6 reserch

Accessing sexual and reproductive health care and information: Perspectives and recommendations from young Asian American women Madeline Frost a,*, Alexa Cares a, Katie Gelman a, Rita Beam b

a OMNI Institute, 899 Logan Street, Suite 600, Denver, CO 80203, USA b Tri-County Health Department, 6162 South Willow Drive, Suite 100, Greenwood Village, CO 80111, USA

A R T I C L E I N F O

Article history: Received 13 May 2016 Revised 16 September 2016 Accepted 25 September 2016

Keywords: Asian American Asian Pacific Islander Sexual health Reproductive health Adolescent health Health communication

A B S T R A C T

Objectives: Understanding the influence of culture on how sexual and reproductive health is perceived and addressed in Asian American communities is important for the effective provision of care and health information. This study aimed to explore how and when sexual and reproductive health information is shared within Asian American families and communities, barriers and facilitators to accessing sexual and reproductive health care and information for young Asian American women, and their recommenda- tions to improve access. Methods: Qualitative data were collected through six focus groups conducted with a total of 33 young Asian American women. Results: The majority of participants reported that stigma created a barrier to discussing these topics within their families and communities, and discussed ways in which they confidentially seek out care and information. Responses varied with respect to participants’ preferred means of increasing access to care and information; some recommended strategies that would increase communication about these issues in their families and communities, while others expressed a desire to maintain confidentiality. Conclusions: These findings suggest that diversified strategies are needed to connect Asian American women with sexual and reproductive health care and information in order to meet their varied preferences, in- cluding strategies that are community-driven and culturally appropriate.

© 2016 Elsevier B.V. All rights reserved.

Introduction

Asians are now the fastest-growing racial group in the United States, and make up approximately 6% of the total population. Nearly three-quarters of Asian American adults were born abroad, meaning that the majority of this group is composed of recent immigrants and their children [1]. Understanding the influence of culture on how sexual and reproductive health is perceived and addressed in Asian American communities is important for the effective provi- sion of care and health information.

In many traditional Asian cultures, sexuality is generally con- sidered an inappropriate subject to be discussed with others, and topics such as sexual and reproductive health may be avoided in Asian American families and communities [2]. Limited research sug- gests that Asian American parents may communicate with their children about sex less frequently than parents in other

racial/ethnic groups [3–5], and they are perceived by their chil- dren to provide very little information about sexual topics [6,7]. Research also suggests that lower use of sexual health-related care in Asian American communities may be related to cultural factors, in addition to barriers such as lack of insurance and discrimina- tion [2,8]. Additionally, Asian American adolescents have reported being reluctant to discuss sexual and reproductive health issues with healthcare providers due to concerns about confidentiality [9]. These factors may create challenges for healthcare providers seeking to connect Asian American patients with sexual and reproductive care and information.

An intergenerational communication gap may be negatively af- fecting some Asian American adolescents’ sexual and reproductive health. As young Asian American women become more accultur- ated to U.S. norms, the likelihood that they will become sexually active increases [10]. Asian American adolescents have been found to delay sexual intercourse relative to their peers; however once sex- ually active they are just as likely to engage in risky sexual behavior [11–14]. Rates of some sexually-transmitted infections (STIs) are in- creasing for Asian American women under 25 years old, and Asian American women have lower rates of STI screening than other groups [8]. Evidence suggests that sexual health interventions are more

* Corresponding author. OMNI Institute, 899 Logan Street, Suite 600, Denver, CO 80203, USA.

E-mail address: [email protected] (M. Frost).

http://dx.doi.org/10.1016/j.srhc.2016.09.007 1877-5756/© 2016 Elsevier B.V. All rights reserved.

Sexual & Reproductive Healthcare 10 (2016) 9–13

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Sexual & Reproductive Healthcare

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effective when tailored to specific populations [15], and efforts to promote sexual and reproductive health among young people should consider the cultural contexts of Asian American families and communities.

Although some research has examined barriers to sexual and re- productive health care and information for Asian American populations (e.g., Vietnamese Americans, Chinese Americans, Indian Americans, etc.), few studies have engaged young Asian American individuals to share their recommendations for increasing access to sexual and reproductive health care and information [4,9]. This paper describes findings from six focus groups that were con- ducted with young Asian American women in 2012 and 2013. The focus groups explored how and when sexual and reproductive health information is shared; barriers and facilitators to accessing sexual and reproductive health care and information; and young Asian American women’s recommendations to improve access.

