Opportunities for action: addressing Latina sexual and reproductive health.

Latinas account for approximately one in every seven U.S. women of reproductive age. (1) Although several national organizations and numerous local groups are dedicated to improving Latino health, significant gaps exist in the breadth and depth of information available on Latina sexual and reproductive health. Analyses from national and small-scale investigations usually compare Latinas with other groups on only one or two sexual and reproductive health indicators. National surveys often include too few Latina respondents to permit rigorous analyses, and sample size constraints prevent researchers from comparing subgroups of Latinas. Moreover, existing information on Latina sexual and reproductive health has not been adequately analyzed or assembled in a way that is accessible to health professionals, policymakers and advocates. Too often, research projects solicit assistance from community-based organizations in translating materials or fielding interviews, only to later alienate them by shaping outreach messages and disseminating findings without community input.

In February 2004, The Alan Guttmacher Institute (AGI) and the Latino Issues Forum (LIF) convened a meeting of health professionals, advocates and researchers to begin a discussion on improving policymaking, research and resources for Latina sexual and reproductive health nationwide. Participants represented a range of experiences with different health care systems and populations. For many, the meeting marked their first opportunity to voice concerns and ideas with colleagues from different disciplines. The priorities they identified to strengthen sexual and reproductive health information and services for Latinas are presented here as an action plan for marshaling the evidence and funding needed to improve Latina sexual and reproductive health across the United States. While the action plan highlights Latinas' experiences with sexual and reproductive health care, it aims to call attention to the issues involved in providing quality health care to all minority groups. Other minority groups, including black, Asian American and American Indian women, face similar difficulties in accessing sexual and reproductive health care. The action plan uses a positive framework for exploring issues related to Latina health specifically and minority health in general. As one participant noted, it is important to incorporate the idea of community and its assets instead of using a perspective that designs research, policy and programs solely around deficits.

As the recommendations make clear, Latina sexual and reproductive health cannot be neatly compartmentalized under the rubric of minority health, women's empowerment, human rights, poverty alleviation or the movement for universal access to general health care. Latina sexual and reproductive health is crucial to the advancement of all these causes and requires targeted and sufficient resources; innovative strategies for collaboration; and direct, immediate attention. AGI and LIF intend the action plan to be a catalyst for an ongoing effort to mobilize new knowledge and resources.

THE CONTEXT: LATINAS AND HEALTH CARE

As the Department of Health and Human Services recognizes in its Healthy People 2010 objectives, the elimination of health disparities among different segments of the U.S. population is one of the country's most important goals. While the high rate of pregnancy and births among Latina teenagers has received a good deal of attention, a relatively scant amount of research has investigated unintended pregnancy and contraceptive use among Latinas in their adult lives. In general, research on sexually transmitted diseases (STDs) in the Latina population has been limited; however, some attention has been paid to HIV transmission, in particular.

Attempts to improve sexual and reproductive health care for Latinas must proceed from a basic understanding of the context surrounding women's lives and health care needs. Latinas are more likely than the general population to be low-income (2) and are therefore more likely to be eligible for publicly funded prenatal, family planning, abortion and STD services. Although they may be eligible for public services, low-income Latinas (and Latinos) are less likely than low-income whites or blacks to have health insurance; 43% of low-income Latinos were uninsured in 2002, in contrast with 25% of low-income whites and 26% of low-income blacks. (3) Many Latinas without insurance depend on publicly funded clinics for their sexual and reproductive health care needs. However, public funding has not kept pace with increases in the cost of contraceptive services, and these clinics have an increasingly difficult time offering uninsured women the most effective-and expensive-contraceptive methods. (4) In addition, 40% of Latinos are immigrants, (5) who may not understand their entitlement to free or low-cost services or may fear that their immigration status could be jeopardized if they seek health care.

The community leaders, service providers and research experts at the two-day meeting convened by AGI and LIF delved into these complicated issues and identified five priorities: access to information and services, adolescents, abortion, advocacy and communication, and approaches to research.

Our action plan, based on the discussion at the meeting, outlines the necessary steps to address these areas.

