Facilitators and barriers to contraception access and use for Hispanic American adolescent women: An integrative literature review
School of Nursing, University of Rochester Medical Center, Rochester, NY, United States of America
School of Medicine and Dentistry, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, United States of America
*Corresponding author E-mail: lindsay_batek@URMC.rochester.edu (LB)Abstract
Statement of the Problem
Hispanic American adolescents experience high rates of pregnancy with profound consequences. Compared with White teens, Hispanic teens use contraception less frequently and often choose less effective forms of contraception. Access to contraception is a primary barrier to use which contributes to relatively high and disparate rates of pregnancy in Hispanic teens. This integrative review identifies facilitators and barriers of contraception access and use for Hispanic women, 13-17 years of age, living in the U.S.
Methodology
Following the Whittemore and Knafl (2005) methodology and PRISMA guidelines, peer reviewed studies were retrieved from PUBMED, CINAHL and EMBASE. The Mixed Methods Appraisal Tool was used to assess the study quality and thematic analysis was used to categorize barriers and facilitators.
Findings
Of 131 studies retrieved, 16 met inclusion criteria. Individual, interpersonal and healthcare provider factors were identified as primary categories of barriers and facilitators with contextual issues comprising an additional barrier category. Individual level barriers were disproportionately represented and further categorized into themes: beliefs/misconceptions, dislike of contraception, pregnancy risk perception, lack of knowledge, and lack of control. The most frequently reported facilitators were perceived parent comfort discussing sexual health and past experience of pregnancy.
Discussion
Limitations in this review may stem from heterogeneity in the acculturation and geography of participants and analysis by a single reviewer. Implications include considering the range of information sources and the influence they have on risk perception and risk mitigation for this population.
Conclusion & Significance
Adolescents describe many modifiable influences on contraception access and use. Misperceptions related to contraception, stemming from beliefs and perceptions, can be corrected through increased access to reliable sources of sex education, parental support, and direct access to nurses and healthcare providers. Awareness of these influences can inform further research and intervention development to address these health disparities.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
The project (LB) described in this publication was supported by the University of Rochester CTSA award number UL1 TR002001 from the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Introduction
Unintended teen pregnancy in Hispanic women is a significant public health problem that has profound consequences. Compared with White teens, Hispanic teens use less contraception and methods used are less effective [1, 2]. Further, Hispanic teens are less likely to have used contraception at last intercourse (24% and 12%, respectively) and to have used a prescription (more effective) method of contraception (38% for White and 18% for Hispanic teens)[3].
Hispanic teens have described significant barriers to accessing effective contraception, which contributes to relatively high rates of teen pregnancy [1]. Hispanic teen women experience teen pregnancy at a rate of 25.3 births per 1,000 women, compared with 11.4 birth per 1,000 Non-Hispanic White women [4]. In addition to being a costly problem with estimated annual healthcare costs of $6 billion in lost tax revenue and $3 billion in public expenses [5], it has significant short- and long-term consequences for teen mothers and their children [6, 7]. Teen pregnancy can affect educational attainment, economic status, and mental, social, and physical health for mother and child. The school dropout rate is higher for pregnant teens, which disrupts education and can subsequently limit employment possibilities, earning potential and increase risk of poverty [5]. Teen mothers have an increased risk of depression, substance abuse, and criminal conviction [5]. Children of teen mothers may have adverse health and developmental outcomes including prematurity, low birth weight, higher risk of perinatal and infant mortality, and poorer long term cognitive development [5]. These consequences affect long-term health trajectories and disproportionately affect Hispanic adolescents and their children [8].
Disparities in Contraception Use and Access
According to the CDC, 75% of pregnancies in women between the ages of 15-19 years are unintended [9]. Unintended teen pregnancy is avoidable through abstinence or consistent use of effective contraception [10]. Contraceptive misuse or nonuse [11] or use of less effective contraception [12] may be partially explained by lack of knowledge about pregnancy risk, birth control, barriers to access, or distrust of the healthcare system [12–14]. The most effective methods of contraception for sexually active teens, such as oral contraceptive pills, intrauterine devices, and contraceptive implants, require a prescription [10, 13].