Methods

Research design

This study took a qualitative approach to exploring young Asian American women’s experiences and recommendations related to discussing sexual and reproductive health and accessing care and information. A local health department in the Denver metro area contracted with a research organization to develop a focus group protocol asking about participants’ experiences and recommenda- tions, as well as a questionnaire that gathered supplemental data on demographics and health behaviors. Prior to beginning data col- lection, the instruments were piloted with two Asian American community members who met focus group participant eligibility criteria, and were subsequently revised to improve their clarity.

Over a two-year period from 2012 to 2013, six focus groups were facilitated with a total of 33 women. The focus groups ranged from three to eleven participants. A purposive sampling method was used in order to assess perspectives of the target population. Eligibility criteria required participants to be women of Asian descent, between 15 and 24 years old, living in the Denver metro area, and able to speak and understand English due to the unavailability of transla- tion services.

Participants were recruited through contacts with local educa- tional and community organizations, email listservs, flyers, and social media. Recruitment materials asked participants to engage in a “dis- cussion about women’s health.” Twenty organizations were contacted to help facilitate recruitment, and flyers were posted at 32 locations, including colleges, neighborhoods with large Asian American populations, and storefronts. The majority of partici- pants were recruited through their involvement with educational institutions or community organizations, and so, as a group, they were likely more highly educated and engaged with community or- ganizations than the broader Asian American population. It is possible that this education and engagement made them more knowledgeable about and willing to discuss sexual and reproduc- tive health topics. In an effort to recruit a more diverse sample during the second round of focus groups, the research team intentionally targeted women who may be less engaged in such institutions by posting more flyers in Asian American neighborhoods and store- fronts. However, no participants were successfully recruited by these flyers.

All participants underwent an informed consent process in which they were told the purpose of the study, that participation was op- tional and that they could discontinue at any time, and that their responses would be kept confidential. They were given the oppor- tunity to ask questions, and then signed a consent form. Guardians of participants younger than 18 years old also signed a consent form.

Participants received a $50 gift card for their participation in 2012, and a $25 gift card in 2013.

Each focus group lasted about 90 minutes, and was conducted by a trained facilitator from the research team in a small confer- ence room. Before the discussion, participants were asked to complete the supplemental questionnaire. Discussions were audio- recorded while an assistant moderator took notes. All researchers who were present during the focus groups were women, and did not have any previous relationship with the participants. The fa- cilitator was a member of the Asian American community. The focus groups had a semi-structured design, allowing the facilitator to gather information on key topics of interest while also allowing the par- ticipants to steer the discussion toward topics they felt were important.

Analysis

Focus groups were audio-recorded and manually transcribed, and transcripts were subsequently reviewed for accuracy. The re- search team integrated deductive and inductive approaches to qualitative data analysis: preliminary codes were developed based on a review of the existing literature and research questions (how sexual and reproductive health care and information is obtained, barriers and facilitators to such care and information, and partic- ipant recommendations to improve access). During the process of coding the first two transcripts, the research team refined the coding structure to improve clarity and address emerging themes.

Two members of the research team used NVivo qualitative data analysis software (QSR International Pty Ltd. Version 10, 2012) to code focus group transcripts. Both coders were research profes- sionals experienced in qualitative analysis. Inter-rater reliability was calculated after the coders had analyzed the first two transcripts (33% of the data) and revised the codebook, with a kappa of 0.86 across all codes indicating strong agreement. The coders then sep- arately analyzed the remaining transcripts. Focus group data were aggregated by code and further analyzed to identify subthemes, and key findings were summarized. Findings and recommendations were later reviewed with an Asian American community coalition to ensure their accuracy and usefulness.

Results

Participant demographics

In total, 33 women participated in focus groups during 2012– 2013. Participants ranged from 15 to 24 years of age, and the average age was 20.1 years. Within a single focus group, the age difference between the youngest and oldest participant ranged from three to five years. All women were of Asian descent, and over half (52%) indicated that their country of origin was the United States. The rest identified their countries of origin as Vietnam (18%), Korea (15%), India (6%), Pakistan (3%), Canada (3%), and Malaysia (3%).

