” Teens most often reported parents, the Internet, and other trusted relatives, including older siblings as sources of information:

“When I have questions about [sexual health] …I’m pretty open with my parents, I ask them.”

“I usually go to my mom or my grandma…but I don’t want to ask them everything… so then I go to the Internet to ask questions.”

“It just feels more comfortable going to the Internet.”

In response to the question “How do you know that the information you receive on things like sex and birth control is correct?”, the importance of engaging with trusted sources, such as a parent or teacher, emerged as a theme. Focus group participants said that they often trusted the information provided by teachers because “[teachers] get all their information from doctors” and other knowledgeable sources. Other teens said that they trusted information from their parents because parents “would not want to harm” their children with inaccurate information.

Perceptions of accessing health services

Participants were asked, “What are the best ways to get information on where to go for health services to teens?” The themes that emerged were the importance of using social media, schools, and television advertisements:

“You need to hear from [your] social network.”

“If I saw [the clinic] pop up on Instagram, then it would catch my attention.”

“[Teens] would probably learn a lot of information if there was a commercial informing everybody.”

When asked, “What do you think keeps teens from going to get birth control or an STD (sexually transmitted disease) test?” The concept that arose across all groups was fear: fear of the results, fear of other people’s reactions, and fear of how it would impact their lives. Among female participants, there were also privacy and confidentiality concerns and a lack of understanding ofminors’ rights regarding their reproductive health care:

“Everybody will know your business.”

“Every day doctors say oh, this is going to be confidential but it’s not. People talk and gossip…and it’s not really that confidential. …you know my mom…you know all of my friends. it’s not confidential.”

“Most of the time if you’re under age, [clinics] have to know that your parents know [that you are at the clinic to get contraception] because they cannot give you any treatment if you’re under 18.”

Participants were also asked, “What could health care clinics do to make teens feel more comfortable?” The themes that emerged were the importance of privacy, desire for a teen-only clinic, and the need for a friendly clinical staff:

“The [more] private the better…you feel more relaxed, more secure.”

“It would probably help to have a little clinic [that is] especially for teens.”

Frequently, teens talked about how important it was for the clinical staff to be friendly and welcoming:

“If you go to a clinic and you know that you have a problem… if [staff are] being rude to you…you’re not going to want to tell them…you’re going to feel a little bit awkward and you’re even going to want to leave.”

Beliefs about contraception

Focus group participants were asked, “What do you think keeps teens from using birth control?” The themes that surfaced were physical pleasure/emotions, and the impact of media and commercial messages:

“I think it’s just like sometimes the heat of the moment, [teens] just do it [have sex without using birth control].”

“On television, there’s all these shows with a whole bunch of sex, but you never see anyone grabbing for a condom.”

“[Contraception] commercials are kind of scary…at the bottom of the screen, the side effects [of the drug] in the small print. I hate it when they say side effects may include dizziness, drowsiness, heart disease…I say no thank you.”

Participants’ comments also reflected inaccurate beliefs about contraceptive methods’ reliability and correct usage:

“If I’m with [a girl] all night, I am using that same condom. I take that thing and rinse it on out.”

“I’ve heard of an implant they put in your arm. I think the doctors put it in with a syringe. But they say it’s not that reliable either.”

Female participants identified side effects of the birth control as a potential barrier to use. Participants frequently mentioned their fears about "gaining weight” and other "weird side effects.” Teens also described the side effects that their friends and family had experienced:

“My mom was taking birth control…now she has patches on her skin from it.”

In addition, parents were identified as a reason that teens may not use contraception. Some teens felt that their “[parents] think if you take birth control it opens the doors to have sex.” Other participants believed that their parents would not allow them to use birth control.

Focus group participants were asked, “Why do you think some teens feel it doesn’t matter if you use birth control?” One notion that surfaced was that teens do have control over whether they get pregnant by correctly and consistently using birth control. This belief was expressed by one teen who said “As long as you do everything right, [birth control] will work.” On the contrary, other teens felt that they do not have control over whether they get pregnant. Most of these beliefs stemmed from three routes: infertility beliefs (“families who are older, who want babies, they have to try for a long time to get pregnant.”); religious influences (“it’s all meant to be or it’s God’s plan”); and a feeling of invincibility (“[teens] think it ain’t going to happen to them”).

Discussion

Focus groups were conducted in two counties to better understand African-American and Latino youth preferences for finding health information, perceptions of accessing reproductive health services, and beliefs about contraception in those counties. Findings from these focus groups highlighted the participants’ concerns about the confidentiality of reproductive health care services, a desire for services that are private and provided in a way that is friendly and welcoming to teens. They also revealed inaccurate beliefs both about teen’s ability to consent to care without a parent’s permission and about the use and effectiveness of birth control methods.

