“I DON’T LIKE BEING STEREOTYPED, I DECIDED I WAS NEVER GOING BACK TO THE DOCTOR”: SEXUAL HEALTHCARE ACCESS AMONG YOUNG LATINA WOMEN IN ALABAMA

Abstract

Background:

Young Latina Women (YLW) in the US and in Alabama are disproportionately affected by sexual health disparities. Our community based participatory research (CBPR) study’s purpose was to examine YLW’s perceptions and experiences of sexual healthcare access (SHCA) toward developing community-driven, multilevel intervention strategies.

Methods:

We conducted 20 semi-structured qualitative interviews with YLW between 15–19 years old and who had been in the US for 5 or more years. We content-analyzed the data guided by the Socioecological Model of Sexual Health (SEMSH). We began analyses by coding independently, built consensus on the codes, then finished coding transcripts independently.

Results:

Sixty-five percent of participants were U.S.-born and 60% had health insurance. Participants identified barriers/facilitators to SHCA including discrimination in clinical settings and embarrassment/stigma about SHCA.

Discussion:

Our study is the first in AL to use CBPR to work with YLW. Interventions should consider the multi-level and intersectional nature of SHCA challenges.

INTRODUCTION

Between 2000 and 2011, Alabama experienced a 145% increase in its Latino population, making it the state with the second largest percentage increase of Latinos during this time-frame [1]. Since then, Alabama has enacted harsh anti-immigrant policies [2], which have negatively impacted Latinos’ healthcare access [3].

Young Latina Women (YLW) in Alabama are disproportionately affected by sexual health disparities (SHD) compared to their non-Hispanic White counterparts. In 2015, the estimated rate of Hispanic/Latinos living with diagnosed HIV infection in Alabama was 267.7/100,000 compared to 123/100,000 for non-Hispanic White young women [4] and the birth rate for YLW, 15–19 years of age, was 51.3/100,000 compared to 26.3/100,000 in non-Hispanic White young women [5]. Forty-six percent of Alabama youth, in grades 9–12th, are sexually active [6]. Regular HIV/STI screenings of sexually active adolescents 15 years or older are recommended [7]. YLW must have sexual healthcare access (SHCA) to adequately care for their health [8].

Studies with adult Latinas in the Southeastern US point to barriers to SHCA [3, 9–12]. However, little is known about SHCA among 1.5 generation (foreign-born, moved the US before age 13) and 2^nd generation (US-born to foreign-born parents) YLW. The purpose of this study was to address this gap in the literature and inform the development of community-driven, theory-based, and culturally-relevant, multilevel intervention strategies. This work represents the first phase of a community based participatory research (CBPR) study in West Alabama. CBPR ensures equitable participation of all stakeholders through partnerships [13].

Theoretical Framework and Authors’ Positionality

Socioecological Model of Sexual Health (SEMSH).

The theoretical framework for the study was the SEMSH, as described by Tolman et al. [14, 15] and adapted to Mexican American adolescents by Rafaelli et al. [16]. This model views the individual as nested in a set of levels of influence (i.e., individual, dating/romantic relationships, social relationships, and sociocultural context)[15]. It proposes that gender and ethnic identity must be considered within the person’s social environment to identify power imbalances and social norms that lead to decreased sexual health and SHCA [14].

Authors’ Positionality.

[1^st author] and [2^nd author] are Latina ourselves. [1^st author] is Puerto Rican and [2^nd author] is a second generation Mexican immigrant. Both of us have native fluency in English and Spanish and conducted our interviews in both depending on our respondents’ wishes. We share some cultural and socio-economic understandings of Latina/o life in South because we have become a part of that story as Latina women and researchers who live and work in the South. We feel that our shared positionality with our participants helped to yield rich and nuanced answers because we were able to draw from our own lived experiences in these conversations.

METHODS

Participants and Data Collection

In 2017, we conducted 20 semi-structured qualitative interviews with YLW who: self-identified as Latina, were 15–19 years of age, had been in the US for 5 or more years, and lived in West Alabama. Topic guide questions included: What kind of sexual health services do YLW need? and What challenges do YLW face in getting SHCA? In line with our CBPR approach, we convened a community advisory board (CAB) early in the project made up of YLW, parents, providers, and community leaders. [13]. The CAB provided crucial input and guidance through each step of the research process. For instance, we expanded the age-range of our sample to include younger adolescents based on their advice and added, previously unplanned, parent interviews (described elsewhere) to our study. Our CAB also aided in reviewing data tables with us to help refine our qualitative coding schemes and provided crucial input on how to build on our study’s results (e.g., development of SHCA access intervention).

