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



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Relationship between contraceptive use and demographics, knowledge, attitude towards CM and number of children among women n=228

We wanted to find out the impact of our explanatory variables (Age, ethnicity, immigration status, education, marital status, employment status, knowledge of family planning, number of children and attitude towards modern contraceptives) to the use of contraceptives. Therefore we fitted these variables into a binary logistic regression model with the contraceptive use as dependent variable.
Table 22. Odds Ratio (OR) with 95% confidence interval (CI) for current contraceptive use according to demographic predictors among South Asian immigrant women of reproductive age







OR

95%CI of OR

p-value

aOR*

95%CI of aOR*




p-value

Age

























20-30 yrs(1)

Ref






















31-45 yrs(2)

2.9

1.6-5.2




<0.001

2.0

0.9-4.7




0.077

Pakistan(1)

Ref






















India(2)

2.2

0.9-5.4




0.061

6.8

1.8-25.9




0.004

Sri-Lanka(3)

2.4

1.0-5.5




0.036

8.4

2.6-26.6




<0.001

Bangladesh(4)

2.1

1.0-4.3




.0.034

4.4

1.3-14.3




0.012

1st generation

Ref






















2nd generation

1.5

0.4-4.8




0.484

1.3

0.3-5.5




0.676

Years of Education

























Less than12 years education

5.4

2.9-10.1




<0.001

8.3

3.7-18.5




<0.001

More than12 years education

Ref










Ref










Employment status

























Employed

Ref







0.427













Unemployed

1.2

0.7-2.2







1.5

0.6-3.6




0.306

Knowledge of FP

























Lack of knowledge

1.8

1.0-3.2




0.039

2.1

1.0-4.5




0.047

Average knowledge

Ref






















Number of children

























0-1(1)

Ref






















2 and more(2)

4.8

2.4-9.3




<0.001

8.4

3.4-20.5




<0.001

Attitude towards CM

























Negative(1)

Ref






















Positive(2)

2.6

1.5-4.7




0.001

2.5

1.1-5.3




0.016

*aOR indicates adjusted Odds Ratio after adjusting for other variables in the model ; Ref.= Reference category

The Hosmer-Lemeshow test supported the model as being worthwhile. The Chi-square value for Hosmer-lameshow test was 10.439 with significance level of 0.236. This value is larger than 0.05. Therefore it indicated support for the model.


The model explained between 33.8% and 47.6% of variance in the contraceptive use. Here ethnicity, education and number of children withstood adjustment for each other indicating that being a Indian women and Sri-lankan woman was the most important predictor of contraceptive use with an adjusted OR of 6.8(95% CI=1.8, 25.9); for Sri-Lankan women 8.4(95%CI=2.6, 26.6); for less than 12 years educated women 8.3(95%CI=3.7, 18.5) and number of children 8.4(95%CI=3.4,20.5). Age, family planning knowledge, employment status, marital status and attitude towards modern contraceptives did not withstand adjustment (control) for other variables in the model.

Chapter 6. Discussion



    1. .Summary of important findings

The main research objective of the study was to investigate family planning knowledge, attitudes and practices among South Asian immigrant women in reproductive age in Oslo, Norway.

      1. Knowledge of family planning:

  • A total of 181 women (58.6%) show they have lack of family planning knowledge while 128 women (41.4%) were in knowledgeable group.

  • The relationship between family planning knowledge and demographics shows significant association with age, ethnicity, and education.

  • Most important predictor of good knowledge of FP with an adjusted OR of 8.4(95% CI=2.6, 27) for age 20-30 yrs women for more than 12 years educated women 19 (95%CI=9.4, 41.7) 3.7 (95%CI=1.5, 8.7) for Indian women; 2.6 (95%CI=0.9, 7.5) for second generation immigrant women.

      1. Attitudes of family planning:

  • Nearly two-thirds of the Indian origin women (66.7 %) show positive attitudes toward family planning discussions. More than half of the Bangladeshi women feel embarrassed during discussions. There was a significant association between ethnicity and attitudes toward FP discussion.

