Attitudes and Beliefs Pertaining to Sexual and Reproductive Health Among Unmarried, Female Bhutanese Refugee Youth in Philadelphia

Abstract

Purpose

We explored attitudes and beliefs pertaining to sexual and reproductive health (SRH) among unmarried, female, resettled Bhutanese refugees 16–20 years.

Methods

Fourteen interviews were analyzed using the constant comparison method, and major themes were identified.

Results

SRH was stigmatized for unmarried youth, making seeking information about SRH or accessing family planning difficult. There were many misconceptions about access to SRH.

Conclusions

Universal, culturally, and linguistically appropriate comprehensive SRH education is recommended for female Bhutanese refugee youth. Terminology used should take into account differences in conceptualization of concepts like dating. Educators and health care providers should clearly describe consent and confidentiality laws regarding adolescent SRH services.

Pediatric research on health following refugee resettlement has focused mostly on younger children, but ~12,500 refugees ages 10–19 years also resettle in the U.S each year [1,2]. Sexual and reproductive health (SRH) concerns are prominent for youth globally. In the U.S., they bear a disproportionate burden of STIs and unplanned pregnancy [3]. Extant work suggests that refugee youth have limited knowledge of STIs and high unmet contraception needs [4–7]. No studies have focused on Bhutanese youth, a Nepali-speaking minority who are among the largest groups of refugee youth in the U.S. To address this gap, we conducted an exploratory study examining SRH attitudes/beliefs among unmarried, female, Bhutanese, resettled refugee youth.

Methods

We conducted fourteen semistructured individual interviews in Philadelphia from June to November 2015. Eligible individuals—recruited during community events—were ages 16–20 years, female, Bhutanese refugees, never married, and never pregnant. Eligibility was purposefully narrow, as SRH attitudes and beliefs are influenced by social and cultural background [8–10]. Recruitment ended after reaching thematic saturation, as determined by the primary investigator (C.P.D.).

The interview guide explored SRH attitudes and beliefs. C.P.D. and project interpreter/translator (D.K. a female, certified interpreter and Bhutanese refugee) translated questions into Nepali, pretested the interview with six youth, and iteratively revised the guide. Interviews—conducted in Nepali and English—were recorded, and English dialogue was transcribed. Transcripts were reviewed by C.P.D. and D.K. with attention to key phrases/nuances that may have been lost in translation. Textual data were analyzed using the constant comparative method: C.P.D. and D.K. iteratively developed a coding scheme using responses from the first three interviews; C.P.D. coded each transcript; C.P.D., D.K., and K.Y. identified key themes.

Participants ≥18 years provided written consent, and those <18 years provided assent with written permission from a guardian. The study was approved by the Children’s Hospital of Philadelphia IRB.

Results

Participants (n = 14) were 16–20 years old (mean 17.4), born in refugee camps in Nepal, resettled in the U.S. from 2011 to 2014 (mode 2012) and preferred to communicate in Nepali.

Cultural norms influenced participants’ attitudes toward SRH: There is no semantic equivalent to the word “dating” in Bhutanese Nepali, and participants did not have a consensus definition. As one respondent noted: the first one is just talking, just getting with a friend. And that is a different kind of dating… And the other dating is having a relationship, like affair (#4). There was consensus that “Culturally we are not allowed to date”(#3).

SRH information was reportedly important for married women, but premarital sex was stigmatized. Hence, unmarried adolescents were not comfortable seeking SRH information or using hormonal contraception: “People feel shy when they are not married, and then they don’t want to talk about birth control…”(#1).

Cultural norms also influence attitudes toward teen pregnancy out of wedlock: “In our culture, we believe that abortion is not allowed”(#14). However, the associated stigma was such that parents might encourage a young woman to have an abortion: “…when the family thinks about their prestige in the community, some of the parents, definitely they encourage her to go and have an abortion”(#14). Alternatively, a family might abandon their daughter to preserve the family’s “prestige”(#6). Stigma could also make young women vulnerable to coercion into marriage: “What I have heard is he is going to blackmail her, saying…I have a relationship, physical relationship, with you…so she was forced to get married with him”(#5).

Knowledge about SRH was variable and depended upon where participants had attended high school: “…back in my country, Nepal, we have a subject…in each school that they used to teach about reproductive health”(#4). Others reported SRH was taught in their U.S. high schools, but some felt information was inadequate. Further, some respondents enrolled in English as a second language courses noted they were excluded from SRH classes. Nonetheless, most participants were aware of the male condom and knew where these could be obtained: “The only thing I know is about using condoms,…when I talk about safety, it means that to use condoms while having sex so that you will not get pregnant”(#14).

