Knowledge, attitudes and practice survey of family planning among South Asian immigrant women in Oslo, Norway
This research was conducted in partial fulfillment of the Masters of Philosophy degree in International Community Health at the department of General Practice and Community Medicine, Faculty of Medicine, University Of Oslo.
Dr. Asma Abedin
Supervisor: Prof. Dr. Babill Stray-Pedersen
DEDICATION
To my parents, children and to my beloved one, for being my greatest critic, for sharing my frustration and for caring me and our children during my work on this thesis.
Acknowledgement
I would like to give my heartfelt thanks to the 309 women who answered the questionnaires - for their participation and interest in the survey. This study could not possible without their participation. I am ever grateful to them.
Prof. Babill Stray-Pedersen, my supervisor, has played an enormous role in helping me to achieve this goal. She is the source of inspiration and encouragement for me. During the study period, whenever I faced difficulties, she answered and made issues of concern easy with her valuable comments and advice. I feel immensely proud to express my gratitude for her continuous contribution.
Anne-Birth Vegge Arlt, leader of the Søndre Nordstrand health clinic for family, children and youth - I gratefully acknowledge her cooperation. She and her employees were of vital importance for my fieldwork.
Special thanks are given to the research assistants and staff of the Grønland, Bjørndal, Prinsdal, Klemetsrud and Holmlia health centres.
It is a pleasure to thank, Kalaivani Thanabalan, Syed Israt Haque, Navneet Kaur, Tony Ban Singh, Nazma Kareem,Tayibah Sheikh, Uzma Khan, Era Fatema, Dr. Asaduzzaman, Rohan, and Sabbir Khan - all of whom made this thesis possible, opened up to me, gave me access to immigrant communities and prompted me to conduct the survey.
I owe thanks to Lien Deip for her enormous and indispensable support in statistics. She is great for me.
I would like to express my sincere thanks and regards to Hildegunn Bomnes, director of Stiftelsen Amathea, for her valuable guidance with fruitful and insightful comments, suggestions and support at various stages of my field work.
I would like to thanks ansatte of Stiftelsen Amathea especially Berit Helde for her supports during my field work.
I want to thank all of the wonderful classmates, especially Neupane who have given me valuable support during the frustrations and prosperities of this course. I am especially grateful to Christina Brux, whose comments in improving my English language and warm friendship have helped me to finish this writing.
I would like to express cordial thanks to Prof. Johanne Sundby and Prof. Akhtar Hossain who inspired me to work with immigrant women.
Special thanks also to Line Low, Ragnhild Beyrer and Vibeke Christie, for always being helpful. Their passionate support and care during my course of study will be memorable. I would like to thanks the IT and other support staff at Fredrik Holst’s Hus for their kindness during the master’s course.
Finally, I would like to give sincere thanks to Stiftelsen Amathea and the Norwegian Directorate for Health and Social Affairs for financial support to do this project.
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Acknowledgement / 3Clarification of terms and abbreviation / 9
Abstract / 11
1. / Introduction / 12
1.1 Background / 12
1.2 Literature review / 13
1.3 Rational for study / 15
2. / Objective of the study / 18
2.1 General objective / 18
2.2 Specific objective / 18
3. / Research methodology / 19
3.1 Study design / 19
3.2 Study population / 19
3.3 Sample size / 20
3.4 Data Collection procedure / 21
3.5 Data collection tool / 22
3.5.1 Demographic / 23
3.5.2 Knowledge / 23
3.5.3 Attitude / 25
3.5.4 Practice / 26
3.5.5 Service for family planning / 27
3.6 Data management / 27
3.7 Data analysis and statistics / 28
3.8 Missing data / 29
4. / Ethical consideration / 31
5. / Result / 31
5.1 Demographic characteristics of South Asian immigrant women
Knowledge of family planning / 33
5.2 Descriptive result for knowledge / 34
5.2.1 Association between knowledge of family planning and marital status / 34
5.2.2 Association between knowledge of family planning and immigration status / 36
5.2.3 Association between knowledge of modern contraceptives and demographics / 37
5.2.4 Association between knowledge of emergency contraceptives and demographics / 38
5.2.5 Association between knowledge of Chlamydia, STI’s and demographics / 39
5.2.6 Association between source of family planning information and demographics / 40
5.2.7 Association between received sex education at school and demographics / 42
Attitude towards family planning / 42
5.3 Descriptive results for attitude towards family planning / 42
5.3.1 Attitude towards family formation among South Asian immigrant married women (n=228) / 43
