Knowledge, attitudes and practice survey of family planning among South Asian immigrant women in Oslo, Norway



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Unmarried youth

A study on “reproductive health survey of adolescents and young adults in Pakistan6” shows that knowledge of contraception among girls is 50%.

P=Prevalence of contraceptive knowledge 50%,

Assuming d=0.10(allowable error of prevalence rate),

N= (1.96*1.96*0.50*0.50)/ (0.10*0.10), N= 96.

Total sample size = 332 participants

Study respondents= 309



    1. Data collection:

Ninety-three percent of study subjects were recruited in the above-mentioned period by cluster and snowballing. Recruitment from health centers was difficult; therefore, the author sent invitations to immigrant communities and visited immigrants meeting places. After having verbal informed consent, the author collected phone numbers from the respondents. In total 36.9% were interviewed through phone by the author, 39.8% were recruited from immigrant communities by research assistants while, 23% came from the Health centers.

Inclusion criteria



  • Immigrant women from Pakistan, India, Sri-Lanka and Bangladesh of reproductive age (13-49)

  • A woman, who was mentally sound, gave verbal consent and was willing to participate.

Exclusion criteria

  • Women who were not able to give verbal consent and not willing to participate.

  • Women who had menopause, although they were of reproductive age.

      1. Data collection by principal investigator

Bjørndal, Prinsdal, Holmlia and Klemetsrud, four health centers under the district of Søndre Nordstrand, were visited by the principal investigator every week from Monday to Thursday during the above-mentioned period. From Grønland health Centre, a health sister informed the author the day before if any South Asian women had an appointment. After finishing the interview with study participants at the health center, the author asked present respondents to nominate other women from the same ethnicity. To obtain the sufficient number of subjects, the author continued this snowball sampling process during the whole study period.

      1. Data collection by research assistant

To collect data, four assistants were appointed from South Asian immigrant communities who had more than 12 years of formal education and knew Norwegian, English and their native tongue. They got training on how to ask family planning-related questions. Before getting the training, they signed a written consent form to protect the participant’s personal information related to this KAP survey. Every assistant got 50 questionnaires with 50 informed consent forms in separate envelop. In total, 61.5 % (123/200) brought back completed questionnaires.

    1. Data collection tool

A two-structured, anonymous questionnaire was designed for the KAP survey. One for married women (annex3) and another for unmarried women (annex4). The survey instrument was prepared in English and then translated into Urdu and Norwegian. The survey instrument has both closed and open questions.

The questionnaire included



  • Demographics of participants

  • Knowledge about family planning

  • Attitudes towards family formation family planning discussions

  • Practice of family planning (fertile background and contraceptive usage)

  • Family planning service

Pilot study with survey instrument: The survey instrument was pre-tested by 12 South Asian immigrant women before actual fieldwork began. The experience showed that the questionnaires needed to be changed. Questionnaire had added some family planning attitude information as statement.

      1. Demographics

All the study subjects were interviewed for their demographics and immigration information. It included information such as participant’s age, height, weight, ethnicity, and highest level of education, marital status, employment status and immigration status (birth country of study subject and their parents, arrival year and age at the arrival year in Norway).

Age

1= 13-19


2= 20-30

3= 31-45


Marital status

0= Unmarried

1= Married


Highest level of education

0= No education

1= Primary

2= Secondary

3= High school/college

4= University



Ethnicity

1= Pakistan

2= Bangladesh

3= Sri-Lanka

4= India


Immigration status

0= Immigration from South Asian country/1st

generation

1= Birth in Norway/ 2nd generation



Employment status

0= Unemployed

1= Employed


      1. Knowledge

Family planning knowledge consisted of knowledge of modern contraceptives and emergency contraceptives, source of information about family planning, sex education at school, and if the women had heard of sexually transmitted infections (STIs), like Chlamydia.

Heard about modern contraceptives, Female and male sterilization, intrauterine devices (IUDs), Hormonal methods (oral pills, inject able, and hormone-releasing implants, skin patches and vaginal rings), Condoms and vaginal barrier methods (diaphragm, cervical cap and spermicidal foams, jellies, creams and sponges3.

0= No method, 1=Oral pill/Condom/IUD (1-3 method), 2= 4 and more methods



Heard about emergency contraceptives 0= No, 1= Yes

Source of information about contraceptives

1= Parents/ siblings/husbands/friends

2=Health care providers/ written information, media (pamphlets, internet, magazines)

Sex education at school 0=No/not remember, 1= Yes

Heard about STI’s like Chlamydia 0=No, 1= Yes


      1. Attitude

Attitude towards family formation consisted of the ideal age of having first child, desired number of children, ideal birth spacing, and contraceptive uses.

Attitudes toward family planning discussions included participant’s attitude themselves, their husband’s attitudes, their society’s attitude from where they originate, and the attitudes among unmarried women themselves.