ACTION PLAN

Improving Access to Information and Services

Latinas are more likely than black and white women to delay health care appointments because of transportation or child care difficulties or an inability to pay for health care services. (6) Research has an important role to play in highlighting structural improvements in health care provision that can address these difficulties, such as extending clinic hours beyond the nine-to-five workday or helping women meet the cost of transportation to clinics. Investigations on this topic should draw attention to the disturbing alternatives that confront women who cannot access family planning services, such as forgoing contraceptive use, even when pregnancy is unwanted; obtaining pharmaceuticals through underground suppliers who cannot guarantee product quality; or finding that basic sexual and reproductive health services, information and referrals are unavailable at the growing number of hospital clinics operated by Catholic institutions.

Placing access issues into a cost-benefit framework is another way to strengthen the case for government support of various interventions-including contraceptive services. As the federal government considers changes to Medicaid policy, and as private insurance companies review their coverage options, researchers need to evaluate existing sexual and reproductive health services to provide a baseline for measuring the costs and benefits of different funding options. Such studies might demonstrate, for example, that by covering a wide range of contraceptive methods, insurance programs can improve contraceptive use and decrease costs by reducing unintended pregnancy.

Even if Latinas can access sexual and reproductive health services, they must contend with a lack of culturally and linguistically competent services. Only 5% of U.S. physicians (7) and 2% of nurses (8) are Latino; yet Latinos comprise almost 14% of the U.S. population. (9) Many health care providers do not speak Spanish and do not have trained, on-site interpreters; as a result, mothers must often use their children as translators. This awkward situation may compromise the quality of information women receive, the services they use and the extent to which they feel their concerns are adequately and sensitively addressed. These reasons may explain why Latinas often report being dissatisfied with their visits to sexual and reproductive health care providers. (10)

Information is needed on the role of providers in Latinas' decision-making and on perceived or real biases in how providers may talk (or perhaps not talk) to Latinas about sexual and reproductive health care and prevention issues. The dynamics between providers and Latina patients may also be shaped by the cursory nature of health care visits that take place in managed care systems or, for uninsured women, in emergency room settings. Nonetheless, investigations should explore strategies for making health care more culturally and linguistically competent by seeking input directly from Latina women and providers themselves-traditional medical providers and nontraditional providers of outreach education, such as community health promotoras, (11) who use peer education to reach underserved communities.

Although nearly half of adult Latinas (46%) have not completed high school and may therefore lack basic health education, (12) there is a shortage of community health education programs designed to improve Latinas' understanding of the health care system and help them play a more active role in their own care. Such programs are especially critical because some Latinas may not use available services as a result of concerns about the medical examination, the gender of their potential clinician or distrust of medical providers. Mass media may have an important role to play in communicating sexual and reproductive health information to women and adolescents who do not regularly visit physicians; research should explore the effectiveness of different media approaches among both English- and Spanish-speaking Latinas.

Adolescents and Young Women

Like their adult counterparts, Latina teenagers experience higher birthrates than their counterparts from other racial and ethnic groups. (13) Latinas are considerably less likely than black or white women to use a method of contraception at first intercourse. (14) Since 1990, birthrates among Latina, black and white adolescents have decreased. However, the decline in birthrates among Latina teenagers was less than half that of blacks, (15) suggesting that socioeconomic disadvantage cannot entirely account for the high rates of teenage births among Latinas. The concept of unintended pregnancy among Latina teenagers and adults requires further exploration: Latinas are more likely than white women to experience contraceptive failure, (16) yet the proportion of pregnancies they report as unintended (one-half) is similar to that reported for all U.S. women. (17)

The dominant research paradigm in mainstream investigations views adolescent childbearing as a negative outcome. However, as the experts at the AGI-LIF meeting confirmed, teenage parenting may be viewed more positively in some Latino communities-especially immigrant populations in which early marriage and childbearing are the norm. Researchers have not explored teenage pregnancy within the wider context of Latinas' lives, in terms of the cultural and familial expectations that shape the futures of Latina teenagers who become pregnant and questions related to subsequent pregnancy prevention or birthspacing. While research has documented high pregnancy rates among Latina adolescents, less attention has been paid to potential factors that explain these rates, including partnership or marital status at the time of conception, contraceptive use and failure, abortion and the extent to which young women report births as mistimed or unwanted. Without this background information, research cannot adequately address the difficult question of how to approach unplanned pregnancy in communities in which adolescent childbearing may be viewed positively and how to support teenagers who choose to give birth.

