APDC Grant Narrative

St. Catherine University

Principal Investigator: Carie Cox

Project Title: Family planning decision-making and couple communication among Somali men and women in the Twin Cities

STATEMENT OF NEED/PROJECT SIGNIFICANCE Unintended pregnancy and the importance of contraception Over 50% of pregnancies in the United States are unintended.1,2 Rates of unintended pregnancy are higher among individuals with less income, lower education levels, non-Hispanic blacks, and Hispanics.2 In a literature review, it was found that unintended pregnancies are associated with a range of negative behaviors and outcomes, including delayed initiation and/or fewer visits of antenatal care, increased risk of negative birth outcomes (observed in some studies), decreased likelihood of breastfeeding, increased risk of child abuse and intimate partner violence, and increased risk of maternal depression and anxiety.3 Increasing intended pregnancies from 51% to 56% is one of the goals of the Healthy People 2020 initiative.4 According to the CDC, the best way to reduce unintended pregnancies among sexually active individuals is through use of effective contraceptive methods.5 In addition to reducing unintended pregnancies, contraception also helps prevent mother-to-child transmission of HIV, contributes to healthier/optimal birth spacing, and lowers infant and maternal morbidity and mortality.6 Understanding factors that facilitate contraceptive use among couples desiring to space or limit childbearing is important for the health of children, women, and families. Yet, despite the growing Somali population in the U.S., there is a dearth of research on the sexual and reproductive health needs of this population, including fertility desires and contraceptive use. Fertility and contraceptive use: The Somali context When civil war broke out in Somalia in the early 1990s, thousands of Somalis fled the country and many resettled in the U.S.7 An estimated 37,000 Somalis currently reside in Minnesota (community estimates are even higher), resulting in the largest Somali population outside of East Africa.8 In Somalia, the total fertility rate is 6.6 children and 15% of women report using contraception with only 1% reporting use of a modern method.9 The average number of children among Somali woman living in Minnesota is 2.7,10 but little is known about contraceptive use among this group of women. Somali couples living in the U.S. and other developed countries have cited economic hardship; loss of extensive social support networks; and time needed to devote to learning English, balancing multiple jobs, and/or obtaining education as reasons to have smaller families.8,11-13 Additionally, Somali women in a Finnish study noted that the pressure to have many children was less than in Somalia and large families were stigmatized in Finland.13 The few family planning studies conducted with Somali refugees and immigrants have found that husband’s attitudes and opposition towards contraception, often due to religious beliefs, are commonly reported barriers to contraceptive use.11,13 For example, participants in a study of Somali women in a Kenyan refugee camp reported that some men use violence or divorce their wives if contraception is discussed or used.11 Somali women in Finland reported that it was not acceptable for them to discuss family size or contraceptive use with their husbands in Somalia, but over 70% noted that they could talk to their husbands about these issues now that they live in Finland.13 To our knowledge, no research has been conducted to understand family planning decision-making and spousal communication among Somali men and women in the U.S. despite several studies citing the positive impact that husband’s approval and spousal communication on family planning can have on women’s contraceptive use.14-18

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RESEARCH QUESTIONS The proposed qualitative study will be conducted with men and women from the Somali community in the Twin Cities. The study will answer the following research questions: 1. How do Somali men and women communicate with their spouse and make decisions about child spacing and contraceptive use? 2. What barriers and facilitators do Somali men and women experience when communicating about contraceptive use with their spouse? 3. How can programs and communities in the Twin Cities support Somali couples in achieving their fertility goals? Given that this study is an exploratory study, no hypotheses will be put forth. RATIONALE The proposed study will:  Contribute to our knowledge of sexual and reproductive health in the Somali community: Findings from the study will fill a significant gap in our understanding of how Somali couples are making decisions and communicating about child spacing and contraceptive use in the Twin Cities. Study findings will likely be generalizable to other Somali immigrant populations in the United States and could influence service provision of reproductive health services among this population. Understanding how Somali couples navigate an increased desire and need for contraception as they resettle and undergo cultural, economic, and social change is essential for meeting the reproductive needs of this population. 

Identify factors that influence Somali men’s participation and role in family planning decisionmaking: Among the few family planning studies that we identified with Somali immigrants only two were conducted with men.11,12 Understanding men’s perspectives is essential in family planning research, especially in Somali households where husbands are often regarded as the decision-maker 12 and husband’s opposition to contraception has been cited as a barrier to use.11,13 The proposed study will include both male and female participants.

