Contraceptive Use Disparities in Asian American Women in 2015–2016: California Health and Interview Survey

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript, which examines contraceptive use among various Asian American racial/ethnic subgroups based on cross-sectional data from the 2015-2016 California Health Interview Survey (CHIS). This study is particularly valuable given the limited research focused on Asian American women within the field of sexual and reproductive health. It highlights both the prevalence and the determinants of contraceptive use within this understudied group. The findings underscore the need for healthcare providers to offer enhanced support to Asian American women seeking SRH care. Feedback and suggestions are noted below.

• In Table 1 and 2, please bold or italicize the subheadings, so they are easier to identify (e.g., age, marital status, educational attainment, etc.)
• In Table 2, for readability, can the ranges be the second line if possible? Can you also note the reason behind the bolded and red numbers in the footnote?
• In line 46, is 38% referring to unintended or actively planned pregnancies? I assume it’s the former, but please clarify.
• In lines 119-120, it would be helpful for the authors to discuss who is included in the group “other Asian women” and explain in further detail why this group could not be further disaggregated. While it is mentioned in the table footnotes and limitations section, I suggest mentioning this earlier.
• Lines 231-232 are a bit confusing to the reader. It seems like a bit of a jump that the research dispels myths while addressing stereotypes. Can you explain this in further detail about what myths and stereotypes the findings address?

• In the introduction or discussion section, the authors might consider touching on the evolving discussion on pregnancy intentions in the field. We’ve seen a lot of evolution and discussion of how to measure pregnancy intention in the last 5-10 years. Specifically, Guttmacher has been assessing intention as a non-binary measure. Please see here: https://www.guttmacher.org/article/2023/04/pregnancies-united-states-desire-pregnancy-estimates-2009-2011-2013-and-2015. It could be interesting to discuss the limitations of using a binary intention measure and how the audience might interpret their findings in this evolved context.

• The conclusion section mentions equity, person-centered care, culturally competent care, and anti-oppressive practices/programs. While there is mention/a nod to this in the discussion (lines 315-325), it would be beneficial to make a stronger link between the findings of this study and how they might inform healthcare delivery. I think describing anti-oppressive practices in the discussion (1-2 sentences) could help.

Comments on the Quality of English Language

• I've briefly noted a few necessary copy edits, but overall, the paper would benefit from a comprehensive copy editing to ensure clarity throughout the text.
• Line 47-49: Change “including” to “include”
• Lines 50-53: Remove “the” before access and add “and” before “unintended”

Author Response

Reviewer#1

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

• In Table 1 and 2, please bold or italicize the subheadings, so they are easier to identify (e.g., age, marital status, educational attainment, etc.)

Response:  Thank you for your suggestion. We italicized all subheadings of Table 1-2 as you suggested.

• In Table 2, for readability, can the ranges be the second line if possible? Can you also note the reason behind the bolded and red numbers in the footnote?

Response:  Thank you for your suggestion. We re-did the Table 1-2 for readability. The bolded and red numbers on the Table 2 was typo. We update the tables, and no numbers are bolded and colored.

• In line 46, is 38% referring to unintended or actively planned pregnancies? I assume it’s the former, but please clarify. 

Response: Thank you for your question. We revised this part as “In the U.S., 38% of births reported by women aged 15-49 years between 2017 to 2019 were unintended planned”.

• In lines 119-120, it would be helpful for the authors to discuss who is included in the group “other Asian women” and explain in further detail why this group could not be further disaggregated. While it is mentioned in the table footnotes and limitations section, I suggest mentioning this earlier. 

Response: Thank you for your suggestion. We added this part after Lines119-120 as “In our analysis, the “other Asians” category included Japanese, Asian Indian, and Pakistani individuals, combined into a single group due to limited sample sizes in these groups.”.

 

• Lines 231-232 are a bit confusing to the reader. It seems like a bit of a jump that the research dispels myths while addressing stereotypes. Can you explain this in further detail about what myths and stereotypes the findings address?

Response: Thank you for your suggestion. We added information after Lines 231-232 as “For instance, Asian cultural values promoting conservative attitudes toward sex might lead some health professionals to mistakenly assume that Asian Americans are at low risk for risky sexual behaviors. Additionally, cultural norms and misconceptions may contribute to lower rates of seeking birth control or sexual health services among Asian American women (Zhao et al., 2017).”