To design effective programs, the roles of partners, family and peers in shaping Latina adolescents' attitudes toward pregnancy must first be understood. Some studies have explored the role of gender and relationship dynamics in HIV transmission among Latinas. (18) However, a dearth of information exists on the roles that authoritarian family dynamics, family and relationship violence, or coercion may play in the lives of Latina teenagers who become pregnant. This may require researchers to be more fully informed about the attitudes and values elucidated by research in Mexico and other Latin American countries. It also requires exploration of decision-making related to other aspects of sexual and reproductive health--such as why some groups of Latinas use condoms to prevent pregnancy but not STDs. (19) Furthermore, research to learn whom Latinas teenagers talk with about sexual and reproductive health issues would allow clinics to better market outreach campaigns concerning STDs, help young Latinas to make informed decisions about their health care and ensure they are supported in their decisions.

Cultural strength is another factor that should be explored. Mention of the role of culture in health care is often weighted with a negative focus on barriers and difficulties. However, Latino communities with strong social networks-often, those that have close ties to their country of origin-may protect adolescents from the negative effects of poverty and have teenage birthrates lower than those of the general Latino population. (20) Latinos' strong sense of family identification and commitment to family support systems is an important factor to consider in designing health care programs for Latina youth. Adolescents whose parents talk openly with them about issues such as contraceptive use are less likely than other adolescents to engage in risky sexual behavior. (21) Although the prevailing belief is that Latino parents are unwilling to talk about this, research may reveal that this is a misperception and that educators should design programs encouraging family discussions about sexual behavior. Additional knowledge about the degree to which Latino parents and communities support in-school sex education would be critical information for policymakers, educators and advocates.

Last, and perhaps most important, research must extend its scope beyond studies of risk behaviors to explore factors that encourage positive health outcomes. Anecdotal stories in the media and from providers have described instances in which resiliency, or the ability to rise above the expectations that social circumstances normally impose, is evident in Latino communities. For example, young mothers may begin using birth control after their first pregnancy and successfully delay further pregnancies, enabling them to complete their education. Research on the determinants of such resiliency could have tremendous policy implications and may suggest ways to improve services, even in the face of poverty and limited resources. Moreover, a focus on resiliency helps to create a framework for success in underserved communities and a hopeful message for policymakers who may feel paralyzed by the scope of other problems in the community.

Abortion: Attitudes and Experiences

It is a commonly held misperception that Latinas do not exercise their right to abortion, because of the influence of Catholicism in their communities. In fact, abortion rates among Latinas are higher than those among non-Latina white women (but lower than those for black women). (22) Still, not enough is known about how these rates vary among Latinas of different generations or different countries of origin--especially given that abortion is illegal in many Latin American countries--or about the factors that influence success in preventing unplanned pregnancy, such as patterns of contraceptive use.

Research can play a vital role in destigmatizing issues such as abortion and contraceptive use by recognizing that they are normative parts of women's lives. Quantitative studies that document Latinas' support for and use of abortion services validate the efforts of advocates who are working to improve access to these services. Qualitative research that explores Latinas' attitudes and experiences with unwanted pregnancy and abortion is important in empowering Latina advocates to confront cultural taboos and address sexual and reproductive health issues. However, because these issues are complex and sensitive, the involvement of community-based organizations in information gathering, message development and outreach is critical. Community members--especially those who are interviewed or surveyed for studies--are an important audience for outreach, since they are not likely to see research as worthwhile if they are not informed of project findings.

Participatory research that involves community-based organizations will incorporate the perspectives and priorities of Latina communities and therefore make a compelling case to legislators that they must address this issue and improve reproductive health services in the communities they represent. Information on abortion rates among Latinas is also important as part of national efforts to draw attention to the disproportionate harm that federal legislation withholding funding for abortion services inflicts on Latina communities, given that Latinas are more likely than the general population to be low-income. In addition, documentation of Latinas' use of these services is important information to convey to directors of clinics that do not offer abortion services but would consider adding them in response to a demonstrated need in the community.