5.3.2 Attitude towards modern contraceptives among South Asian immigrant married women (n=228) / 45
5.3.3 Attitude towards family planning discussion among South Asian immigrant married couples / 46
5.3.4 Attitude towards family planning discussions among South Asian immigrant women’s society from where they originate (n=228) / 47
5.3.5 Attitude towards FP information among unmarried South Asian immigrant women (n=81) / 48
5.3.6 Preferable source for FP information among unmarried women / 49
Practice of family planning / 49
5.4 Descriptive result of practice of family planning / 49
5.4.1 Fertility background / 51
5.4.2 Association between contraceptive use and demographics and knowledge, attitude of family planning and number of children reported by South Asian immigrant women (n=228) / 52
5.4.3 Reason for not using contraceptives / 52
5.4.4 History of requesting induced abortion and reason for termination of pregnancy among South Asian immigrant married women / 53
Family planning service / 53
5.5 Preferred to talk or ask about family planning information by South Asian immigrant women / 53
5.6 Outcome / 55
5.6.1 Logistic regression analysis to estimate the ORs and 95% CIs for significant predictors of family planning knowledge among South Asian immigrant women / 57
5.6.2 Logistic regression analysis to estimate the ORs and 95% CIs for significant predictors of contraceptive use among South Asian immigrant women
6 / Discussion / 59
6.1 Summary of important findings / 59
6.2 Discussion of result / 61
6.3 Methodological consideration / 65
6.4 Recommendation / 67
7 / Conclusions / 68
Reference / 69
Appendices / 74
Annexure 1. Informed consent form for unmarried women / 74
Annexure 2. Informed consent form for married women / 75
Annexure 3. Questionnaire for married women / 76
Annexure 4. Questionnaire for unmarried women / 83
Annexure 5. Ethical clearance letter from REK / 86
Annexure 6. Map of Oslo districts / 87
Clarification of terms and abbreviation
Knowledge, attitude and practices (KAP): A KAP survey is a representative study of a specific population to collect information on what is known, believed and done in relation to a particular topic.
Unmet need: The concept of unmet need points to the gap between women's reproductive intentions and their contraceptive behavior. Women with unmet need for family planning for limiting births are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of the next child.
Contraceptive prevalence rate is the proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at a given point in time.
Contraceptive methods include clinic and supply (modern) methods and non-supply (traditional) methods. Clinic and supply methods include female and male sterilization, intrauterine devices (IUDs), hormonal methods (oral pills, injectable and hormone-releasing implants, skin patches and vaginal rings), condoms and vaginal barrier methods (diaphragm, cervical cap and spermicidal foams, jellies, creams and sponges). Traditional methods include rhythm, withdrawal, abstinence and lactational amenorrhea.
Emergency contraception, or emergency post-coital contraception, refers to birth control measures that, if taken after sexual intercourse, may prevent pregnancy.
Sex education is a broad term used to describe education about human sexual anatomy, sexual reproduction, sexual intercourse, reproductive health, emotional relations, reproductive rights and responsibilities, abstinence, contraception, and other aspects of human sexual behavior. Common avenues for sex education are parents or caregivers, school programs, and public health campaigns
Immigrants are defined as being born abroad by two foreign-born parents, and registered as residents in Norway. (“First-generation immigrants” or “migrants”)
Norwegian-born to immigrant parents is defined as those born in Norway with two immigrant parents. (“Second-generation immigrants”)
http://www.nakmi.no/opplastede_filer/Public_Health%20 (2).pdf
South Asian Countries consists of Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka.
(http://en.wikipedia.org/wiki/South_Asia)
Ethnic minority: A group that has different national or cultural traditions from the majority of the population.
Chlamydia infection is one of the most common sexually transmitted infections (STI) in humans caused by the bacterium Chlamydia trachomatis.
IUD / Intrauterine deviceECP / Emergency contraceptive pill
STI’s / Sexually transmitted infections
FP / Family planning
CM / Contraceptive method
ESCAP / Economic and social commission for Asia and Pacific
Abstract
‘Every man and woman has the right to be informed of, and to have access to, safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth as well as provide couples with the best chance of having a healthy infant.’[1]
Objective: The aim of the study was to investigate the family planning knowledge, attitudes, and practices among the South Asian immigrant women (13-45 years) in Oslo, Norway.