Although the focus groups for this study were conducted separately with African-American and Latino youth, it is note-worthy that the issues highlighted in these groups were applicable to all teens, not just for those who are African-American and Latino. Concerns about confidentiality and privacy of services have been raised in multiple studies of barriers to teens’ access to health care [6,23,24]. Similarly, prior research has identified misperceptions about birth control methods and their side effects as a barrier to adolescents’ use of these methods [25]. This study adds to the sparse literature on these barriers specific to African-American and Latino teens and also provides examples of how these barriers were addressed in a specific project.

These focus groups were conducted as part of community-wide initiatives to address the unintended pregnancies among African-American and Latino youth in Horry and Spartanburg counties, two communities with disproportionately high teen pregnancy and birth rates. Input from these groups helped to guide organizational efforts to enhance the provision of reproductive health services for African-American and Latino teens in the target communities. Key findings from the groups and the strategies used to address these findings are provided in Table 1.

Table 1

Strategies to address focus group findings

Findings	Strategies
Teens recognized parents and the Internet as valuable sources of information about reproductive health	A Web site (notrightnowsc.org) providing accurate information about contraception, minors’ rights to health care, and other sexual health topics for teens and their parents. Work with local community-based organizations to provide parents resources for conversations about sexual health with their teens.
Teens suggested using advertisements, social media, and schools to provide information about health services.	Advertising time targeted at local teens on internet radio directing them to notrightnowsc.org. Using Facebook, Twitter, and a teen-driven blog to reach youth. Health centers participated in school-related events to increase awareness about available reproductive health services.
Confidentiality was a major concern raised by teens in the focus groups.	Specialized training to clinics about improving and communicating about confidentiality of services. Development of publications for clinicians and teens about minors’ rights to confidential reproductive health care.
Focus group participants identified the need for friendly clinical encounters	Trainings for clinical staff on adolescent growth and development, increasing positive encounters with teens, answering sensitive questions about reproductive health. Clinics provided tours for teens and their families during community events (e.g., block party, back-to-school night) to address teens’ concerns about going to a clinic.
Teens emphasized the importance of privacy and expressed the desire for a teen-only clinic.	Two health centers instituted teen-only hours to increase sense of privacy. One health center developed a special teen-only waiting area with a private entrance. Health centers created teen-friendly spaces (i.e., bright colors, age-appropriate materials that reflect diversity) in their waiting and examination rooms.
Inaccurate information about contraception was common and the side effects of contraception could be a barrier to use.	Partnership with Cicatelli Associates Inc. Global to offer a specialized contraceptive counseling training (Reducing Unintended Pregnancy: Contraceptive Counseling Approaches for Adolescents) including techniques that dispel myths and address concerns about side effects.

Although this study provides insight into a population that has received little attention in this area, there are several important limitations. Youth were recruited from a limited geographic area, and these results do not represent all African-American and Latino adolescents. The number of focus groups conducted was based on resources and as such it was not a true grounded theory, iterative process where data collection continued until saturation was reached. Likewise, the limited number of groups in each category constrained the analyses conducted, so that differences between the responses of African-American and Latino teens were not examined. Another limitation is that while level of acculturation affects access to reproductive health care among Latinos [14], no measure of acculturation was collected for Latino participants in this study. It is possible that Latino members of the groups were at different levels of acculturation. Focus groups with Latino participants were conducted by a facilitator who works with Latino populations and is fluent in Spanish. While this allowed two of the four focus groups to be conducted fully or partially in Spanish, this moderator is not Latina herself, and it is possible that she missed some nuances of participants’ experiences.

African-American and Latina youth share a disproportionate burden of teen pregnancies, due in part to lack of access to contraception and reproductive health care services [1]. This research focused on how youth find health information, their beliefs about contraception, and how these factors influence contraceptive use. Findings highlight the importance of involving youth in the process of developing interventions aimed at increasing reproductive health care access for teens, particularly youth from groups who experience significant disparities in reproductive health outcomes such as African-American and Latino youth, so their beliefs and perceptions are taken into account when developing culturally competent services. These focus groups informed changes intended to improve access to care for not only African-American and Latina youth but also for all teens in Horry and Spartanburg counties. Efforts should continue to provide teen-friendly, culturally competent reproductive health services and help reduce disparities in teen pregnancy experienced by African-American and Latino adolescents.