1. Natural Family Planning Use Among Hispanic and African American Young Adult Women: Qualitative and Quantitative Approaches
January 14, 2008
Jennifer Manlove, PhD
Lina Guzman, PhD

2. Background Overall NFP use is low: 1-4% of all women use NFP each year
Higher ever use of NFP:
12% of young adult women (18-29)
Higher use among minorities
Especially Hispanics and African Americans
Failure rates:
3-5% with consistent and correct use
25% with typical use (user failure)
experience an unintended pregnancy within the first year of using this method

3. Gaps in Research
Little is known about the who, why and when of NFP use in the US
Current measures may underestimate NFP use
Little research has examined factors associated with NFP use
Information about NFP users’ knowledge, attitudes and perceived benefits of NFP use is also limited
Incomplete understanding of the effectiveness of NFP use for preventing unintended pregnancy

4. Key Questions and Potential Problems
Preliminary findings from Hispanic unmarried parents suggests that many women equate “birth control” with hormonal methods and underreport NFP use:
I: What about the withdrawal method? Did that come to mind when you were thinking about birth control in this question?
R: No, I was thinking about something like, specific, like medicines or something.
I: And why would you say that those two methods [rhythm method and withdrawal] you don’t really consider as much as the others?
R: Cause we’re not really doing anything really to prevent, the fertilization of an egg.  I mean when I think of birth control, I think of like something, a product. 
I: So when you heard the phrase birth control, what kind of methods did you think of?
R: Um, the first one I thought of was the depo-provera shot.  When I think of birth control I think of something permanent.

5. Key contributions We build on previous research by:
Identifying multiple domains of influence on NFP (family, individual, partner/couple and community)
Examining knowledge, attitudes and perceptions about NFP among young adult women and family planning staff
Assessing the effectiveness of NFP use compared with no method and with other methods

6. Conceptual framework: Behavioral model of health service use
redisposing
Enabling
Perceived Need
Characteristics
Resources
for Services
Demographics
Family/Individual P
erceived/
Age
Insurance
Evaluated
Need R
ace/ethnicity
Poverty status
Immigrant
Funding
for
services
Sexual activity
Relationship status
& prescriptions
Perceptions of
Previous children p
regnancy, STD risk
Partner
risk -
taking
Condom use
Use of
Social Structure
Community Resources
Hormonal method use
natural
Family structure
Presence of
accessible/
family
Parent education
affordable family
planning
Individual education
planning services
Predisposing: individual and family socio-demographic characteristics
Family structure (e.g., married and cohabiting more likely to use NFP b/c of communication about contraception)
Cultural/religious factors – e.g., against birth control
Attitudes: e.g., perceived side effects of hormonal use (weight gain, links to cancer) or difficulties using NPF
Enabling: factors that enable use of NFP
Women facing life disruption(loss of insurance, concerns about immigrant access to svcs) may use NFP
Access to svcs. May increase hormonal use vs. NFP
Perceived/actual need
e.g., sexually active
Low perceptions of pregnancy risk may reduce any method
Partner characteristics (ability to community)
Other method use (e.g., hormonal/condom) may reduce NFP use
Feedback loop – experience with NFP may affect attitudes
Culturally appropriate
Attitudes/Beliefs/Knowledge
program
staff
Awareness of
programs
Cultural
/religious
beliefs
Knowledge
re:
family p
lanning
Perceived
barriers/facilitators
to NFP, hormonal methods
Family, peer,
&
partner belief s

7. Study’s Three Stages
Stage 1: 3 waves of one-on-one semi-structured cognitive interviews
Stage 2: Focus groups with program staff and service providers
Stage 3: Quantitative analysis
Combining 2 types of qual methods with quantitative analyses will allow us to better understand NFP use among young adult Hispanic and Latina women and how successful a method it is for avoiding unintended pregnancy
(see notes)

8. Qualitative Components: Stages 1 & 2

9. Stage 1: Key Research Questions
What are the factors associated with the use of NFP?
How is knowledge about and perceptions of NFP associated with use?
What are predictors of successful NFP use and factors associated with discontinuation in use?
The qualitative part of the study is designed to help us explore the why, how and when to a greater extent than is possible in the available survey data.
The qualitative components will complement the quantitative parts (that Jen will talk more about briefly) and seek to address the following key research questions:
--First, what are the factors associated with NFP use? In essence who is using it or if we look back to the conceptual model what predisposing and enabling resources are associated with its use.
--A large focus of the qualitative interviews will be on exploring participants knowledge, understanding and perceptions of NFP (what do they know and think about NFP, what is the level of accuracy in their knowledge, what misperceptions do they hold and so forth) and how is that associated with its use (both in terms of whether they use it or not and how effectively they use it).
--Third, the qualitative interviews will seek to identify predictors of successful use (what make some women effective users of NFP and other less so) and what leads some to stop using it.