At the time of the focus groups, nearly half of participants (49%) indicated that they were either in college or had completed college. Two participants (6%) had completed a graduate degree and one (3%) had completed an Associate’s Degree. The remaining participants had completed 9th grade (3%), 10th grade (9%), 11th grade (15%), and 12th grade (15%). The majority of participants (85%) indicated their occupation as “student,” four (12%) indicated other occupations,1

and one (3%) indicated no occupation. Over half of participants (52%) indicated that their relationship status was single; the rest indi- cated that they were dating or in a relationship (44%), or married

1 Other occupations included “quality control analyst,” “family service worker,” “program assistant,” and “information technology.”

10 M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

(3%). One participant had been pregnant at the time of the focus group.

Discussing sexual and reproductive health topics

A major theme that emerged in all focus groups was commu- nication barriers surrounding sexual and reproductive health in participants’ families and communities. Most participants felt that there is a “stigma” or “taboo” associated with discussing these topics in their communities, which some directly attributed to their culture. Many felt that this prevented them from having a safe forum to start discussions or ask questions.

“In my culture, the expectation is that you can only get pregnant if you’re married…There are just some things that you can’t talk to your parents about it.”

“When I was young, I actually talked to my dad before I talked to my mom about certain things, like even my period. My mom’s Korean and my dad’s [white], so I felt more comfort in talking to my dad about it. I couldn’t talk to my mom about it at all.”

While some participants indicated that they do discuss sexual and reproductive health issues with sisters, cousins, friends, or co- workers, most said that they would not talk to their parents, partners or significant others, or members of their church. Some partici- pants also felt that their parents and members of their communities equated birth control with promiscuity, even though it may be taken for purposes other than contraception (e.g., to regulate periods or prevent acne).

Participants made frequent distinctions between the values of Asian American families compared to non-Asian families (some- times referred to as “American” or “Americanized”) and felt that non- Asian families are typically more open to discussing and addressing sexual and reproductive health. A few participants described their families as being more “relaxed” or “progressive” than other Asian American families, but some still felt pressure to adhere to their com- munity’s cultural norms. Several participants discussed how generational differences shape behaviors and perspectives related to health, emphasizing how these differences could make health- related discussions with their parents and grandparents challenging.

“For Asians, having sex at like this age before marriage is a danger. And then in the American community, [there are] safe ways to have sex, like it’s different.”

“My mom’s a little different. I mean she’s progressively Asian if that make sense…she’s very open about, ‘You need to know all your options and you need to be informed when it comes to that.’ But that’s not something I’m going to get from her. That’s something I need to go out and get on my own…I didn’t feel comfortable just saying, ‘Oh mom I think I should get [a gynecological examination].’ ”

“I think my parents’ views are slowly aligning with mine. They’re getting more aware of just the typical culture that we – their daugh- ters and sons – are living in, so they’re trying to understand what we’re going through because it’s so much different than what they went through. So they’re slowly being Americanized and under- standing we can go out there and access whatever we want, and they trust us.”

Additionally, some participants indicated that their families and communities did not discuss preventative healthcare more gener- ally. They felt that individual health is not discussed unless it is an emergency or critical issue, and that their families did not under- stand the need for preventative care unless a doctor explained it to them.

“I think for my family, at least what I’ve seen within the Vietnam- ese community, a lot of [health] is discussed if something major

happens because it’s an emergency and it has to be, but it’s never discussed as a preventative thing, or like let’s be healthy and talk about this. We never talk about it unless we have to, and I think that’s a major issue, and to prevent pregnancy you kind of have to talk about it beforehand.”

“I feel like I should be more active about preventative care…but I think in my culture, you don’t really go to the doctor unless some- thing’s wrong, like you don’t go just for a checkup.”

Accessing sexual and reproductive health care and information

Focus group participants discussed how stigma and communi- cation barriers surrounding women’s health in their families and communities can influence whether and how they access sexual and reproductive health care and information. Some participants ex- pressed that their concerns about confidentiality would deter them from talking with a family doctor about these topics, corroborat- ing findings from Zhao et al. [9]. Many participants were compelled to navigate these issues in ways that would offer them anonymity and privacy, such as finding their own OB/GYN provider or going to clinics such as Planned Parenthood.