Methodology: A cross-sectional study using a quantitative approach was carried out from August 2010 to December 2010 among 309 women - of which 23.3% were recruited from health centers, and 76.3% from South Asian immigrant’s native communities.
Result: One third participants originated from Pakistan, 72.5% were 1st generation immigrant women. Among 309 respondents, 73.8% married; 66% unemployed; 62.1% had less than 12 years education and 41% were between 20-30 years. More than half, South Asian immigrants 181 (58.6%) showed they have lack of family planning knowledge while 128 women (41.4%) have average knowledge. The majority (62.5%) received family planning information from their family members and friends. Only 33% women had received sex education at the school. The majority of the women (79.6%) never heard of STI’s like Chlamydia and among them 94.4% 13 to 19 years old. 84.2% women stated to discuss family planning information with unmarried women is shame or embarrass in their society. Contraceptive use among the immigrant women was 68.9%. Education is one of the most important predictors for FP knowledge and practices. Conclusion: Nearly fifty percent women have average family planning knowledge. FP knowledge before marriage is significantly associated with country of origin. Therefore, there is need culturally sensitive initiatives to encourage immigrant women for their positive attitude towards discussion on family planning with unmarried women.
Chapter 1. Introduction
1. Introduction:
Family planning allows individuals and couples to anticipate and attain their desired number of children in addition to the spacing and timing of their births. It is achieved through the use of contraceptive methods (1). Family planning is not only focused on the planning of when to have children and use of birth control. Rather, in a broad view, it includes sex education, prevention and management of sexually transmitted infections (STIs), preconception counseling and management, and infertility management (2). Family planning offers a positive view of reproductive life and enables people to make informed choices about their reproduction and well-being (3).
1.1 Background:
The practice of family planning methods has increased since the 1960’s - both in developed and developing countries. According to the United Nations in 2009, the use of any contraceptive methods among women is at 62.9% worldwide, 81% in Northern Europe and 54.2% in South Asia (4). On the other hand, the rate of induced abortion has also reduced in both developed and developing countries. The induced abortion rates are 29% in worldwide, 17% in Northern Europe, and 29% in Asia (4). Though the decline in induced abortion rate reduced from 34% to 29% in Asia, more than half of abortions in developing countries were illegal and unsafe (4). In addition to induced, illegal and unsafe abortion, unmet need for family planning is another consideration in developing countries, especially in South Asia. Studies from South and Southeast Asian countries indicate that the unmet need for contraception in Bangladesh is 18.7%; in Pakistan, it is 23 %, while in India, it is 27.1% (5). Thus, the South Asian countries presented a different picture (6) in contraceptive prevalence rate, induced abortion rate and unmet needs of sexual and reproductive health services. The combination of high unmet need of family planning with contraceptive unawareness among the South Asian adolescents and youth will increase the risk considerably (6).
Of the present, worldwide there were estimated 200 million immigrants, with 70.6 million immigrants living in Europe (7). In Norway 2011, 600 900 persons or estimated 12.2% of the total population has an immigrant background (including Norwegian born with two immigrant parents) (8)
1.2 Literature review:
A KAP study was done at Manipur India, to assess the knowledge, attitude and practice of family planning (KAP) among the Meitei women. The knowledge of condom and IUD was higher in the age groups of 31-35 years (34.9%) and 20-25 years (32.0%) compared to the respondents in the age group of (24.0%) 36-40 years and (20.0%) 26-30 years. The main source of knowledge was friends at 44 percent. (9)
In Karachi, Pakistan, a study was done to find out the level of awareness, attitude and practice of family planning among rural women. The study revealed that non-supportive attitudes towards family planning exist among the people due to the low level of education, desire for male children and misinterpretation of religion. (10)
Another study at the urban health care center, Azizabad Sukkur, in Pakistan investigated the awareness and pattern of utilization of family planning services among women. The study shows that, before 18 years of age, 69.5% were married, some desiring 4-5 children (37.5%) or more than five children (36%); 40% participants had never used any contraceptive method. Health care providers were the main source of family planning information among 48.5% of women. (11)