Participants had misconceptions about access to SRH services. Most assumed services were not available to unmarried adolescents or required parental consent: “When I am above 18, I can go and talk [to the doctor] by myself. But if I am below 18, under age, I definitely have to take my guardian with me”(#13). Respondents believed the male partner would need to provide consent for abortion: “to do an abortion, both partners have to sign the paperwork…. That’s what I have heard”(#5).

Although gender roles were not the focus of the interview guide, respondents raised this topic. When describing community views on dating, one respondent stated, “they keep on blaming the girls [for dating]”but not the boys”(#8). Other respondents were hopeful that in the U.S. the position of women would improve.

Discussion

SRH education is critical for resettled refugee youth. In the Bhutanese refugee community, seeking SRH education and services is stigmatized for unmarried youth. Therefore, safe, confidential spaces are needed for unmarried youth to receive knowledge and services. Most participants in this study reported that they would prefer education provided outside of the community through Web sites or other reading materials, individual education, or female-only group meetings. To this end, we recommend universal, culturally, and linguistically appropriate comprehensive school-based SRH education that includes discussion of gender roles and norms providing space for discussion in same-gender groups when appropriate. We also recommend that health care providers provide SRH education for all Bhutanese adolescent patients, regardless of “dating” history, and that they clearly describe laws pertaining to consent and confidentiality. Finally, screening for emotional abuse/coercion is important for Bhutanese refugee youth, as it is for all youth.

Although this study focused on a single ethnic community, certain lessons learned are likely to be applicable to other groups of refugee youth. For example, SRH programs working with other groups of refugee youth should identify words, phrases, and concepts commonly used for SRH education that lack one-to-one interpretations in young refugees’ preferred languages or cultural contexts (e.g., “dating”). Programs should carefully develop strategies to explain these words or concepts. Similarly, it is unlikely that refugee youth recently arrived in the U.S. would be familiar with state laws pertaining to adolescent consent for SRH services or the provision of confidential SRH services. Education regarding consent and confidentiality should be a routine part of health care for all refugee youth.

Table 1.

Sexual and reproductive health attitudes and beliefs shared by unmarried, female Bhutanese resettled refugees ages 16–20 years

Dating

#1: “It’s not a good idea to do that. If the parent, they know that somebody or their kids are dating, they will definitely beat them, so it’s not a good idea to date.”

#1: “For me, dating is like meeting two people in a car, or going somewhere else. And sometime, what will happen is they just … would elope from there.”

#2: “But what I have heard from my friend is two partners, they just go to a separate space and pretty much they talk about what we can do after we get married, how can we help our parent. So they talk about love, what is love? So it’s pretty much that is dating to me.”

#3: “Culturally we are not allowed to date.”

#4: “The first one is just talking, just getting with a friend. And that is a different kind of dating… And the other dating is having a relationship, like affair. So that’s the other dating…. But with the affair dating, pretty much we talk about two of us, like myself and the other partner, personal stuff.”

Stigma

#1: “People feel shy when they are not married, and then they do not want to talk about birth control…”

#2: “Because in our culture, we are supposed to have sex only after we get married. So before we get married, we are not allowed to have sex.”

#3: “I think our girls, they are not doing abortion, because it’s not culturally accepted.”

#3: “Yeah, actually depend on what kind of people they are. If they are – say, for example, like my [redacted name], she was pregnant before she was married, and then everybody, they knew about their relationship, what is going on with her. And then they accept her relationship. And finally, everybody help her. And then she was married, finally. And then she has a good relationship right now. She has a baby. But it depend on family. Some family, they do not accept that. And then the boy, usually, they do not accept the girl after she gets pregnant. And then finally, the girl, if she decide to share this information with her parents, so there comes the situation of suicide. So it depend on family members”

#4: “It’s really – in our culture, it’s not a good idea to have sex and to get pregnant before we get married. So when people, they have sex, and when they get pregnant before they marry, the community people, they keep on talking about them. And then the parent will be embarrassed about that, so it’s not a good idea.”

#5: “What I have heard is he is going to blackmail her, saying that I have a relationship with her and she’s my girlfriend and stuff like that, and I have a relationship, physical relationship, with you, so I’m gonna blackmail you in that way…. So she was forced to get married with him.”