“I know there are HIPAA laws, but I felt like I couldn’t go to my primary care because she and my mom are friends and there’s that sort of community, like they’re in the same community. And so I was like, ‘I’m gonna find an OB/GYN.’ ”

“You wouldn’t have an Asian mom say, ‘Oh, you should have your OB/GYN when you’re eighteen.’ … I was twenty-one and then I did it with my friend, and we both have the same family background and so we’re like, ‘We have to do this.’ So we made back-to-back appointments and it was our first time and we were scared about it, you know. We didn’t know what to expect, but we did it together.”

“I know some of my friends have gotten a lot from Planned Par- enthood and I’ve heard such good things about them and their experience with it, because they couldn’t talk to their parents about going on birth control or have it go on their health plan. They want to keep it on the [down-low], so they go to Planned Parenthood and get it.”

Many participants said that they access women’s health infor- mation on the Internet because it is confidential, and they feel like they can seek answers to their questions without judgment. However, they also expressed concerns about the accuracy of information, as well as the quantity of information they have to sift through in order to find credible information.

“I always go to the Internet first for confidentiality. I know this is anonymous, but I recently contracted an STD, which is a really common one that one in four women have. I was freaking out and I didn’t know what to do and I needed a confidential source, so I read more articles than was good for me on the Internet, and it really gets in your head.”

“For the most part I feel like a lot of people would just go online and Google it which is not the most, you know, you can’t trust every website. But most people are able to distinguish between a reli- able source and a not so reliable internet source… It might be the most convenient thing for you outside of what you hear from people and friends.”

Participant recommendations for improving access to health care and information

Participants gave recommendations to improve access to sexual and reproductive health care and information in their communi- ties. Recommendations tended to fall into two categories: (1)

11M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

strategies that promoted increased communication about these health issues in their families and communities, and (2) strategies that would allow women to maintain confidentiality when seeking health information and care.

Many, but not all, participants shared a desire to open doors for increased communication about sexual and reproductive health in their families and communities. Participant recommendations related to this goal included:

• Organizing discussion groups that allow Asian American women to discuss their health questions and experiences, with a health- care professional available to respond to questions

• Matching women with one-on-one peer mentors, or young women with older mentors, to create a safe space to discuss sexual and reproductive health-related issues

• Offering free sexual and reproductive health information in a neutral format (e.g., pamphlets or posters) at Asian American community centers or events

• Engaging campus organizations such as Asian student groups, Asian sororities and LGBTQ groups to plan forums and dissem- inate information on an ongoing basis

• Including young Asian American men in conversations about sexual health, particularly regarding pregnancy prevention and consensual sex

Participants disagreed as to whether parents should be in- cluded in conversations about reproductive and sexual health. While some recommended that parents be included, others did not wish to have such discussions with their parents, preferring to have them with other mentors or friends. Participants also provided mixed re- sponses about whether or not they would want to know other attendees in discussion groups; some said it would be more com- fortable to be with people they know, while others said that they would not want to share information if friends or acquaintances were present.

“There are a lot of events in the [Asian American] community…gathering of a lot of people, so there’s that exposure. So, even if you’re seeing pamphlets and posters, and not necessar- ily talking about it just yet, at least there’s that visibility, that this is an issue that is worth bringing up.”

Many participants also expressed a desire for strategies that would allow them to maintain confidentiality when seeking and ac- cessing sexual and reproductive health care and information. Recommendations related to this goal included:

• Offering text message-based information dissemination, where students can receive information on an ongoing basis or text in their questions anonymously

• Informing women about credible online resources that will allow them to seek out accurate information privately

• Creating a credible online forum for women to discuss health issues anonymously

• Providing sexual education curriculum in schools that is not based on an abstinence-only approach, but rather offers specific in- formation about preventing pregnancy and sexually transmitted diseases

• Informing high school students about options for sexual and re- productive health care, such as clinics

• Encouraging healthcare providers to proactively and confiden- tially provide young women with information about sexual and reproductive health and available resources

“Well, I think because I didn’t find out about the clinic until I was nineteen, which was pretty recent, and I just felt like, if more people

told me about it when I was still in high school it would have been better.”

“Maybe having [healthcare providers] also know other re- sources… I’m not comfortable talking to him, but then if he said, ‘These are the resources, if you’re not comfortable talking to me, you also have these places that you can go to.’ … because if a teenager is under their parents’ plan, they have another way of going outside but getting help from within the people we already have.”