10. Stage 1: Qualitative Interviews Study Design
Baseline Interviews
Collect data on predisposing characteristics, enabling resources and perceived need
6-Month Follow-Up Interviews
Focus on short-term changes in contraception methods, relationship and pregnancy status and sexual activity.
12-Month Interviews
Focus on predictors of contraceptive success, (the avoidance of an unplanned pregnancy)
To address explore these questions, we have designed a longitudinal study with three waves of interviews.
The baseline interviews will focus on collecting data on predisposing characteristics (collecting information on their demographics, family conditions, and, most importantly, knowledge and beliefs); enabling resources (AKA Family, individual and community Resources) and perceived need (their sexual activity, perceived risk for pregnancy, and so forth).
The 6 month follow up will focus on short term changes in contraception, relationship and pregnancy status and sexual activity. If using NFP methods we’ll check in on how things are going. We also begin here an more in-depth discussion about their consistency and accuracy in s use including what is helping them stay accurate or keeping them from being accurate.
The 12 month will continue that discussion focusing on predictors of contraceptive success.

11. Stage 1: Sample Design Target sample:
Hispanic and African-American women using Title X funded clinics in DC
EVER used NFP
Ages 18-29
Our target sample for this part of the study is:
Hispanic and African-American women using Title X funded clinics in DC
Who have EVER used NFP and
Are between the age of 18-29
As we noted earlier, we focus on these two minority group because:
Of their high rates of unintended pregnancy and because of their higher rates of NFP use.
Additionally, women in their late teens and early 20s have the highest rate of unintendd pregnancy across all age groups.
In short, this is a critical group to target and they represent key groups on which to focus educational efforts that may be informed from these studies.
In developing our sample design we began with the incidence rates that we calculated from NSFG which suggested that 13% of Hispanic and AA women have ever used NFP AND our desire not to have fewer than 30 case for each racial/ethnic group.
SO working both forwards from the 13% estimate and backwards from 30 cases, we estimate that we will need to conduct 1000 screener interviews to identify a sufficient number of women who have ever used NFP.
From these 1000 screener interviews, we estimate that we’ll identify 133 women who have ever used NFP.
Assuming that 80% will agree to participate, we’ll begin with 108 participants
Assuming that we’ll be able to retain 85% of them, we’ll have 92 at the 6 month follow-up
And, assuming 75% retention by 12 months approximately 70 completed interviews.

12. Stage 1: Recruitment & Screening
Building from current local contacts
Work with 2-3 local clinics
Anticipate recruitment will take at least 6 months
Key to success will be establishing strong partnerships and buy in from program at all levels
Offering stipend to clinics;
Communicate potential benefits of study to clinics
Screening
High levels of screening to identify target population
Brief interview, easily administered by staff or research staff
Questions designed to identify the methods women are currently using and those that have ever used NFP
Questions will seek to ensure that:
Target population is identified
Underreporting of NFP is minimized
How are we going to find these women.
Well, we’ll begin by recruiting program and build from our local contacts that we’ve developed through similar studies.
We hope to work with 2-3 local clinics and that these clinics will provide us access to their clients. In short, our goal is to screen all of their clients that go through their door to identify those that use NFP.
Given number of clients served, we anticipate that recruitment will take at least 6 months. This longer than usual recruitment period will also help us to better manage the sample and to ensure that once we identify someone we can quickly do an interview with them.
We are focusing on recruitment right now and we have a lot of details to iron out, including how do we make sure we don’t have duplicates, how do we administer the screener and so forth but for now we are focusing on getting the programs on board.
Based on our initial contacts, we know that key to the success of the study will be establishing strong partnerships and buy-in. We’ve already heard some distrust about NFP and hesitation on the part of providers to offer this to their clients. We also know the study will take some time and effort on the part of staff. To help address this, we are offering clinics a stipend and are working to clearly communicate the potential benefits of the study for the clinic and their population.
Given the relatively low prevalence rates of NFP use, there will be a high level of screening.
To minimize cost, increase the “attractiveness” of the screener, and reduce the burden for program staff, we will develop a brief screener interview.
The question will be designed to identify methods used by women and those who have ever used NFP. For example, we know from our work that we need targeted questions to get at nonhormal methods. We also need to do direct probing as secondary or nontraditional methods often get missed. And, we need to include multiple terms used in the community to describe NFP. (for example, withdrawal is known as pulling out, finishing outside, and so forth
The questions will seek to ensure that the target population is identified and underreporting is minimized.