Ideal age of having first child

1= Age 18-24

2= Age 25-30

3= Age 30 and over

0= Don’t know


Desired number of children

1= Children 1-2

2= Children 3 -4

3= Children 5 and more



Birth spacing

1= 1-2 years

2= 3-4 years

3= 4-5 years




Attitude towards contraceptives

0= I never used

1= I have used without any problems

2= I have used in spite of problems/troubles

3= Its against the nature/ I don’t like to use


Unmarried girl need to know about family planning

0=No / Don’t know

1= Yes


Before marriage get family planning knowledge

0=No / not remember

1= Yes


Attitude among married participants themselves towards family planning discussion

0= Negative/ Don’t want to talk

1=Positive/ enjoy the discussion

2=Embarrass/ avoid discussion



Attitude among participants husband towards family planning discussion

0= Negative/ Don’t want to talk

1=Positive/ enjoy the discussion

2=Embarrass/ avoid discussion



Attitude among unmarried participants themselves towards family planning discussion

1=Feel embarrass to talk

2=Not common in our society

3=I never think this topic before

4=I don’t like to talk/ don’t want to give answer


Attitude of married participants society from where they originate towards family planning discussion

1= Not common in society

2= Embarrass or shame to discuss





      1. Practice

Practice of family planning included age of getting married, after marriage use of any contraceptives, planned pregnancy, birth spacing, and history of requesting abortion, cause of induced abortion, desire for more children, use any contraceptives now, which method of contraceptives were being used and causes of not using any contraceptives.

Usage of contraception refers to the use of contraceptives by at least one method, either traditional or modern method such as pills, Injection, IUD, condom, male or female sterilization, diaphragm, or withdrawal and abstinence.

Contraception refers to the use of any natural or artificial method to prevent conception or pregnancy.

Traditional method refers to natural methods, including withdrawal and abstinence.

A modern method refers to artificial methods that include injection, IUD, condom, male or female sterilization, and diaphragm.

Not used refers to who doesn’t use any natural or artificial method of contraception.

Age of marriage

0= less than 18 years

1=18-24 years

2= 25-30 years



After marriage use any of contraceptives

0=No


1= Yes

Number of children

1= 0-2,

2= 3 and more


Desire for more children now

0=No,


1= Yes

Planned pregnancy

0=No/ not remember,

1= Yes


History of requesting induced abortion

0=No,


1= Yes

Which method are currently using

1=Condom


2= Oral pills

3=Intra uterine device

4=Calendar / withdrawal method

5= Sterilization (male/ female)

6= Others


Cause of abortion

1= Study/student

2= Pregnancy was not planned

3= Too young for having 1st child

4= Economical reason

5= Too little birth space



Reason for not using any contraceptives

1= I want to be pregnant

2= I preferred traditional method

3= Fear of side effect

4=Others





      1. Service for family planning

This part included the place of service and satisfaction with the services. Place of service included health centers, general physicians, gynecologists, and pharmacies. Satisfaction with the available services included facing problems to have service and the cause of the problem to have service (i.e., can’t explain in Norwegian, depend on husband for ease communication, and others, if any).

For unmarried girls, we asked about to whom they prefer to talk and to where they prefer to go.



Unmarried girl prefer to go: 0=No answer, 1=General physician/school nurse, 2= Clinic for sexual information, 3=Health centre for youth, 4= Internet, 5= I never thought about this before

Unmarried girl prefer to talk: 0=No where, 1= Parents, 2=Siblings 3=Friends, 4= General physician, 5=School nurse, 6= Health center for youth

Face problem to seek FP service

0=No


1= Yes

Possible cause to face problems

0=I can’t speak in Norwegian

1= I depend on my husband

3=Health staff never understand me

4= I don’t know where I can go


    1. Data management

Data input was done by the author of this report. Questionnaires were gathered every week and the data was entered at the Stiftelsen Amathea office. A codebook for each variable was prepared beforehand. The data was recorded into Excel and later converted into SPSS, version 16.

    1. Data analysis and statistics

All analysis was done using SPSS, using a significant level of <0.05.

Cleaning of data as a first step was done to detect variables that could be missed or invalid.

Descriptive analysis was done for all categorical variables by using frequencies (n) and percentages (%). Variables with three or more categories were grouped into two categories and analyzed with cross tabulation. Chi-square tests were used for significant differences. Fishers’ exact test was used when variables/cells had less than 5 counts.

The Chi-square tests was used to find the association between age, education, immigration, marital status, employment status and knowledge, attitude and practice of family planning. To get the correct p-values, spearman’s rank correlation was used.

Logistic regression Relationship between demographics and family planning knowledge, attitude and practice was analyzed at bivariate level. After bivariate analysis, the significant association data was analyzed at multivariate level. A binary logistic regression model was used to identify significant predictors for FP knowledge and practice.

To measure the level of knowledge, three questions were asked; for the answer, the score was 1, and for no answer or no response, score was 0. The highest score was 3, while 1 was lowest. Initially, the level of the knowledge group was categorized into three groups: good knowledge-scored 3, average knowledge scored 2, and lack of knowledge-scored 0-1.