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Inform and strengthen an established family planning program: The research team identified the study aims based on existing research and WellShare International’s current programmatic needs. WellShare International conducted qualitative research in 2004 to identify barriers to contraceptive use, which shaped the design and cultural sensitivity of their ongoing Spacing Pregnancies Program for East African and Karen Communities (SPEAK).8 However, past research efforts in the Somali community did not explore couple communication or decision-making in family planning. Findings from the proposed study will directly inform and strengthen current activities for Somalis in MN implemented through SPEAK.

INNOVATION: This study takes an innovative approach by focusing on the Somali community in the Twin Cities. This is an underserved community that is significantly underrepresented in research. Furthermore, men are often excluded from reproductive health research and our study will address this common omission by including men in our study sample. Use of qualitative interviews will allow us to conduct an in-depth exploration of the research questions and gain insight that would not be feasible through a quantitative survey. RESEARCH PLAN Target population In-depth interviews will be conducted with men and women from the Twin Cities’ Somali community. Sample size will be determined by the point at which no new information is collected (saturation), which 2 APDC Grant Narrative; Carie Cox

we estimate to be 10 men and 10 women. To be eligible to participate, individuals must: 1) be married, 2) be between 18 and 44 years of age, 3) identify as Somali, and 4) reside in the Twin Cities. We will aim to obtain a sample in which half of the participants use a method of contraception and half do not. We will also aim to recruit a varied sample by age in order to gain diverse perspectives and experiences. IRB approval This study will be submitted to St. Catherine University’s IRB for ethical review. Materials will be submitted by October 23rd and reviewed at the IRB’s November 6th meeting. Data collection will not commence until IRB approval has been obtained. Recruitment Two members of the research team (Ganey and Kahin) will assist in recruiting participants and conducting interviews. Ganey is the program coordinator and Kahin is the community health worker for the SPEAK program at WellShare International. Both are Somali, speak fluent Somali, and have experience recruiting and conducting qualitative research. Recruitment will take place during regularly scheduled outreach activities for WellShare International, which includes home visits, small group sessions, and one-on-one conversations at locations frequented by the Somali community. Potential participants will be informed of the study and, if interested, screened for eligibility. Flyers will also be posted in community centers, universities/colleges, and medical clinics that serve a large Somali population for recruitment purposes and will include contact information that people can respond to if interested in learning more about the study. Data collection In-depth interviews will be scheduled based on participants’ availability and conducted in a private location convenient to participants, which may include the participant’s home or a private room in Wellshare International’s office or a local community center. Two members of the research team (Ganey and Kahin) will be trained in qualitative data collection by the principal investigator (Cox) and will conduct the one-hour, audio-recorded interviews in Somali. In order to reduce potential bias and protect the safety of study participants, couples will not be interviewed together and only one partner from a marriage will be invited to participate in the study. Male participants will be interviewed by Ganey (male) and female participants will be interviewed by Kahin (female). Voluntary, informed consent will be obtained prior to all interviews. Semi-structured interview guides will be developed to facilitate the interviews and will align with the research questions (see Table 1) and translated to Somali by Ganey and Kahin. The interview guides will be field tested with members of the Somali community. Data collected during the field test will not be included in the study but rather used to refine our study materials and help the interviewers become comfortable with the interview guide. Participants will receive a $40 gift card to compensate them for their time. We will track distribution of gift cards per University requirements. Table 1: Key areas of inquiry by research question Research Question Background Information

Research Question 1: How do Somali men and women communicate with their spouse and make decisions about child spacing and contraceptive use?

Areas of Inquiry - Country of origin and relocation history (if applicable) - Employment - Age of participant - Number of children - Duration and country of marriage - Attitudes and desires about fertility, child spacing and contraception o Ideal number of children and rationale o Preferences and attitudes about child spacing o Past and current contraceptive use - Degree of couple communication on contraception o If communication has not occurred:

3 APDC Grant Narrative; Carie Cox

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Research Question 2: What barriers and facilitators do Somali men and women experience when communicating about contraceptive use with their spouse? Research Question 3: How can programs and communities in the Twin Cities support Somali couples in achieving their fertility goals?