Recruitment.

The second author of this research and project director, conducted an ethnography, over the course of 8 years, in the local community [17]. Through this work and her engagement as an activist-scholar, she had an established network of community contacts, from which we recruited our sample. We used purposeful convenience sampling and snowballing to recruit a community-based sample from this previously established network. We purposefully adjusted our recruitment strategy during the recruitment and analyses periods to ensure that we attained a sample who represented the different perspectives that we were trying to gather (e.g., born in the U.S. and those born in other countries etc.). We also asked participants to nominate other young women who met the eligibility criteria (i.e., snowballing). We contacted YLW and their parents via phone or electronic message. After screening, if eligible and interested, we obtained parental consent and adolescents’ assent from participants 17 years and younger. Adolescents 18–19 years of age provided their own consent. We conducted interviews in private locations. The recordings were transcribed verbatim. All study procedures and materials were approved by The University of Alabama’s Institutional Review Board.

Analyses

The two authors content-analyzed the data guided by the Socioecological Model of Sexual Health (SEMSH). They began analyses by coding independently, then they built consensus on the coding scheme through in-person meetings. Once they had reached consensus with regard to themes, subthemes and codes and their definitions, they finished transcript coding independently. They used the framework method to organize their data analyses [18]. Recruitment and analyses occurred concurrently. We discontinued recruitment when we reached thematic saturation (i.e., when no new patterns or themes were being identified in the data)[19]. We maintained detailed audit trails, including notes on data analyses and coding decisions.

RESULTS

Out of the 20 participants in our study, 79% percent self-identified as Mexican/Mexican American and 65% were US-born. (Table 1). Ninety percent had spent 5 or more years in West Alabama and 60% had health insurance. We identified SHCA themes at different levels of the SEMSH, except the dating and romantic relationships level (Table 2). Below, we detail the themes by level of the SEMH starting form the most distal (Sociocultural Level) to the most proximal (Individual Level) to the individual.

Table 1.

Sample Characteristics (n=20)

Variable	Frequency (%)
Country of Birth
United States	13 (65%)
Mexico	6 (30%)
Guatemala	1 (5%)
Years in West AL
5 years or less	2 (10%)
More than 5 years	18 (90%)
Age
15–16	9 (45%)
17–19	11 (55%)
Works Outside the Home
Yes	13 (65%)
No	7 (45%)
Ethnicity
Mexican/Mexicana	13 (65%)
Mexican-American	2 (10%)
Other	5 (25%)
Health Insurance
Yes	12 (60%)
No	6 (30%)
I don’t know/Missing	2 (10%)
Insurance Type (n=12)
Private	4 (33%)
Medicaid	8 (67%)
Ever had Sexual Intercourse
Yes	7 (35%)
No	12 (60%)
Missing	1 (5%)
Used Contraception at Last Intercourse (n=7)
Yes	6 (86%)
No	1 (14%)
Contraception Type (n=6)
Male Condom	4 (67%)
Long Acting Reversible Contraception (LARC)	2 (33%)

Table 2.

Sexual Healthcare Access Themes and Subthemes by the Levels of the Socioecological Model of Sexual Health

Levels of the Socioecological Model of Sexual Health	Barriers and Facilitators to Sexual Healthcare Access Themes
Sociocultural (n=15)	Lack of or Availability/Access to:  Documentation, insurance/high healthcare costs−,+ (n=9)  Need for interpreters−,+ (n=7)  Transportation−,+ (n=5) Feeling stereotyped or discriminated against in clinical settings− (n=5)
Social Relationships (n=17)	Parental Attitudes toward Sexual Healthcare Access−,+ (n=17)  Disapproval− (n=15)  Parental Support toward and aid in accessing care+ (n=3) Support from Others in Social Network+ (n=6)  Bringing someone to appointment+ (n=4)
Individual (n=7)	Embarrassment, stigma, or lack of confidence about accessing care−, + (n=8) Lack of awareness/awareness of services−, + (n=4)

⁻Indicates that one or more participants identified this theme as a barrier to healthcare access.

⁺Indicates that one or more participants identified this theme as a facilitator to healthcare access.