Advocacy and Communication

Perhaps the most urgent priority in the realm of Latina sexual and reproductive health is the need to communicate information more effectively to policymakers and program leaders. This goal shapes advocates' and researchers' calls for further investigation into the specific areas outlined in the preceding sections.

Advocates have begun to deconstruct the belief that Latino communities do not want to talk about issues of sexual and reproductive health, do not use these services, and would not vote for candidates who support sexual and reproductive health and rights. (23) Research must assess Latinas' need for and use of these services to raise the priority of Latina sexual and reproductive health on the agendas of state and federal legislators. Documenting Latina support for sexual and reproductive health services is also an important step in encouraging mainstream Latino organizations to address this issue directly. Improving the communication of information on Latina sexual and reproductive health will require a wide range of strategies on the part of researchers, advocates and funders.

First, advocacy messages should frame issues of sexual and reproductive health in ways that are appealing to other interest groups, the media and policymakers. This may require outreach strategies that balance information on abortion services with information on wanted pregnancies and prenatal care. Information on Latina sexual and reproductive health should emphasize that this area of health care encompasses issues such as fertility, childbearing and healthy pregnancies--issues that should concern the entire community, given that Latinas have a maternal mortality rate that is 1.7 times that of white women. (24) Outreach on these issues can also be strengthened by research that links sexual and reproductive health to interrelated issues--such as education, poverty, insurance, domestic violence and mental health--that affect Latinas' ability to access services.

Second, effective advocacy messages must be based on an understanding of the most urgent program and policy issues in Latina communities. Research is useful to advocates when it answers relevant questions such as whether large numbers of undocumented immigrants forgo HIV testing and treatment because of U.S. policy on deportation of HIV-positive noncitizens, or whether the incidence of HIV infection among Latina mothers could be decreased through family-centered prevention programs. Advocates also need information on emerging issues, such as the proliferation of antichoice "crisis pregnancy centers" in Latina neighborhoods. This information will help advocates develop effective outreach messages by anticipating issues that are likely to surface and develop preemptive plans to respond immediately. More information on the role of Spanish-language media in influencing public opinion on these issues could be of great use in this effort.

In creating and marketing these messages, Latina advocates and researchers can draw on the success of advocates, professionals and communication experts in other fields. This knowledge-sharing can be supported by studies and workshops on how to use credible research to develop clear, successful advocacy messages. Previous health care research, for example, has demonstrated that programs using community health workers were cost-effective in reducing asthma rates, (25) and this information helped to convince several insurance companies to invest in programs that use these workers. Latina advocates also need a mechanism or forum for distributing information to each other on their own success and "best practices" in message development. As one meeting participant noted, "We need more information on what works."

Finally, researchers can enhance the quality and impact of their work by collaborating with community-based organizations to shape the development of research studies, frame outreach messages and disseminate findings. This collaboration benefits the organizations by helping to build their expertise in advocacy and research design; researchers gain an invaluable understanding of contemporary issues affecting ever-changing communities. Forums for networking between researchers and advocates are critical to initiating and sustaining these efforts. Funders can lead the way in encouraging collaboration between researchers and advocates by building in to their requests for proposals a requirement that researchers work with community-based organizations in the design of research projects and dissemination of findings.

Research Approaches

Several key approaches must be used to address the areas for urgently needed research. These approaches are no different from what is needed to develop a solid evidence base for any other group, but they are particularly urgent for addressing gaps in research on Latinas.

* Interdisciplinary. First and foremost, a systematic review of research on different aspects of Latina sexual and reproductive health in different fields is critical to identifying areas in which the knowledge base is most lacking. A series of working papers to summarize what is currently known could provide a solid basis from which to begin this initiative. Ultimately, this effort could culminate in an online database to showcase the review and facilitate access to studies according to topic and methodology. Ideally, this would be designed in a format that could be continually updated.

* Longitudinal. The scope of research must be expanded to encompass longitudinal data that take into account Latinas' sexual and reproductive health experiences over their entire lifetime. The many uses of such research might include demonstration that investment in the sexual and reproductive health of Latina youth is cost-effective and will improve adult and maternal health outcomes.