Healthcare access is defined as “the timely use of personal health services to achieve the best health outcomes” [15]. The Institute of Medicine definition of ‘access’ combines it with healthcare use, which can be considered “realised access” [16]. Identified barriers to contraception access include affordability, shame, embarrassment and physical difficulty reaching services and these barriers disproportionately effect individuals from marginalized populations based on age, income, race/ethnicity, rurality, and education [17]. In contrast, expanded access to family planning services has been shown to increase use of contraception and reduce teen pregnancy rates [10, 13]. However, adolescents may have little experience and fewer resources to access care and are less likely to receive adequate care when they receive services [12, 18].
Despite the myriad of known barriers to contraception access, three out of four teens are successfully finding and using contraception [1] which raises questions about the factors that determine contraception access and use and how some women are able to access contraception while others are not.
Definitions
This integrative review was conducted to identify literature related to the access and use of contraception among female Hispanic adolescents or teens, living in the U.S. The World Health Organization defines ‘adolescence’ within the age range of 10-19 years [19]; however, for this study we used a narrower age range of 13-17 years old because of the high rates of inconsistent contraceptive use and unintended pregnancy in this group [20]. ‘Hispanic’ is defined as “a person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race” [21]. Given that Hispanic is an ethnic identity, individuals who identify as Hispanic may pertain to several distinct racial groups, the majority of whom identify as multiracial [22]. ‘Contraception’ is defined as the “intentional prevention of conception through the use of various devices, sexual practices, chemicals, drugs, or surgical procedures” [23]. While abstinence is included in the definition of contraception, for this review, our interest is in sexually active teens accessing contraception.
Methods
Study search
This integrative review follows the Whittemore and Knafl [24] methodology which is a five-step process that identifies the problem, conducts a well-defined literature search, assesses study quality, analyzes data, and articulates conclusions. The Mixed Methods Appraisal Tool, Version 2018 (MMAT)[25], was used to assess the quality of included studies. The data from primary sources was extracted into tables and categorized, synthesized, and summarized into integrated conclusions.
A systematic search was conducted from three online databases: PUBMED, CINAHL and EMBASE. Keywords searched were (Hispanic[tiab] OR Latina [tiab]) AND (“Adolescent”[Mesh] OR “teen*”[tiab]) AND (“Contraception” [Mesh] OR “birth control”[tiab]) AND (“Access”[tiab] OR “decision” [tiab]). Additional hand searching and searching from reference lists of included studies contributed to the search.
Eligibility Criteria
Inclusion criteria for this review were studies published in English, in peer reviewed journals, prior to February 2024 that addressed female Hispanic adolescent access to contraception or birth control. Studies were included when the sample included Hispanic adolescent women between the ages 13-17 years of age living in the United States. Studies were selected based on meeting the inclusion criteria and non-Hispanic groups, males and multiple age groups were included if data was presented separated by race/ethnicity (Hispanic), gender (female), and age (13-17 years old).
Studies were excluded if they were not peer reviewed, gray literature, non-English studies, and studies that were not related to the research questions such as intervention studies, healthcare provider strategies or studies about parental views of contraception. Intervention studies were excluded because the purpose of this review is to identify naturally occurring strategies reported by adolescents that facilitate access to contraception.
Selection Process
Once the search was completed, duplicate studies were removed, titles and abstracts were screened for eligibility, and full texts were then reviewed for inclusion including relevance to the study aims. Excluded studies were grouped by reason for exclusion as noted on the PRISMA flow diagram (Fig 1) [26]. The initial search resulted in 131 studies, of which 16 were included in this integrative review.
Quality Appraisal
The MMAT [25] is a critical appraisal tool designed for reviews that include qualitative, quantitative, and mixed methods studies [25]. This tool facilitates the process of appraising various types of literature in one tool by answering the series of quality assessment questions as they are presented rather than calculating an overall score [25].
Data Extraction and Synthesis
Following the process outlined by Whittemore and Knafl [24], data were extracted from the 16 selected articles including sample characteristics, location, study design, theory used, measurement tools, outcomes, barriers, and facilitators. Barriers and facilitators were identified by reviewing the data, and thematic analysis [27] was utilized to create initial codes, collate, and group codes into themes and categories. Each occurrence of a barrier or facilitator in the 16 selected studies was counted, and the total frequencies across all papers were tabulated and organized into tables and figures.