 

Zhao, J., Lau, M., Vermette, D., Liang, D., & Flores, G. (2017). Communication between Asian American adolescents and health care providers about sexual activity, sexually transmitted infections, and pregnancy prevention. Journal of Adolescent Research, 32(2), 205-226.

 

• In the introduction or discussion section, the authors might consider touching on the evolving discussion on pregnancy intentions in the field. We’ve seen a lot of evolution and discussion of how to measure pregnancy intention in the last 5-10 years. Specifically, Guttmacher has been assessing intention as a non-binary measure. Please see here: https://www.guttmacher.org/article/2023/04/pregnancies-united-states-desire-pregnancy-estimates-2009-2011-2013-and-2015. It could be interesting to discuss the limitations of using a binary intention measure and how the audience might interpret their findings in this evolved context.

Response: Thank you for your suggestion. We had added this part in the discussion as “Also, patients’ concerns about LARC might be influenced more by information from media, partner(s), family, or peers than by providers’ knowledge [35]. While some discussions exist about the relationships between LARC use, delayed pregnancies, personal contraceptive preferences over time; there is limited information specially regarding Asian American women (Swiatlo et al., 2023]..” on Page 14.

 

Swiatlo, A., Curtis, S., Gottfredson, N., Halpern, C., Tumlinson, K., & Lich, K. H. (2023). Contraceptive Behavior Dynamics and Unintended Pregnancy: A Latent Transition Analysis. Demography, 60(4), 1089-1113.

• The conclusion section mentions equity, person-centered care, culturally competent care, and anti-oppressive practices/programs. While there is mention/a nod to this in the discussion (lines 315-325), it would be beneficial to make a stronger link between the findings of this study and how they might inform healthcare delivery. I think describing anti-oppressive practices in the discussion (1-2 sentences) could help.

Response: Thank you for your suggestion. We added these part as “Our study found that Filipina women reported higher percentages of receiving birth control from a doctor in the past year; however, they showed lower utilization rates of IUDs. This pattern was not observed among Vietnamese women. Contraceptive method preferences varied significant across different Asian groups. It is important to implement anti-oppressive sex education and health practices, recognizing that the Asian population is not homogeneous. Understanding these diverse needs and identifying unmet family planning requirements are crucial for making informed healthcare decisions and preventing sexually transmitted infections.” after Line 318.

 

English language

• Line 47-49: Change “including” to “include”

Response: Thank you for your suggestion. It has changed in Line 47-49.

 

• Lines 50-53: Remove “the” before access and add “and” before “unintended”

Response: Thank you for your suggestion. We revised this part as “Given the prevailing political atmosphere in the U.S., where access to abortion may not be universally available, the consequences of unintended pregnancies can be even more significant for individuals and their families”.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors of the current paper use secondary data to demonstrate potential contraceptive use disparities among racial/ethnic diverse women in California, with a particular focus on Asian sub-groups. They claim that the significance of their research "lies in challenging the dispelling myths while addressing stereotypes surrounding sex and safe sex practices in Asian American women." Meanwhile, I am not convinced that their literature review sufficiently supports their above argumentation, thus the need to publish this paper. Therefore, if the authors feel that they have addressed this issue properly, they should support it properly.

1.Introduction

Your sentences in English are generally understandable, but need some corrections to be grammatically correct and clearer,

e.g., “Factors that influence unintended pregnancy rates including age, socioeconomic status, racial or ethnic minority background, and across states with differing social welfare”

I guess that you mean:

Factors that influence unintended pregnancy rates include age, socioeconomic status, racial or ethnic minority background, and differences in social welfare across states.

or,

“Despite these associations, the connections between those factors and the effectively usage on contraceptives remain unknown.”

You probably mean

Despite these associations, the connections between these factors and the effective use of contraceptives remain unknown. etc., etc.

“Despite its large size, there is a dearth of research on the attitudes and norms of contraceptive use among Asian American women, particularly within distinct racial/ethnic subgroups… Building upon the knowledge gap, this study aimed to identify the prevalence of contraceptive use and its pattern within Asian American subgroups of women.”