* Diverse and multigenerational. Some research has explored variation in sexual and reproductive behaviors according to Latinas' country of origin and generation. (26) However, the reasons why subgroups differ in their sexual and reproductive health decisions have not been as well studied. Research should examine these differences according to the following measures, assessing the relative importance of each: generational status, citizenship status, acculturation, country of origin, socioeconomic status, sexual orientation and rural-urban residence. Critical to this effort will be the development of more forums in which to publish and promote high-quality research on Latina sexual and reproductive health.

* Qualitative. Quantitative research must be balanced by qualitative documentation of Latinas' sexual and reproductive health experiences. A qualitative perspective lends a more nuanced understanding to the interpretation of quantitative data and actively engages Latinas in research and discussion on sexual and reproductive health in their communities. Qualitative research also provides valuable opportunities for involving-and empowering--community-based organizations.

* Representative. In addition to developing new methods and survey tools, researchers must work to improve existing instruments for measuring Latina health care and gathering demographic information. The U.S. census, the National Survey of Family Growth, the Current Population Survey and the Youth Risk Behavior Survey may need to update the phrasing of their questions or to ask new questions that better reflect issues, behaviors and service needs specific to Latinas and other minority groups. To improve analysis of different subgroups of Latinas, it is also important to increase the number of Latina respondents.

* Participatory. Research is unlikely to be relevant to community needs or to be successfully communicated if it is developed without input from culturally competent researchers--especially when dealing with difficult research concepts such as acculturation and unintended pregnancy. This insight is invaluable in conducting affirmative research that draws on community strengths--research that is likely to be of use to program and policy leaders in the community. Participatory research guided by the input of Latina researchers and community-based organizations is also likely to carry considerable political weight, especially among local leaders. Mentoring programs that facilitate professional networking opportunities would help to increase the number of Latina researchers and the participation of community-based organizations in research. Funders and policymakers can also encourage participatory research by supporting Latina-led investigations and ensuring that Latina researchers and community-based organizations have equal roles in the development of collaborative efforts with other researchers.

The way in which knowledge on Latina sexual and reproductive health is disseminated is as important as the content of the information. The research approaches for individual studies and surveys are only one part of the answer. It is equally necessary to strengthen the communications infrastructure and the collaboration that we have described throughout this action plan to ensure that research is effectively disseminated to policymakers, advocates, program leaders and community members. Support from concerned funders is central to all of these efforts.

CONCLUSION

From 1990 to 2000, the rate of Latino population growth was more than four times that of the total U.S. populations. (27) As participants in the expert meeting confirmed, there is an urgent need to address the knowledge gaps that stand in the way of the design and implementation of effective programs and policies for Latina sexual and reproductive health. Meeting the health care needs of this population will be a major step toward achieving the Healthy People 2010 goal to eliminate health disparities among different groups of Americans. Although this is a challenging goal, it represents a tremendous opportunity to improve the health of a major U.S. minority group through best practices that can be adapted in addressing the needs of other racial and ethnic groups. The expert meeting made it clear that the springboard for these efforts must be improved collaboration between researchers and advocates. With their combined insights and expertise, the community of professionals concerned about Latinas' sexual and reproductive health needs can move forward with the goal of filling the knowledge gaps outlined in this plan for action. This collaboration will generate the evidence needed to support successful policies and programs that are informed by Latinas themselves and that are relevant to the everyday lives of Latina women and their families.