  • Even though more than two third of the respondents’ husbands were positive towards family planning discussion and 59.3% of the respondents were themselves, 81 married women (35.5%) have a history of induced abortion.

  • The majority of married women did not receive any information before they got married. Second-generation immigrant women, 12(68.4%) received family planning information before marriage, while only 36 (16.9%) out of 209 first generation immigrant women got this information. There was a significant association between immigration status and attitudes toward family planning information before marriage (p-value<0.001).




      1. Practice of family planning:

  • Among the married women, 68.9% were using contraceptives. Furthermore, 84.5% of women with less than 12 years of education and 80.1% of those between 31-45 years were using contraceptives.

  • The majority of the women 76.7% of Sri-Lankan origins were using contraceptive. There was significant association between use of contraceptives, age groups and education.

  • Over seventy eight percent of women who had the positive attitudes toward family planning and 85.9% women who have 2 or more children were using contraceptives. There was a significant association between modern contraceptive attitudes, number of children and contraceptive use.

  • The odds of contraceptive use were 2.9 times higher among women 31-45 years compared to women of 20-30 years (95% CI was 1.6 - 5.2).

  • Contraceptive use was 5.4 times higher among women who had less than 12 years of education compared to higher educated women (95% CI : 2.9, 10.1).

  • For women who have 2 and more children the odds of contraceptive use were 4.8 times higher compared to women who have only 1 child (95% CI :2.4, 9.3).

  • The positive attitudes toward modern contraceptives among immigrant women were associated with a 2.6 fold increased Odd ratio for using any contraceptives (95% CI was: 1.5, 4.7).

  • The odds ratio for contraceptive use was increased when education adjusted for age 5.7 (95%CI: 3.0, 10.8); attitude towards contraceptives 5.5 (95%CI: 2.9, 10.5); and for knowledge of family planning 2.1 (95%CI: 1.0, 4.5)




      1. Family planning service:

  • For family planning service, only 17.5% preferred to visit health centres, while 27.7% would not prefer to go anywhere.

  • During seeking family planning service, 60 respondents (26.3%) faced problems. Language barrier was the main reason to face problems.



    1. Discussion of result

‘Knowledge, attitudes toward family planning and contraceptive use are the most fundamental indicators that are used by different national and international organizations to assess the success of family planning programs. Regarding the level of contraceptive use, knowledge has an effect on the women to practice family planning more than others who have lack of the knowledge’. (48) ‘Migrants possess limited knowledge of modern contraceptive methods and, therefore, may experience unmet need for contraception or may have a limited choice of modern contraceptive methods during their first years in an urban destination.’(49)

      1. Knowledge and attitude of family planning

Age. Sexual and reproductive health education is part of the health education of the Norwegian educational system, and it is generally assumed that adolescent females who live in Norway are well aware of basic physiology and how to avoid unwanted pregnancy. The present study indicates that knowledge of family planning is higher among younger than older age groups. The majority of the respondents (55.9%) were female adolescent of 20-30 years of age who have average family planning knowledge.

Immigration status First-generation immigrants were associated with an 3 fold increased OR for family planning knowledge compared to second generation immigrant women. This finding is not consistent with the other findings as study in Denmark in 2007. Though, most of the 2nd generation immigrant women received family planning information before getting married and received sex education at school while the majority of 1st generation women never received any family planning information at school.. The 1st generation immigrants get contraceptive information’s either from friends, family members or media and this is compatible with the findings from India,8 Sri-Lanka 11 and Pakistan 9.

The country of origin among immigrants showed that there was a taboo to discuss about reproductive health with unmarried adolescents. In addition when the adolescents answered questionnaire with same ethnic or same race; it might be influence them to not answer correctly whether anybody get to be informed that she had knowledge of family planning. During study, it was noticed that there was presence a lack of trust between health care providers and unmarried adolescents which was also found in the ESCAP region (15) Therefore, women have little knowledge on contraceptive due to country of origin even though they born in developed country. This study indicates that family planning discussions were not common in their society from where they originate. After adjusting education to other independent variables, the study reveals that demographically, family planning knowledge has improved among immigrant women. It is acknowledged that education can improve the knowledge about reproductive health, but knowledge doesn’t always transfer into actions.