Reasons for not discussing contraception Level of interest in discussing contraception and/or concerns  Perceived roles in family planning decision making o If communication has occurred:  Initiation of conversation(s) (who, how, when)  Content of conversation(s)  Tone of and reaction to conversation(s)  Outcome of conversation(s)  Perceived roles in family planning decision making Barriers to discussing contraception with spouse Factors that facilitate discussing contraception with spouse

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Sources of information about child spacing and contraception Acceptability of proposed ways in which support could be provided to couples regarding contraception Perceived support needed to improve couple communication on contraception

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Data analysis Audio recordings will be transcribed and translated verbatim and uploaded into Nvivo, a qualitative data analysis software. The Somali members of the research team (Ganey, Kahin, and Ahmed) will conduct quality checks to ensure that transcription and translation are accurate. Data analysis will be an iterative process by which data collection and analysis occur simultaneously. This strategy will allow the research team to identify areas to probe further, add questions that arise from earlier interviews, and provide feedback to interviewers. Transcripts will be reviewed and a coding scheme developed based on emerging patterns and themes, which will subsequently be used to code the transcripts. Coded text from transcripts will be compiled by code and analyzed for patterns and relationships. Findings will be compared across key characteristics (e.g. gender, use of contraception, and age) and similarities and differences will be reported. Results will be written-up and disseminated. Timeline Table 2 shows the anticipated timeline for each component of the study, beginning in September 2015 and ending August, 2016. Please note that if awarded the APDC grant, the funds would cover data collection activities, which will take place between February and May 2016. Table 2: Timeline 2015 Prepare and submit IRB application Develop study materials Train interviewers for data collection Recruit participants Conduct interviews Analyze data Write-up research findings Disseminate findings

Sept

Oct

Nov

x x

x x

x x

2016 Dec

Jan

Feb

Mar

Apr

May

Jun

x

x x

x x x

x x x

x

x x

July

Aug

x x

x x

x

4 APDC Grant Narrative; Carie Cox

EXPECTED OUTCOMES The expected outcomes of this research project include submission of: 1) a manuscript for publication at a peer-reviewed journal, 2) an abstract for presentation at the Population Association of America conference, and 3) an external grant proposal to advance research in this area. The findings will strengthen programmatic efforts, begin to fill a gap in family planning research among Somali men and women, and inform future studies. Furthermore, it is expected that this study will foster relationships between investigators at St. Catherine University and WellShare International for future research collaborations. SIGNIFICANCE TO THE MISSION OF THE UNIVERSITY AND DEPARTMENT This research study advances the mission and strategy of St. Catherine University and the Public Health Department through the: 1. Promotion of intellectual inquiry by seeking to answer an important health question through in-depth, qualitative research methods. 2. Development of ethical and socially responsible leaders by involving a student research collaborator who will be trained in research ethics, assist with the submission of the IRB application, and participate in the implementation of a research study. 3. Commitment to social justice by aiming to improve our understanding of a key reproductive health issue among an underserved population in order to help improve their health. 4. Implementation of a study that values and builds collaborations with other cultures and communities within the Twin Cities. Specifically, this study is a collaboration with Wellshare International a nonprofit health organization located in Minneapolis that is committed to developing sustainable community-based programs that improve the health of women and children around the world. 5. Use of qualitative research methods, which values individual experiences and respects diverse voices and perspectives. 6. Selection of a topic that is important for the advancement of women in their communities. DISSEMINATION PLAN Findings will be disseminated both locally and nationally:  A two-page research summary will be shared with participants who indicate that they would like to be informed of results and provide their mailing address.  Programmatic recommendations will be developed in collaboration with the research team for the purposes of strengthening the SPEAK program implemented by WellShare International.  A manuscript will be submitted for publication in a peer-reviewed journal for broader dissemination.  An abstract will be submitted in September 2016 for presentation at the Population Association of America conference in 2017. PLANS TO PURSUE EXTERNAL FUNDING External funding will be sought from sources such as NIH, the Patient-Centered Outcomes Research Institute (PCORI), the Minnesota Department of Health, or foundations to fund a larger, quantitative study that examines reproductive health decision-making among Somali men and women in the Twin Cities. Findings from the proposed, qualitative study will strengthen future grant applications for external funding by: 1) helping identify research questions, 2) informing survey design, and 3) establishing partnerships.

5 APDC Grant Narrative; Carie Cox