APPENDIX: MEETING PARTICIPANTS

Community leaders: Angela Acosta, Hispanas Organized for Political Equity; Karla Alvarado, Planned Parenthood of Pasadena; Adriana Andaluz, Planned Parenthood Los Angeles; Adam Arzate, Planned Parenthood of Pasadena; Yolanda Arzate, Planned Parenthood of Pasadena; Luz Chacon, Maternal and Child Health Care Access; Melinda Cordero, Planned Parenthood Los Angeles; Rocio Cordoba, California Coalition for Reproductive Freedom; Janette Robinson Flint, Black Women for Wellness; Thelma Garcia, East Los Angeles Women's Center; Gloria Giraldo, Orange County Latina Breast Cancer Task Force; Cristina Gomez-Vidal, Darin M. Camarena Health Centers; Sandra Ibarra, East Los Angeles Women's Center; Bethany Leal, California Women's Law Center; Rocio A. Leon, National Council of La Raza; Esther Arias McDowell, Los Angeles County Office of Women's Health; Jesus Maria Nunez, Organizacion en California de Lideres Campesinas; Virginia Ortega, Organizacion en California de Lideres Campesinas; Rosalinda Palacios, National Latina Health Organization; Araceli Perez, American Civil Liberties Union of Northern California; Patricia Perez, Valencia, Perez and Echeveste; Lourdes Rivera, National Health Law Program; Ana Rodriguez, Pacific Institute of Women's Health; Claudia Rodriguez, Bienestar-Hollywood; Margie Fites Seigle, California Family Health Council; Esperanza Sotelo, Organizacion en California de Lideres Campesinas; Olga Talamante, Chicana/Latina Foundation; Esperanza Torres, Breast Cancer Fund; Mily Trevino-Sauceda, Organizacion en California de Lideres Campesinas; Francine Trujillo, National Council of La Raza; Loretta Franke Valero, ACCESS; Nora Vargas, Planned Parenthood of Orange and San Bernardino Counties; Nicole Zendedel, Women and Youth Supporting Each Other.

Research experts: Marilyn Aguirre-Molina, Mailman School of Public Health, Columbia University; Claire Brindis, University of California, San Francisco (UCSF); Vignetta Charles, The William and Flora Hewlett Foundation; Anne Driscoll, UCSF Institute for Health Policy Studies; Elena Flores, School of Education, University of San Francisco; Melissa Gilliam, University of Illinois at Chicago; Cynthia Gomez, UCSF Center for AIDS Prevention Studies; Sylvia Guendelman, School of Public Health, University of California, Berkeley; Elena Gutierrez, University of Illinois at Chicago; Silvia Henriquez, National Latina Institute for Reproductive Health; Fatima Juarez, The Alan Guttmacher Institute (AGI); Kathy Kneer, Planned Parenthood Affiliates of California; Carmen Rita Nevarez, Public Health Institute; Norma Ojeda, San Diego State University; Victoria Ojeda, Harvard Medical School; Britt Rios-Ellis, California State University, Long Beach; Diana Romero, Mailman School of Public Health, Columbia University; Laura Romo, Graduate School of Education, University of California, Santa Barbara; Beatriz Solis, Cultural and Linguistic Services, L.A. Care Health Plan; Kathy Toner, The David and Lucre Packard Foundation.

Moderator: Inca Mohamed, Management Assistance Group.

Organizers: Latino Issues Forum--Luis Arteaga, Raquel Donoso, Marisol Franco; AGI--Risha Foulkes, Beth Fredrick, Jennifer J. Frost, Susheela Singh.

Acknowledgments

Preparation of this report was supported by The California Endowment and the General Service Foundation. The views expressed are those of the authors.

REFERENCES

(1.) U.S. Bureau of the Census, Census 2000 summary file 1 (SF1): 100-percent data, <http://factfinder.census.gov/servlet/DTGeoSearchBy ListServlet?ds_name=DEC_2000_SF1_U&state=dt>, accessed Dec. 13, 2004.

(2.) U.S. Bureau of the Census, Census 2000 summary file 3 (SF3): Poverty status in 1999 by sex by age (PCT49 and PCT75H), <http://factfinder. census.gov/servlet/DatasetTableListServlet?_ds_name=DEC_2000_SF3 _U&_type=table&_program=DEC&_lang=en&_ts=123602660831>, accessed Jan. 25, 2004.

(3.) Mills RJ and Bhandari S, Health insurance coverage in the United States: 2002, Current Population Reports, 2003, Series P-60, No. 223.

(4.) Dailard C, Challenges facing family planning clinics and Title X, Guttmacher Report on Public Policy, 2001, 4(2):8-11.

(5.) Ramirez RR and De la Cruz GP, The Hispanic population in the United States: March 2002, population characteristics, Current Population Reports, 2003, Series P-20, No. 545.

(6.) Kaiser Family Foundation, Racial and ethnic disparities in women's health coverage and access to care, findings from the 2001 Kaiser Women's Health Survey, Issue Brief, Menlo Park, CA: Kaiser Family Foundation, 2004.

(7.) Pasko T and Smart DR, Physician Characteristics and Distribution in the US, 2003-2004 ed., Chicago: American Medical Association, 2003.

