Dissertations and Theses

Date of Degree

6-2-2022

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.)

Department

Community Health and Social Sciences

Committee Members

Meredith Manze

Christian Grov

Sujatha Jesudason

Subject Categories

Public Health

Keywords

Contraceptive Use, Family Planning, South Asian, New York City

Abstract

Introduction: Currently, there are approximately 5.4 million South Asians residing in the United States (U.S.). The limited literature illustrates that contraceptive use is underutilized among Asians and Asian sub-groups, including South Asian Americans, compared to other racial and ethnic groups. Using Los Angeles County Health survey data, one study found that 22% of Asian Americans reported always using condom in the past 12 months compared to 37% of African Americans, 27% of Whites, and 27% of Hispanics. A study among New Jersey women revealed that compared to non-South Asian women, South Asians (SAs) were less likely to have used ever contraception (68% vs. 85%). There are many underlying factors that impact contraceptive use among South Asians: age, marital status, language, education, language, financial barriers, and cultural environment. As one of the fastest growing populations in the U.S. and low utilizers of contraception, there is a need for further research to examine factors specifically associated with contraceptive use among South Asians Americans to better understand reproductive goals, identify unmet contraception needs, and assess reproductive autonomy.

Methods: This study used the New York City Community Health Survey (NYC CHS) data from 2013, 2014, and 2016 to examine indicators of sociodemographic, behavioral, and health care access, and contraception use. Subsequently, to better understand the quantitative findings and explore attitudes, knowledge, socio-cultural influences, I conducted semi-structured, in-depth interviews with community leaders (N=10) who work closely with this population and knowledgeable about their sexual health needs. I then conducted additional in-depth interviews (N=30) with South Asian women to explore factors including their sexual health services utilization, attitudes, knowledge, and socio-cultural factors related to contraceptive use.

Results: Using the NYC CHS survey data, I found that two thirds of SAs (67%) used birth control at last sexual encounter. After full adjustment in the primary analysis, compared to SAs, other Asians were more likely to use birth control at last sexual encounter (aOR 1.54; 95% CI: 1.05, 2.26). In the secondary analysis of SAs, only marital status remained significant after adjustment, where those who were married/living together (aOR 0.19; 95% CI (0.08, 0.45) or divorced/separated/widowed (aOR 0.14; 95% CI: 0.03, 0.68) were less likely to use birth control, compared to those who were never married. The themes that that emerged from my key informant interviews (N=13) conformed to the Socio-Ecological Model (SEM). Specifically, I found that societal influences included silence around family planning issues due to traditional cultural norms and expectations, which also affected decision making around contraceptive use and childbearing. Fear of judgement and shame from the larger community was prominent. Interpersonal relationship influences included lack of autonomy and dependency on family and hiding use of or discussion of contraception from family. Lastly, individual-level factors were a lack of knowledge, birth control effectiveness, and individual characteristics. Societal factors often trickled down to the community, relationship, and individual levels creating a cascading effect. Thirty-two individuals participated in the in-depth interviews with SA women. There were three primary themes that emerged from the data: the ways in which participants internalized but adapted to the socio-cultural expectations that their family and South Asian community had steeped in beliefs from their home country; how their sexual and birth control attitudes, knowledge, and behavior changed over the life course; and the participants’ experiences and mostly supportive attitudes related to abortion.

Discussion: Overall, the results from this study demonstrate that a complex web of factors influence contraceptive use and family planning decisions in this community ranging from systems level factors that trickle down to the individual level. However, the understanding of contraceptive use and family planning decision-making in the South Asian community is limited by who participated in the data collected versus those who were excluded. The characteristics of study participants (i.e. educational level, employment, language, insurance status) likely influenced their attitudes, beliefs, and experiences around SRH and cannot be generalized to all South Asian women in NYC. The results from this formative mixed-methods study contributes significantly to the field of sexual health research given the dearth of research for the South Asian diaspora in the U.S. The study provides critical insight to the factors that are associated with and influence the attitudes, knowledge and experiences around birth control, abortion, and family planning decision-making in the South Asian community residing in NYC, filling a major gap in this research. Some of the study results illustrate the risk of aggregating certain racial and ethnic groups together. This study can help researchers, health care practitioners, and health care agencies to better understand the needs of this population in relation to contraceptive use. Moreover, the results from this study can help develop and pilot effective and comprehensive interventions that take into consideration the socio-cultural context of this population. These interventions must take a multi-pronged approach that can help address the various factors that will ultimately not only lead to safer sex practices, reduce the unmet need for contraception, create an open dialogue about these topics to decrease the associated stigma but also increase sexual and reproductive autonomy within the community.

Available for download on Sunday, November 05, 2023

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