Results
Study Selection
Of the 131 articles identified from the database search, 31 duplicates were removed, 100 articles were screened by their title and abstract, 46 of which were excluded because they were off topic. The retrieval of full text was sought for 54 records. Full text articles were unavailable for 8 articles, and 46 were screened. Reasons for exclusion are noted on the PRISMA [26] flow diagram. The remaining 16 articles were included in the review.
Study methodology
This review was based on 16 peer reviewed articles published about barriers and facilitators to contraception in Hispanic adolescent women living in the U.S. This review included qualitative studies (n=11), quantitative descriptive studies (n=3), and mixed method studies (n=2). For the qualitative studies, the type of qualitative methodology (grounded theory or ethnography, etc.) was rarely described. Qualitative studies relied mostly on interviews [28–34] and focus groups [8, 11, 18, 31, 35]. Barral et al. [6] used mixed methods and grounded theory focus groups and open-ended questions. Gilliam et al. [1] used focus groups to develop a survey instrument to later give to participants. For the quantitative studies included in this review, there were very few validated scales or measurement tools that were used to measure the outcomes of interest. Of the few quantitative studies that used survey instruments, measures used included the contraceptive failure rate (CFR); contraceptive risk indices (CRI), which represents pregnancy risk; and the pregnancy risk index (PRI), which is the probability of pregnancy based on sexual activity and birth control method [2]. Two studies were secondary analyses [2, 36] and one was a retrospective chart review [13].
Study Quality
The aim and purpose of the studies were well-aligned with the research questions, chosen methodology and interpretation of the data. The MMAT indicated that the selected studies were generally of high quality with low risk of bias although a few weaknesses were apparent, such as use of a convenience sample, conceptual issues such as grouping belief and experiences together, not explicitly stating the validity of the measures used, and a lack of information about non-responders. The results of the quality assessment are listed on the third column of Table 1.
Study Characteristics
Study Size and Geography. The sample size in the studies ranged from small (n=8) in the qualitative studies, to large, the National Survey of Family Growth, N=9321. One study had focus groups from Mexico and California [31] and all of the remaining studies took place in the U.S. in both rural [6, 34] and urban areas [1, 11, 35]. Some studies described the state or city locations, with represented regions in the U.S. including the East Coast (Baltimore [35]); Midwest (Kansas [6], Chicago [1, 11]); the South (Alabama [32], North Carolina [34]); and the West Coast (California [31]).
Demographic Descriptions
Frequent labels used to describe participants included Latino or Hispanic youth [1, 2, 6, 8, 13, 18, 29, 30, 32–34, 36]. Some studies described the samples (at least partly) as Mexican American [11, 28, 31] and immigrant Latinas [35]. The countries and places of origin of participants were not always described but those reported were Mexican [28, 31, 33], Puerto Rican [8, 33], and Dominican [8].
Acculturation
The acculturation level of the participants was inconsistently provided. Some studies describe the acculturation level of participants in the results [1, 6, 28, 31, 33]. When acculturation was described, it was by place of birth [30, 32, 34, 35], length of time in the U.S. [32], or acculturation score which was determined by a language based scale [1, 33] or a modified version of the Short Acculturation Scale for Hispanics (SASH) combined with years living in the US [6].
Theoretical Frameworks
Facilitators and Barriers to Contraception Described by Category
Through the data extraction and synthesis process, both the facilitators and barriers were grouped into the following overarching categories: individual, interpersonal (family, spouse/partner, friend), and healthcare provider levels; further, contextual matters emerged as an additional category of barriers. Each of these main categories was further subdivided into thematic subcategories as displayed in two sunburst charts, one for facilitators (Fig 2), and one for barriers (Fig 3). On both charts, the categories that resulted from the thematic analysis are visible in concentric rings with themes in the center and related subthemes on the periphery. The sizes of the parcels in each chart are proportional to the number of occurrences of that barrier or facilitator category across the 16 selected studies.
Discussion
This analysis sought to better understand barriers and facilitators that influence access to and use of contraception in female Hispanic teens ages 13-17 years old. Sixteen studies were included, and 40 specific barriers and 16 facilitators were found and presented as subthemes. The facilitators that emerged from this analysis provide insight into potentially outcome-changing influences that support women’s reproductive autonomy, decision making, and acquisition of contraception.