13. Stage 1: Benefits of Qualitative Interviews
Sensitive and highly personal topics can best be explored in a one-on-one interview
Semi-structured interviews:
Allow a thorough exploration of the respondent’s thoughts, feelings, attitudes and behaviors
Ensure that key topics and issues are addressed similarly for all participants
Provide greater flexibility than a structured interview to pursue topics unique to the individual’s situation
Cognitive probes helpful in identifying target group and better understanding complex topics (e.g. why and when)
READ

14. Stage 2: Focus Groups Study Design
Research Question:
How are reproductive health decisions influenced by enabling resources, in particular programs and services?
Target Population:
Providers (e.g., program directors, nurses, doctors) from programs and clinics in Washington, DC
As suggested by our conceptual model, we hypothesize that women’s reproductive health decisions are influenced by enabling resources that include programs and services available to or that a person may use.
In stage 2, we will conduct as series of focus groups with providers to explore how enabling resources (programs and services) may influence the reproductive health decisions of women.
This part of the study is meant to complement the qualitative interviews with women by taking a look at what the potential barriers or facilitators to the use and dissemination of information about NFP may be from the perspective of programs and clinics.
Because we want to make sure to include a range of perspectives and experiences we will include various types of providers including program directors, nurses, doctors, and other clinic staff.

15. Stage 2: Focus Groups Sample: Content: 3-4 focus groups
8 to 10 participants per group (total 24-40)
Group segmented by roles & responsibilities
doctors and nurses
program staff who meet directly with clients about reproductive health
program and clinic directors
Content:
Providers’ perceptions of NFP
How prevalent is it use among its clients?
Should NFP be offered as an option?
Dissemination of information
How often is information about NFP requested?
Do they offer this information? Why or why not?
Do they think it should be offered?

16. Stage 2: Benefits of Focus Groups
Useful for providing insights based on group interactions and assessing the extent to which there is consensus on an issue
Focus groups are more appropriate settings for identifying barriers and facilitators to NFP use from a program/service perspective
Help identify and receive feedback on recommendations for improving access to NFP information

17. Quantitative Analysis: Stage 3

18. Stage 3: Quantitative Analysis
Research Questions
How are predisposing, enabling, and perceived need factors are associated with NFP use among young adult women?
Do predictors of NFP use differ by race/ethnicity?
How is NFP use among young adult women associated with unintended childbearing?

19. Stage 3: Quantitative Analysis
Data
NSFG (2002 and forthcoming )
Cross-sectional
Over-samples Hispanics and African Americans
Measures of immigration, language status
Family planning providers
National Longitudinal Study of Adolescent Health (Add Health) (Wave III and upcoming Wave IV)
Large, longitudinal sample (15,000+)
Large Hispanic sample
Measures unintended pregnancy

20. Stage 3: Dependent Variables
NFP use
Ever used NFP (NSFG)
Used NFP in the past year (NSFG, Add Health)
Contraceptive method (NSFG, Add Health)
Unintended birth
Unwanted birth or mistimed birth (Add Health)

21. Stage 3: Descriptive Information (NSFG)
Table 2. Natural Family Planning Use by Young Adult Women (18-29) in NSFG 2002
Total
12.0%
Race/ethnicity
Hispanic
13.1%
Black
13.4%
White
11.2%

22. Stage 3: Descriptive Information (NSFG)
Table 2 cont. Natural Family Planning Use by Young Adult Women (18-29) in NSFG 2002
Previous children
Has a child
13.5%
Has not had a child
10.6%
Marital/Union status
***
Married
15.2%
Cohabiting
7.3%
Outside a Union
10.8%

23. Stage 3: Predictors of NFP use
Predisposing factors
Socio-demographics (age, race/ethnicity, immigration)
Family structure / marital/union status
Reproductive health knowledge
Enabling resources
Insurance coverage, poverty level
Publicly-supported family planning provider in county
Perceived need for services
Sexual experience and activity
Characteristics of sexual partners and relationships
Attitudes about pregnancy, perceived STD risk
Other contraceptive methods

24. Stage 3: Analysis Bivariate and multivariate analyses
Logistic regression (NFP use vs. no use; unintended birth vs. no birth/intended birth)
Multinomial logistic regression (NFP use vs. other method use vs. no use)
Interactions by race/ethnicity and immigrant status

25. Conclusion
Three stages will inform each other and provide a better understanding of the use of NFP among young adult women