Authors should be persuasive about the "knowledge gap" in the current literature. A more detail literature review on the attitudes, norms towards the contraceptive use and its pattern by the Asian American and other ethnic subgroups is needed. (For example, I'm not sure I understand your sentence in the Discussion section where you say “…Future national studies should collect data from specific Asian subgroups to examine the relationships between acculturation, culture, immigration, and birth control use.”).

After exhaustively citing the sources supporting this gap, specific research questions should be formulated and appropriate working hypotheses introduced to help the reader follow the answers to the questions and the checks to be made on the hypotheses.

2. Methods

2.1. Data and Participants

“This study utilized cross-sectional data from the 2015-2016 CHIS…” is there a special reason why you chose to get information from this year's health data? In any case, clarifications are needed.

“The analyses were conducted on a weighted sample of 16,177,759 participants (raw population N= 7,630) based on public-accessed, de-identified CHIS data.”

Since you are not using your own material but referencing data collected by others, the above quote seems completely vague. Please provide the appropriate explanations with the corresponding bibliographic citations.

2.2. Measures

Additional, it is suggested that you define your independent and dependent variables, describe them under subheadings, and do scale reliability checks where applicable.

2.3. Data Analysis

Similarly, to the previous note, define your independent and dependent variables for each analysis. I wonder if the independent variables need further modification e.g. Construct dummy variables where values ​​are >2.

3. Results

The results (and the Discussion section) will be presented under subheadings that respond to the research questions and working hypotheses.

Although I am not a statistician, I believe I have the rudimentary knowledge to make some basic observations. There is too much information gathered in the tables that even the expert reader will find it difficult to read. I don't understand the necessity of the abundance of all this information in table 1. I also wonder if it would be better instead of using the enter method to run a forward LR method listing the results of only the variables that will be important. I suggest to the editors that all these analyzes and my observations be reviewed by a qualified statistician.

Comments on the Quality of English Language

The sentences in English are generally understandable, but need some corrections to be grammatically correct and clearer.

Author Response

Reviewer#2

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

 

The authors of the current paper use secondary data to demonstrate potential contraceptive use disparities among racial/ethnic diverse women in California, with a particular focus on Asian sub-groups. They claim that the significance of their research "lies in challenging the dispelling myths while addressing stereotypes surrounding sex and safe sex practices in Asian American women." Meanwhile, I am not convinced that their literature review sufficiently supports their above argumentation, thus the need to publish this paper. Therefore, if the authors feel that they have addressed this issue properly, they should support it properly.

1.Introduction

Your sentences in English are generally understandable, but need some corrections to be grammatically correct and clearer, 

e.g., “Factors that influence unintended pregnancy rates including age, socioeconomic status, racial or ethnic minority background, and across states with differing social welfare” 

I guess that you mean: 

Factors that influence unintended pregnancy rates include age, socioeconomic status, racial or ethnic minority background, and differences in social welfare across states.

or, 

“Despite these associations, the connections between those factors and the effectively usage on contraceptives remain unknown.”

You probably mean

Despite these associations, the connections between these factors and the effective use of contraceptives remain unknown. etc., etc. 

Response: Thank you for your suggestion. Both sentences have been revised as:

“Factors that influence unintended pregnancy rates include age, socioeconomic status, racial or ethnic minority background, and across states with differing social welfare”.

“Despite these associations, the connections between these factors and effectively contraceptive use remains unknown”

“Despite its large size, there is a dearth of research on the attitudes and norms of contraceptive use among Asian American women, particularly within distinct racial/ethnic subgroups… Building upon the knowledge gap, this study aimed to identify the prevalence of contraceptive use and its pattern within Asian American subgroups of women.”

Authors should be persuasive about the "knowledge gap" in the current literature. A more detail literature review on the attitudes, norms towards the contraceptive use and its pattern by the Asian American and other ethnic subgroups is needed. (For example, I'm not sure I understand your sentence in the Discussion section where you say “…Future national studies should collect data from specific Asian subgroups to examine the relationships between acculturation, culture, immigration, and birth control use.”).

After exhaustively citing the sources supporting this gap, specific research questions should be formulated and appropriate working hypotheses introduced to help the reader follow the answers to the questions and the checks to be made on the hypotheses.