Discussion

There were several limitations to this study. First, although a qual- itative approach provides rich data reflecting the experiences and recommendations of participants, these results cannot be viewed as generalizable. Notably, the recruitment challenges described in the methods section resulted in most participants being highly engaged with educational or community institutions, and their per- spectives may not accurately reflect those of other Asian American women. Additionally, this study did not have adequate resources to translate materials or use interpreters, limiting participation to English-speaking women. Finally, due to small sample size, the anal- ysis was unable to assess any potential differences between different Asian ethnic groups.

Further studies are needed that can assess differences between Asian American sub-populations. A more diverse sample may help determine what health promotion strategies are preferred by Asian American women of different educational backgrounds, English- speaking abilities, and levels of engagement with institutions. Additionally, although participants in this study suggested that culture plays an important role in Asian American women’s health, a larger sample is needed to better assess the role of culture through examining differences by ethnicity and generation status.

These focus groups revealed that Asian American women may face barriers to accessing sexual and reproductive health care and information related to communication and stigma, and that they use varied strategies to obtain such care and information. Our find- ings corroborate previous research suggesting that young Asian American individuals perceive communication about sexual and re- productive health to be limited in their families and communities [3–7], and may be hesitant to discuss these topics with providers [9]. Perceived stigma and confidentiality concerns have been iden- tified as barriers to sexual and reproductive health care for the adolescent population broadly [16], and other U.S. minority groups, such as Latina women, have also attributed limited parent– adolescent communication about sexual topics to cultural norms [17]. Although the barriers experienced by Asian American women may not be completely unique, it is important to recognize that par- ticipants in this and other studies have explicitly linked these barriers to Asian cultural norms, and therefore consideration of culture may be necessary to address them.

Through asking young Asian American women to share their rec- ommendations, our study further revealed that this group is not uniform with respect to their preferred means of increasing access to sexual and reproductive care and information; some recom- mended strategies that would increase communication about these issues in their communities, while others expressed a desire to main- tain confidentiality. This finding raises the need for a multi- pronged and varied approach to connecting Asian American women with sexual and reproductive health care and information in order to meet their diverse preferences related to communication and con- fidentiality. However, it is necessary to consider that the following specific recommendations are based on the responses of women who are highly educated and/or engaged with institutions, and who may be more comfortable discussing these topics in confidential or

12 M. Frost et al. / Sexual & Reproductive Healthcare 10 (2016) 9–13

public settings than Asian American women not represented in this sample.

Our findings support the maintenance and expansion of oppor- tunities for young women of all races and ethnicities to discretely or confidentially access sexual and reproductive care and informa- tion. Strategies may include information dissemination through electronic media such as text messaging, credible online re- sources, and online forums. Other strategies include providing information proactively in person, such as sexual education in schools or information offered in a confidential and neutral manner by healthcare providers. Additionally, based on concerns raised by some participants, it seems important that providers emphasize their ob- ligation to maintain confidentiality regarding these issues to young patients, particularly when they know their parents.

Simultaneously, strategies that seek to increase communica- tion about sexual and reproductive health within Asian American families and communities are also important to consider, as this was a desire expressed by many participants in this study. Some ideas suggested by participants include in-person discussion forums, pro- viding information at community centers or events, engaging Asian American student groups, and including young Asian American men in information dissemination. Such programming may also address the need to promote the importance of preventive health care more generally in Asian American communities. Importantly, we believe it is essential that these efforts be developed and implemented either by or in close partnership with members of Asian American com- munities. Community-driven efforts are more likely to effectively address the challenges described by participants in this study and result in culturally-appropriate interventions.

Providers working with Asian American families and commu- nities should be aware that sexual and reproductive health may be an uncomfortable topic of discussion for their patients, and that young Asian American women may be particularly concerned about their confidentiality with respect to these topics. Further, provid- ers should recognize that one approach will not meet the needs of all community members: while some young Asian American women may desire increased opportunities to discuss sexual and repro- ductive health within their families and communities, others may wish to maintain discretion and anonymity in accessing care and information. Differences in cultural and communication norms can present challenges to providers in connecting individuals with sexual and reproductive health care and information. However, illuminat- ing these differences presents opportunities to improve practice and meaningfully engage with communities in order to improve sexual and reproductive health in all populations.

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