Sociocultural Level (n=15)

The sociocultural level is the outermost layer of the SEMH and contains community/historical/structural factors (e.g., institutionalized discrimination and public transit availability) [16]. Seventy-five percent of our sample described at least one barrier or facilitator to SHCA at this level of the SEMSH.

Documentation, Insurance/High Healthcare Costs (n=9)

Nine participants discussed documentation status, lack of insurance or high costs of care as barriers to SHCA. One YLW mentioned not “having papers” as a SCHA challenge and believed that immigration documentation was needed for care, which is not the case.

Participant: What challenges? Because like we don’t have papers or… like in the doctor’s [office they ask] don’t you have to have papers or something? So they can check on you and stuff like that.

Interviewer: Papers, do you mean immigration papers?

Participant: Yes. (15-years old, born in US)

One YLW alluded to leaving an appointment because she did not have insurance or documentation.

Me, personally, [the biggest challenge to healthcare is] no insurance… it was super hard to get an appointment because they always asked you for insurance or not even just really insurance… but other documentation that they ask for… so you just kind of skip out from it [the appointment]. (19-years old, Mexican-born)

Some participants discussed health insurance and immigration documentation interchangeably. These barriers, whether perceived or real, created a sense of uncertainty that made young women apprehensive to access services.

Need for Interpreters (n=7)

Although all participants were fluent English speakers, when asked what challenges YLW their age faced in accessing sexual healthcare services (SHCS), seven participants mentioned the need for interpreters.

Not all girls can speak English. They always have an interpreter. For me, it would be fine, because I know English. But for someone like my mom who doesn’t know English and has an emergency… some people I know wouldn’t have an interpreter or doesn’t know somebody who speaks English. (17 years old, born in Mexico)

This theme highlights that YLW were acutely aware of the challenges experienced by others in their families and communities. The need for interpreters was salient to them, even if it was not a need that they experienced themselves.

Transportation (n=5)

A quarter of the sample identified transportation as a barrier or facilitator to SHCA.

I guess depending how old they are it [a barrier] could be transportation… If they live in an area—and I know [name of city] has that bus that goes around, but I’m not sure if it is just for the city or for the county. (19-years old, born in Mexico)

One participant relayed that she was able to start getting reproductive health services when she got her own car.

Interviewer: How did you decide to have her [your mom] stop going with you [to the doctor]? Was this something that she chose, or did you tell her to stop coming in with you?

Participant: No, I got a car when I was 16. She works. (19-year old, born in US)

This theme helps illustrate the SHCA barriers encountered by emerging young rural populations in the US South. The mention of parental disapproval highlights how facilitators and barriers are fluid and intersectional across layers of the SEMSH.

Feeling stereotyped or discriminated against in clinical settings (n=5)

Finally, five participants felt that providers unfairly judged or discriminated against them for being Latinas, discussing a perceived apathy and lack of healthcare “deservingness” from their providers.

…they [providers] tend to generalize us [Mexicans] as we’re uneducated, we wouldn’t know what they’re trying to tell us… they just think that we’re less informed. And sometimes they’re right, we are less informed, and it does affect the way they treat us because they… have less empathy for us… They don’t really try to actually understand us…they don’t really care if you have any questions, really. (19-years old, born in Mexico)

One participant discussed going to the doctor for a urinary tract infection and feeling like her doctor was discriminatory toward her. This experience was so negative that she discussed never wanting to return to the doctor.

Interviewer: Do you think that being Hispanic influences how doctors, nurses, or other healthcare providers treat you?

Participant: Definitely. That’s actually why I stopped going to that doctor. She [the doctor] would make direct snarky comments on me getting pregnant young… Hispanics and Latinas are stereotyped to being young moms, and pregnant, and uneducated towards sex or towards even just an education. It’s just a stereotype that you’re not going to go to school, that you’re going to get pregnant and married young, or not even married… ‘Oh, she’s not even going to get married. All they’re going to do is live together and have a whole bunch of kids…’ I definitely don’t like being stereotyped…I decided I was never going back [to the doctor]. (19 years old, born in US)

This theme helps illustrate the discrimination that YLW face in clinical settings. These barriers to SHCA can make sexual wellness less accessible for YLW in the US South.

Social Relationships (n=18)

The social relationships layer of the SEMSH includes YLW’s families and friends who can provide information and support (e.g., transportation to a clinic) with SHCA [16]. Ninety percent of our sample mentioned at least one barrier or facilitator at this level of the SEMSH. Parental attitudes was the most salient theme.