Among barriers identified, sentiments such as “abortion is murder” or that contraception is equivalent to abortion [6, 28], and the belief that withdrawal will work if pregnancy is not desired [11] illustrates how ideology can intertwine with misconceptions leading to inaccurate perceptions about risk and risk management. These views, combined with barriers such as embarrassment, stigma and lack of confidence accessing care [32, 34] and lack of knowledge about biology and physiology [30], highlight the complex influences that make it challenging for teens to seek information and ask questions from reliable sources such as trusted adults and healthcare providers. This complexity can contribute to a sense of lack of control, exacerbated by male partner dominance (with age difference) [11, 29, 30, 35] and reliance on the male partner for the withdrawal method [11], and a lack of control over pregnancy due to beliefs about fertility, religious influences, and feelings of invincibility or the perception that ‘it won’t happen to me’ [11, 18, 28]. Interventions that inadequately address these barriers in meaningful ways may be less effective or ineffective.
In contrast, key facilitators include a clear intention to avoid pregnancy, parental comfort discussing sexual health, positive reinforcement from family, friends and school, and good communication and trust and respect from healthcare provider and their office staff. These are actionable items that warrant consideration in the development of future interventions.
Implications
The Role of Sex Education and Experience
When considering how an individual makes decisions regarding contraception, perception and understanding of risk and ease of mitigating risk are each important. This review demonstrated the different sources of influence ranging from individual beliefs to personal experience of pregnancy, to people who directly support and influence teens such as parents, peers, partners, and healthcare providers. Many of the barriers identified in this review are addressed in sex education classes in schools in the U.S. including misconceptions and lack of knowledge; yet, Hispanic students may receive less sex education because they are more likely to drop out of school [40] or move frequently, which may preclude them from receiving adequate sex education [6]. Even when Hispanic students receive sex education in school, the quality and content provided is inconsistent ranging from abstinence-only to comprehensive sex education leading to disparities in what is learned, and related outcomes [41]. These disparities contribute to socially driven health and systemic inequities for Hispanic teen pregnancy rates [41].
Parents, peers, partners, and healthcare providers can have a strong influence on contraception access and can serve as barriers or facilitators. Morales-Alemán’s et al. [32] finding that parent disapproval of teens having sex was their main barrier to access to care for SRH, which indicates the importance of parent attitudes towards teen access to contraception as either a barrier [11, 32, 34] or facilitator [32]. Male partners can be barriers through male partner dominance and controlling withdrawal or facilitators through mutual agreement with partner about pregnancy intentions, positive reinforcement, providing contraception or supporting access to the healthcare providers. Healthcare providers are positioned to prime parents to be supportive of teen’s access to care for SRH. They can also support teens independently by providing care that is private, confidential, nonjudgmental, non-discriminatory, and patient-centered and in an accessible location.
Further research can build upon the findings presented here by discerning what meaningfully differentiates those who have adequate awareness of pregnancy risk and the ability to access contraception from those who do not. This may reveal the relative impact of different factors on teens, how these factors synergize to serve as barriers or facilitators, and patterns in how these influences affect teen contraceptive access and use. Understanding these dynamics may identify targeted strategies to reduce disparities in teen pregnancy.
Limitations
The studies included in this analysis grouped teens by the umbrella terms of ‘Hispanic’ or ‘Latina’ but there is considerable diversity and variation within this group. Though commonalities such as taboos, stigma, and misconceptions were found, it is unclear if more research across ethnic or national subgroups may reveal important differences. The presence of bias in the findings presented in this review cannot be ruled out as a single author [LB] conducted the literature search, assessed studies for inclusion, rated bias, extracted, analyzed, and synthesized the data. The search sought to identify studies about Hispanic teens but did not search all potential places of origin of Hispanics in the U.S. such as Mexican, Guatemalan, Puerto Rican, Columbian etc., so studies about those specific groups, while applicable, may not have been identified.
Conclusion
This integrative review sheds light on the barriers and facilitators to contraceptive access from the perspective of female Hispanic teens, aged 13-17 in the U.S. The synthesis of perspectives and experiences revealed in this review is informative and significant, given the disparities in contraception access and pregnancy rates in this group. Identification of barriers and facilitators can stimulate discussion and research aimed at improving the delivery of education and healthcare to meet the contraceptive needs of female Hispanic teens. The implications presented here underscore the importance of addressing the unique multilevel barriers and leveraging facilitators encountered by this population to promote health equity and improve access to contraception.
Data Availability
I am unable to share any additional pertinent data.