Response: Thank you for your suggestion. For the research question being exploring the prevalence and patterns of contraceptive use among Asian American subgroups of women, we realized the way we were wording about the research gap has been too forward. We planed to first investigate descriptive data then move on to potential more in-depth inquiry about attitudes and norms using qualitative methods in future studies. Hence, we had revised the wording to better reflect what we could do at the moment and added to investigate norms and attitudes in future studies in the Discussion section. This way, the Introduction and research question will be more aligned with each other.

 

2. Methods

2.1. Data and Participants

“This study utilized cross-sectional data from the 2015-2016 CHIS…” is there a special reason why you chose to get information from this year's health data? In any case, clarifications are needed.

Response: Thank you for your suggestion. The 2015-20216 CHIS included question items that the authors were interested in exploring (written on Page. 6 “The utilization of the 2015-2016 CHIS data was driven by the data availability on Asian American subgroups and contraceptive methods”). Also, the recent CHIS data on family planning and birth control method section were collected from females aged 18-49 years, whereas the 2015-2016 data were limited to females aged 18-44 years. Thus, the data could not be aggregated across survey years.

“The analyses were conducted on a weighted sample of 16,177,759 participants (raw population N= 7,630) based on public-accessed, de-identified CHIS data.” 

Since you are not using your own material but referencing data collected by others, the above quote seems completely vague. Please provide the appropriate explanations with the corresponding bibliographic citations.

Response: Thank you for your suggestion. This number 16,177,759 was derived from survey design (adjusted for survey weight), based on a raw sample size of 7,630. Such method was cited in the Data Analysis section with bibliographic citation [18].

2.2. Measures

Additional, it is suggested that you define your independent and dependent variables, describe them under subheadings, and do scale reliability checks where applicable.

Response: Thank you for your suggestion. We re-structured the part of measures section on Page. 7. No scale reliability checks since we did not use any validated measures. 

 

2.3. Data Analysis

Similarly, to the previous note, define your independent and dependent variables for each analysis. I wonder if the independent variables need further modification e.g. Construct dummy variables where values ​​are >2.

Response: Thank you for your suggestion. Since we had defined the outcome variables in the measures section. In addition, we added an explanation as “Next, four adjusted binary logistic regression models were conducted to examine each type of contraceptive use across racial/ethnic groups in comparison to non-use” (Page. 8) and “The analyses controlled for confounding factors including age, marital status, education, health insurance coverage, employment status, poverty level, self-related health, received birth control information from the doctor’s office, received birth control prescription, and acculturation. The findings reveal that, compared to non-use, NHB (OR: 0.57; 95%CI: 0.34-0.95), Filipina (OR: 0.37; 95%CI: 0.16-0.83), Korean (OR: 0.22; 95%CI: 0.06-0.79), and Vietnamese (OR: 0.16; 95%CI: 0.04-0.59) women were less likely to use LARC compared to NHW” (Page. 10).

 

3. Results

The results (and the Discussion section) will be presented under subheadings that respond to the research questions and working hypotheses.

Response: Thank you for your suggestion. We added subheadings in the result section.

 

Although I am not a statistician, I believe I have the rudimentary knowledge to make some basic observations. There is too much information gathered in the tables that even the expert reader will find it difficult to read. I don't understand the necessity of the abundance of all this information in table 1. I also wonder if it would be better instead of using the enter method to run a forward LR method listing the results of only the variables that will be important. I suggest to the editors that all these analyzes and my observations be reviewed by a qualified statistician.

Response: Thank you for your suggestion. For Table 1, it is standard practice to include percentages along with their corresponding 95% confidence intervals to ensure accuracy and reliability of the data presented. This approach will allow us to emphasize the disparities between distinct Asian subgroups more clearly. By providing these statistical details, we can highlight the significant differences in contraceptive use across these groups, drawing attention to the unique challenges and needs within each subgroup.

The forward LR method is indeed more refined and could offer a more streamlined model by focusing on the most significant variables. However, for our current analysis, all covariates have been pre-selected based on their recognized importance to the model. Therefore, we have chosen to include them all in the analysis. We do realize in future studies, maybe employing the forward LR method could serve as a valuable sensitivity analysis to supplement the main findings for more robustness and identify additional nuances in the data.