Parental Attitudes toward SHCA (n=17)

Disapproval (n=15).

A majority of participants identified parental disapproval of them having sex and, therefore, accessing reproductive health services as a major reason why they could not access services (n=15).

Interviewer: What do you think are the biggest concerns that young Mexican women your age face when taking care of their [sexual] health?

Interviewee: For me, my parents. Just not really having a way to tell your parents like hey, I want to go to the doctor… Just having like someone to tell you that you need to… put yourself on this type of contraception or things like that… I think in general, most girls are… scared to talk to their parents… So that makes it a little harder for them to go see the doctor. (19-years old, born in US)

Some of the participants’ comments suggested the root of this disapproval of birth control lied in misconceptions regarding contraception and fertility (n=4).

Well, I told my mom that my friends use birth control pills and… that’s fine if they use that. But when they’re older and want to have kids, it’s going to be a little bit tougher and they will have problems with the kids because of that pill. Or have problems trying to get pregnant. (17-years old, born in Mexico)

When asked what would make it easier for young Latina women to access care, thirty-five percent of participants mentioned that access would be possible if their parents were comfortable with talking about sexual health and SHCA.

Parental Support and Aid in Accessing care (n=3).

Only three out of the 20 participants mentioned that their mothers had spoken to them about or taken them for SHCA.

I’m not sure why exactly she wanted to [get me birth control] or if she just thought, I’m going off to college soon. She did know that I would end up having a gap in health insurance… I have an IUD, so I think she was trying to plan ahead for… having me get one before that gap… She’s on top of it. (19 years old, born in Guatemala) …mom usually tells me… if you ever have… sex without protection, then we could take you to the medical center, make sure you don’t have no type of infections or anything… But…I’m still scared, though… (16-years old, born in US)

Although only a handful of YLW mentioned this facilitator, it is worth noting that some Latino/a parents are having these conversations with their daughters.

Support from Others in Social Network (n=6)

Six participants discussed support from others in their social network as an important facilitator to SHCA.

Bringing Someone to the Appointment (n=4).

A quarter of the sample discussed that having someone who could go to the doctor with them would facilitate SHCA.

Individual Level (n=7)

The individual level of the SEMSH is the innermost layer and represents the traits, attitudes, beliefs and characteristics of the person [16]. Thirty-five percent of our sample discussed a barrier or facilitator at this level of the SEMSH.

Embarrassment/Lack of Confidence about Accessing Care (n=8)

Eight of the participants mentioned embarrassment, stigma or lack of confidence as a barrier to SHCA.

Participant: I think it is more of being scared or embarrassed to ask for help or to be… to ask for the information about it. Not because they [girls] are necessarily in a certain situation where they need that, but where they would like to know… it is like embarrassing… (16-years old, born in Mexico)

This theme illustrates the “sexual silence” that many YLW experience in their families and communities, making SHCA more challenging [20].

Lack of Knowledge or Awareness of Services (n=4)

Four participants mentioned that lack of knowledge or awareness about where to get services was associated with SHCA.

Interviewer: What challenges do Hispanic women your age face in getting the sexual healthcare services that they need?

Participant: I think it kind of starts with knowing that there is any access or where to even go… (19-years old, born in Guatemala)

When asked where they would go if they needed services, less than half (n=9) were able to identify a clinic or provider.

DISCUSSION

The purpose of this study was to examine the perceptions and experiences of YLW in Alabama on SHCA, guided by the SEMSH, to inform the development of community-driven, theory-based, culturally-relevant, multilevel intervention strategies. YLW in states like Alabama are disproportionately affected by sexual health disparities as they come of age in a sociopolitical environment characterized by harsh anti-immigration laws, non-evidence based state-level sexual education mandates, and increasing restrictions on reproductive rights [21] [22]. As described in one of our other papers, this context, produces structural power imbalances and social norms that disempower YLW as immigrants, adolescents, and women [23]. Better understanding the SHCA perceptions of YLW, within this context, is an important first step toward identifying, developing and implementing effective SHCA intervention strategies.

In line with other studies conducted with YLW and adult Latinas, our participants discussed lack of documentation, lack of health insurance, high healthcare costs, and language access as barriers to SHCA [3, 9–12, 24]. All of the YLW in our sample were US-born or had deferred action for childhood arrivals status [25]. However, their families were of mixed status and, as has been shown by other work, this influenced their SHCA [26, 27]. For instance, one of our US-born participants mentioned that “we don’t have papers” as a reason why young women could not access care. Community-level outreach based interventions, like patient navigator/community health worker models, have shown success at engaging immigrant communities in care [28]. However, these have not been well disseminated among Latino/a communities in the US South. The implementation of these outreach strategies has the potential to better health outcomes for YLW in emerging Latino states.