(8.) Smedley B et al., eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Washington, DC: National Academies Press, 2003.

(9.) U.S. Bureau of the Census, Annual estimates of the population by sex, race, and Hispanic or Latino origin for the United States: April 1, 2000, to July 1, 2003 (NC-EST2003-03), 2004, <http://www.census. gov/popest/national/asrh/NC-EST2003-srh.html>, accessed Dec. 13, 2004.

(10.) Forrest JD and Frost JJ, The family planning attitudes and experiences of low-income women, Family Planning Perspectives, 1996, 28(6): 246-255 & 277.

(11.) Planned Parenthood Federation of America, A guide to promotora programs, 2004, <http://www.plannedparenthood.org/pp2/portal/files/portal /educatinnoutreach/educationprograms/programspromotoras-guide.pdf>, accessed Jan. 12, 2005.

(12.) U.S. Bureau of the Census, Census 2000 summary fire 3 (SF3): Sex by educational attainment for the population 25 years and older (P148H), <http://factfinder.census.gov/servlet/DTTable?_bm=y&-state= dt&-ds_name=DEC_2000_SF3_U&-mt_name=DEC_2000_SF3_U_P148H&-redoLog=true &-_caller=geoselect&-geo_id=01000US&geo_id=NBSP&-format=&_lang=en>, accessed Jan. 25, 2004.

(13.) Martin JA et al., Births: final data for 2002, National Vital Statistics Reports, 2003, Vol. 52, No. 29.

(14.) Abma J et al., Fertility, family planning, and women's health: new data from the 1995 National Survey of Family Growth, Vital and Health Statistics, 1997, Series 23, No. 19.

(15.) Martin JA et al., 2003, op. cit. (see reference 13).

(16.) Ranjit N et al., Contraceptive failure in the first two years of use: differences across socioeconomic subgroups, Family Planning Perspectives, 2001, 33(1): 19-27.

(17.) Henshaw SK, Unintended pregnancy in the United States, Family Planning Perspectives, 1998, 30(1):24-29 & 46.

(18.) Frost JJ, A review of the literature on Latina sexual and reproductive health, paper prepared for The Alan Guttmacher Institute-Latino Issues Forum expert meeting on addressing knowledge gaps in Latina sexual and reproductive health, Pasadena, CA, Feb. 2-3, 2004.

(19.) Sangi-Haghpeykar H, Horth F and Poindexter AN 3rd, Condom use among sterilized and nonsterilized Hispanic women, Sexually Transmitted Diseases, 2001, 28(9):546-551.

(20.) Denner J et al., The protective role of social capital and cultural norms in Latino communities: a study of adolescent births, Hispanic Journal of Behavioral Sciences, 2001, 23(1):3-21.

(21.) Miller S et al., Patterns of condom use among adolescents: the impact of mother-adolescent communication, American Journal of Public Health, 1998, 88(10):1542-1544.

(22.) Jones RK, Darroch JE and Henshaw SK, Patterns in socioeonomic characteristics of women obtaining abortions in 2000-2001, Perspectives on Sexual and Reproductive Health, 2002, 34(5):226-235.

(23.) Donoso R and Henriquez S, Our Health, Our Rights: Reproductive Justice for Latinas in California, San Francisco: Latino Issues Forum, 2003.

(24.) Ventura SJ et al., Births: final data for 1998, National Vital Statistics Report, 2000, Vol. 48, No. 3.

(25.) Jurasek G, Community-based asthma interventions work-even in the inner city, RespiratoryReviews.com, 2003, 8(8), <http://www.respiratoryreviews.com/aug03/rr_aug03_community.html>, accessed Dec. 13, 2004.

(26.) Frost JJ, 2004, op. cit. (see reference 18).

(27.) Guzman B, The Hispanic population, Census 2000 Brief, 2001, <http://www.census.gov/prod/2001pubs/c2kbr01-3.pdf>, accessed Dec. 13, 2004.

isha Foulkes is deputy director of development, Beth Fredrick is senior vice president and chief operating officer, Jennifer J. Frost is senior research associate and Susheela Singh is vice president for research, all at The Alan Guttmacher Institute, New York. Raquel Donoso is deputy director, Latino Issues Forum, San Francisco.

Author contact: [e-mail]