Of the 2nd generation immigrant women who participated in this study most were unmarried and unemployed and most of the young girl have less than 12 years education. Therefore, knowledge of family planning among 1st and 2nd generation immigrants was significantly different by demographics.

Attitudes of family planning discussions among immigrant women are related to their husband’s attitudes. There is a significant association between attitudes among married couples towards FP discussions, but there is no significant association between uses of contraceptives and husbands attitudes as Inter-spousal communication towards contraceptive use has been observed in many studies in Pakistan 1999, 15 in Nigeria 2005 52, and in Ghana 1993 51.



Experience during the KAP survey: One of the married study respondents after giving an interview was asked by the author to let her daughters to participate in this survey. Study respondents gave verbal informed consent with regards to her daughter’s interview. A few days later, the respondents called the author to withdraw her information. She didn’t want to let her daughter to participate in this survey. Another few weeks later, the author called other respondents of same ethnic community, study subject mentioned that she didn’t want to participate because it involves very personal and family planning information and it also involves an unmarried young girl which is not acceptable. The study subjects’ comment was that unmarried girls never give any interviews related to contraception and sexual health. After this incidence, the survey was discontinued within this ethnic group.

Experience during the survey with unmarried young girl:

  • One of respondents mentioned they were not allowed to go school on the scheduled day when they were supposed to get their class on reproductive health. The young respondents mentioned that she lives in one district but prefers to visit other districts health centre for youth.

  • During survey, there was a discussion on sex education in school among the immigrant native communities. The guests of get together program in festival stated that when children were 13 years they moved from Oslo to their native country to avoid the sex education. When the children became 18 years they back again and started their required education. According to their statement, a young girl shouldn’t need to learn about sex before marriage furthermore, it depends on time when they need family planning relevant information.

  • To fulfill the required sample size, the author asked respondents to nominate others to whom she knew like her sisters or cousins or friends and if they would be willing to participate. The author received negative feedback from one of unmarried respondents that was, respondents didn’t prefer to let the author introduce her siblings or friends because they will be informed that respondents visited health centers or have knowledge of contraceptives. It would make a negative impression about the respondents to her family or friends.

      1. Explore the contraceptive practices

Age. The use of contraceptive is lowest among women of 20-30 years while the percentage is highest among 31-45 years. Nearly two third of respondents of 31-45 years old in this study show that they were positive towards contraceptives and they were using modern contraceptives without any problems. They have achieved the desired family size and want to limit births. Therefore, it is logical to say contraceptive usage is highest among the older age group. In descriptive analysis and logistic regression analysis, age groups show a significant difference in use of contraceptives. An increase in the proportion of contraceptive users with age has been also observed in Thailand (46) among Myanmar migrant women, and in Nigeria (50).

Ethnicity. A consideration of the use of any contraceptives by country, according to the United Nations in 2009, shows that contraceptive prevalence rate among Pakistani women is low compared to those from Sri-Lanka, India and Bangladesh. This study also indicates that immigrant women from Pakistan were using less contraceptives compared to other immigrant women in Oslo (Table 25).

Table 25 Percentage of contraceptive use among women

Percentage using contraception among women (2009) according to United Nation

Percentage using contraception among women (2009) according to United Nation

Worldwide

62.9 %

Norway (20-44)

88.4 %

Asia
South Asia

67 %

54.2 %


Europe
Northern Europe

70.5 %

81 %



Percentage using contraception among women (2009) according to United Nation

Percentage using contraception among women (during August-December 2010) (20-45) this KAP survey



Sri Lanka(15-49)

68.0 %

76.7%




India(15-49)

56.3 %

75.7%




Bangladesh(15-49)

55.8 %

74.6%




Pakistan(15-49)

29.6 %

57.6%



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