In line with the literature on SHCA among adult immigrant women in the US South, participants cited transportation as a major SHCA barrier [9, 10]. West Alabama, is largely rural with few sexual health providers and public transportation options [21]. Lack of geographic access to SHCS poses significant barriers to non-urban populations, particularly for youth who may not own a vehicle and, even more so, for immigrant youth who experience additional challenges attaining driver’s licenses [24, 29]. Youth-focused, evidence-based healthcare interventions that can reduce the need to drive to clinics (e.g., school-based health clinics, mobile healthcare services etc.) are crucial to bridging these gaps to SHCA for YLW in underserved areas like West Alabama [30–33].

A quarter of the sample discussed feeling stereotyped or discriminated against in clinical settings as a deterrent to SHCA as we have seen in studies with adult Latinas [9, 10, 34]. However, unlike many of the Latinas in previous studies, these YLW have grown up in the US and possess language proficiency, cultural fluency (e.g. they regularly code switch or culturally adapt in their daily interactions [35]), and legal immigration status. However, our findings suggest that these behaviors are not sufficient to bridge the SHCA gap for YLW in the Southeast. Addressing this issue more fully must involve working with providers, who hold the power in patient-provider relationships [36]. Medical Schools and residency programs around the country have started developing, establishing and institutionalizing cultural humility training and instruction on structural inequality at their institutions [37, 38]. Preliminary empirical evidence suggests that these emerging models (e.g., train the trainer) may be promising in fostering a generation of more culturally competent and compassionate providers [39, 40].

At the social relationships level of the SEMSH, we found that the majority of the YLW in our study cited parental disapproval of sex and SHCA as a barrier while a handful mentioned that their mothers had helped them with SHCA. Since young women rely on their parents for healthcare access, this has implications for SHCA. These findings point to the need to collaborate with parents of YLW toward parent-focused interventions. Several evidence-based interventions have targeted the YLW-parent dyad [41, 42] with regard to sexual health knowledge, communication and SHCA, however, these have not been widely implemented in the US South. Cost-effective, primary healthcare-based, brief evidence-based interventions, like Families Talking Together, may be promising toward addressing these SHCA challenges [43].

Finally, at the individual level of the SEMSH, YLW reported that lack of awareness of services and embarrassment were significant barriers to healthcare access and less than half knew where to access care. The implementation of partnership-based models that can establish formal linkage and referral relationships between youth-serving organizations (e.g. schools and after school programs) and sexual healthcare providers/clinics may be important tools toward reducing stigma/embarrassment, increasing knowledge of services and, in turn, decreasing SHD [32].

Limitations

This study had some limitations. Our work was designed to provide the foundational research for a wider CBPR agenda aimed at increasing SHCA for this population. Although useful in better understanding the experiences and needs of YLW in the US South, these data are not generalizable to YLW in other parts of the country. Additionally, 35% of our sample was sexually active, which is less than the national average [5]. It is possible that YLW who engage in higher risk sexual behaviors (e.g., early sexual initiation, multiple partners etc.), are also less likely to participate in this type of study. Future work, should seek to explore the SHCA barriers experienced by these “difficult to reach” subgroups.

Contribution to the Literature and CBPR Approach

This study contributes to the literature by highlighting the insights of an understudied group: YLW in the US South. Their perceptions as 1.5 and 2^nd generation immigrant YLW living are related to but ultimately unique from other racial/ethnic minorities and from older adult Latinas. To our knowledge, our research team is the only group in Alabama (and one of only 2 groups in the Southeast) partnering with communities to better-understand and amplify YLWs perspectives through a CBPR process. Through our CAB, we have brought a diverse group of stakeholders together, as partners, in this initiative. By employing simultaneous Spanish-English interpretation (with two interpreters and headsets) in CAB meetings, stakeholders who were previously unable to dialogue have partnered toward bringing evidence based interventions to West Alabama and developing our own culturally-tailored peer-to-peer SHCA program. Our long-term commitment to the local community is central to this community-academic partnership approach. Collaborations that center the community and leverage provider, organizational, academic and community leader partnerships can play important roles in improving health outcomes among Latino/as in the Southeast.