Later, for the logistic regression model, knowledge group was categorized into 2 groups: average knowledge (good knowledge group was merged here) and lack of knowledge.


    1. Missing data

Some information was missing in demographics; height, weight, and in information of family planning attitude; attitude towards birth space, information about contraceptives before get marriage. In all descriptive analysis, only valid percentages were used after omitted missing data.


Missing Variable

n

%

Weight

4

4.1 %

Height

3

3.7%

Birth space between two children

2

0.9%

Get family planning knowledge before marriage

2

0.9%

If you need to know about FP where you would prefer to go

1

1.2%

Want more children

2

0.9%

Preferable service for family planning

8

3.5%


Chapter 4. Ethical Considerations

Discussion of family planning varies from country to country, and depends greatly on the cultures. Every individual is also varying from each other’s when it comes to sharing their perceptions towards modern contraceptive methods and practices. Sometimes talking about family planning methods might be regarded as embarrassing or asking about practices of contraceptive methods among unmarried young girl as unacceptable. According to the declaration of Helsinki in 2000, all medical research should be following the general ethical research principles. As the study was done among immigrant unmarried youth and married women, according to Bhopal in 1997, research among ethnic minorities involves additional ethical concerns (38). Bhopal suggests that ethnic minorities are vulnerable (4) groups in a society (39) and that research amongst them demands careful consideration of privacy. Therefore, this researcher practiced fundamental ethical consideration in relation to this survey.



    1. Informed consent

“Recruiting subject is the first step in the informed consent process. Any provision of information by the investigator to a prospective subject or source of referral subject begins by giving information about the project” (33).

The principal investigator used the snowball sampling method to obtain sufficient sample size. The principal investigator asked present respondents to nominate another one, whom she knew, as a potential participant. When the present participant was interested in nominating other participants, she herself explained the survey and provided information about the research project to the nominated and potential study subjects. If and when the nominated woman indicated interest in participating, then the respondent who had recruited her provided the contact information to the principal investigator. The survey began with verbal informed consent.

The four research assistants from four ethnic groups were also committed to having informed consent prior to collect the data. The data was never collected without any informed consent. During the study period, one respondent withdrew her information and was not interested letting her daughters participate in this survey. That information was removed from the collected data.


    1. Confidentiality

The principal investigator always considered the issues of privacy and confidentiality of all study participants. Research assistants made an agreement with the author to keep the confidentiality of the respondents and their opinions. The author also signed an agreement in the health centre’s of the Søndre Nordstrand districts to protect the information of patients who attended the health centers.

Each study respondent was assigned an ID number that was kept separate during the study; this ID followed throughout the data handling. A list was made for the respondent’s identity with the ID number, which was destroyed after the valid data was assured.



4.3 Ethical clearance and approval

All the necessary ethical and administrative approval was obtained before the study took place. To obtain the ethical clearance, the protocol was sent to the regional committee for medical research ethics (REK) in Norway (Annexure 5).



Chapter 5. Result

Demographic characteristics

    1. Demographic characteristics of South Asian immigrant women

Table .Demographic characteristics of 309 South Asian immigrant women in Oslo, Norway













1st generation immigrant women

2nd generation immigrant women




Variables




n=309

%

n=224

%

n=85

%

P-value

Age

13-19

71

23.0 %

11

4.9 %

60

70.6 %







20-30

127

41.1 %

107

47.8 %

20

27.5 %

<0.001




31-45

111

35.9 %

106

47.3 %

5

5.9 %































Ethnicity

Pakistan

106

34.3 %

82

36.6 %

24

28.2 %







Bangladesh

52

16.8 %

30

13.4 %

22

25.9 %

0.064




Sri-Lanka

59

19.1 %

43

19.2 %

16

18.8 %







India

92

29.8 %

69

30.8 %

23

27.1































Education

Less than 12 years education

192

62.1%

122

55.4%

70

80%

<0.001




More than 12 years education

117

37.9%

102

46.6%

15

20%































Marital status

Unmarried

81

26.2 %

15

6.7 %

66

76.6%

<0.001




Married

228

73.8 %

209

93.3 %

19

22.4%































Employment status

Unemployed

204

66 %

125

55.8 %

79

92.9 %

<0.001




Employed

105

34. %

99

44.2 %

6

7.1 %




In total 309 South Asian immigrant women of reproductive age residing in Oslo, Norway were recruited. Table 1 shows the demographic characteristics of women. The range of ages was between 13 to 45 years. The mean age was 27.35, and standard deviation was 8.253. The participants were divided into three age groups. 41.1% were in the age group of 20-30 years, dominant immigrant country was Pakistan (34.3%), followed by India, Sri-Lanka and Bangladesh. As seen in the table 1, 117 immigrant women (37.9%) had more than 12 years education and more than two-thirds 228 women were married.
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