#6: “When people came to know that she is taking pills, the community people, they just talk about her, and they will just laugh at her.”

#6: “If our daughter gets pregnant before she gets married, sometime their parents think that my prestige has gone…. And some of the families, they will kick out the daughter from the family.”

#6: “Yeah, in my opinion, like if we get pregnant before we get married, I feel like the boy think that I have already used the girl. So maybe in future, he will just leave me. He will not marry me later in the future.”

#6: “If the girls are really strong, they can give birth to the baby, and then she can [raise] up a baby… But if the girls are weak, if they are not independent, if they cannot do anything, they just [commit] suicide.”

#8: “People will talk behind about like she got pregnant before she was married, and then it’s a sinful thing to talk about, so she’s a bad girl. So people think that way.”

#11: “Yeah, actually in our culture, we usually do arranged marriage. And in arranged marriage setting, the parent has to choose a boy for a daughter. And then that’s why it’s not a good idea to get pregnant before you are married.”

#14: “In our culture, we believe that abortion is not allowed.”

#14: “…when the family thinks about their prestige in the community, some of the parents, definitely they encourage her to go and have an abortion.”

#14: “Usually our culture, they just think that it’s just – they do not think that we made the mistake. They just think that the girl made the mistake, and they usually blame the girl.”

Education

#1: “Yeah, last time we have a team that walk into our high school to teach about those stuff, and then they have done a urine test where everybody has, and they gave a card to us. So if we need it, we can call them. And I do not know where they will send those stuff. Maybe they will send home or somewhere else. I do not know. But they will send those stuff if we need it.”

#2: “Yeah, actually what I have learned from school is, we have to look at the expiration date, and if it is expired, we’ll get pregnant. That will be not helpful. And if they have certain kind – if the condom have holes in it, it will not work. So we have to check this stuff before using it.”

#4: “…back in my country, Nepal, we have a subject, a specific subject, in each school that they used to teach about reproductive health”

#4: “Yeah, actually the problem is back in Nepal, we used to have like the health subject. We used to have like this detailed information that we can learn from the book and the teacher, and then the classroom. But here, we do have health subject, but it’s not in detail.”

#9: “Yeah, for birth control what I have learned is we can use pills, we can get a shot and then we can get a kind of tube inserted in our [arm] to protect from having babies.”

#9: “The people who are senior than me, and then the people who are my classmate, we have learned about those thing when I was – we were in grade nine. So pretty much, they have idea about that.”

#10: “back in our country Nepal, we used to live close by one another. So we learn from people talking to one another in a family friend group, in a friend circle. And the other way we learn is from in school.”

#14: “The only thing I know is about using condoms. So for – when I talk about safety, it means that to use condoms while having sex so that you will not get pregnant.”

Misconceptions

#5: “The other thing is to do an abortion, both the partner has to sign the paperwork, and then we can do abortion. That’s what I have heard.”

#10: “But people who are married, they can get service from the doctor office. So the people who are not married will not get the family planning service.”

#13: “When I am above 18, I can go and talk [to the doctor] by myself. But if I am below 18, under age, I definitely have to take my guardian with me.”

#14: “I guess, if they are under 18, they are not allowed to go to a doctor to get those stuff.”

Gender

#6: “Back in Nepal, they used to discriminate [against] girls…. The parent, they used to think that the girl is totally different from boy. For example, like a boy is allowed to go to school, but the girl is not allowed to go to school…Actually, we have to learn about that boys and girls are equal. So it’s better not to give up everything. We can do anything, what the boys can do.”

#8: “they keep on blaming the girls [for dating] but not the boys.”

#10: “There is a great discrimination in our community. After coming to United States, the boys and girls, both, they can go to school. But back in our country, we have a bad issue. They usually do not allow girls to go to school. And finally, in terms of pregnancy, too, they prefer to have more boys.”

#11: “we have people – those who have those kind of idea in their mind. Yeah, and another problem is with the pregnancy, they always want boys. And then if they have always five or six girls, they keep on giving birth to more babies for the wonderful boy.”

IMPLICATIONS AND CONTRIBUTION.

Stigma prevents female Bhutanese refugee youth in the U.S. from seeking sexual and reproductive health (SRH) education, and misconceptions about confidentiality and consent are barriers to seeking SRH services. Universal, culturally, and linguistically appropriate comprehensive school-based SRH education is needed as is universal education in health care settings.