Applying the Background and Methodology of the Research Process to Problems in Health Care

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Document 1 of 1 Who Will Listen? Rural Teen Pregnancy Reflections Author: Weiss, Josie A ProQuest document link Abstract: Nurse practitioners, especially those who work with adolescents in rural communities, are often frustrated in their efforts to discourage teen pregnancy. Though the rates of teen pregnancy rates are higher in rural communities, barriers often inhibit open conversations about prevention. Rural high school students were asked to discuss the question, "Is teen pregnancy a problem in our community?" The participants acknowledged pregnancy and sexual activity prevalence and discussed consequences, causes, and prevention strategies. These findings could help decrease the resistance that providers often face when initiating conversations with teens and their parents about sexual issues, especially pregnancy consequences and prevention methods. Links: Check Document Availability Full text: Approximately 750,000 US teens become pregnant annually, and many do not finish high school, are single parents, and live in poverty.1,2 Teen pregnancy often results in hardships for teen mothers, their children, and communities.1,3 Nurse practitioners who provide care to adolescents, especially those in school-based clinics and rural communities, address these realities almost daily. Although NPs are well aware of evidence- based strategies to discourage early pregnancy, many parents resist discussing and promoting them to their teens. Knowing the perspectives of teens regarding pregnancy could break down barriers that inhibit prevention strategies. The purpose of this research was to analyze essays written by high school students to gain insight about the high teen-pregnancy rate in their rural community. Significance Teen pregnancies present increased infant and maternal risks of complications and hardships, often at significant cost. Adolescent mothers are less likely to graduate from high school and attend college, less likely to marry and remain in stable relationships, and more likely to live in poverty. 4,5 Teen fathers have a persistently decreased income that results in US tax revenue losses of $1.7 billion annually.6 Children often pay the greatest price for teen pregnancy. These children are more likely to be premature and/or at low birth weight, increasing their risks for hyperactivity, blindness, deafness, chronic respiratory problems, infant death, and mental retardation. 3 Rates of abuse and neglect are higher for children of teen parents, and these children are 50% more likely to repeat a grade in school, perform lower on standardized tests, and drop out of school.3 Sons of teen mothers are 13% more likely to go to prison than sons of older mothers.1 Florida ranks 6th in the nation for the highest rate of teen births,2 and rural counties have the highest rates in the state. The county where this research was conducted ranks 9th of 66 in teen births, nearly double the state rate. 7 Teen pregnancy contributes to lower educational and socioeconomic and higher poverty levels of rural counties. Compared to state rates, this county has lower average incomes ($18,375/state: $26,503), educational levels (69% high school grads/state: 85%), and higher poverty (22% below poverty level/state: 15%). 8 Social, cultural, and religious influences in many rural Southern communities often discourage public education about safe sexual practices. Appreciating the perspectives of teens could help remove some of these barriers. This research is based on the Theory of Adolescent Sexual Decision Making (TASDM) (Figure 1 ), which evolved from 2 grounded theories.9-11 According to this theory, adolescents live in risk-promoting environments. Some adolescents normalize risky sexual behaviors, say "yes" to sexual opportunities, and make high-risk choices. Other teens see beyond the immediate appeal of their risk-promoting environments, avoid exposure to risky

situations, and make low-risk choices. This research was conducted through the lens of this theory to gain insight into rural risk-promoting environments and adolescent sexual decision making. Methods Data Source and Analysis The prevalence of teen pregnancy and lack of prevention initiatives is a concern to many educators and health care providers in the rural south Florida community where this research was conducted. A timed writing exercise was given to 125 10th grade students (53 males, 72 females)--ages 15 (30 males, 42 females), 16 (16 males, 27 females), and 17 (3 males, 3 females) (4 males omitted their age)--to help them prepare for state examinations. This assignment took place during English classes with no prior intervention. The students were directed to handwrite essays during class discussing whether teen pregnancy was a problem in their community. The essays were not graded and submitted to their teacher anonymously except for gender and age. After teacher and administrative review and approval and institutional review board approval, the essays were analyzed by the researcher. The handwritten essays were transcribed, then compared and contrasted within each and among all essays, within each gender, and among both genders. Using constant comparative methods, the data were analyzed using the MAX Qualitative Data Analysis©12 software. Guided by the TASDM, data were initially color-coded to identify major themes relevant for understanding rural teen pregnancy and then coded line by line to identify categories within themes. Results Many students were fairly specific in their initial sentences, writing that teenage pregnancy was good or bad, right or wrong, followed by an explanation for this stance. Other students wrote ambivalent statements, making contradictory remarks or stating that teen pregnancy was good and bad. Some students said that teen pregnancy "just happened" or it was not her/his concern. These responses were labeled ambivalent. The numbers of these responses are displayed in Table 1 . After initial answers, most participants explained their views about teen pregnancy. Six themes emerged: prevalence, consequences, explanations, prevention suggestions, positive perspectives, and sexual activity acknowledgment. Subcategories further clarify each theme. Prevalence Many students (65.5%) supported their beliefs by discussing the significant number of pregnant teens they knew or saw in school. Females (86%) noted the prevalence of pregnant teens more than males (37.7%). Some participants centered their discussions about prevalence on the difficulties pregnant teens experienced. Even some teens who were ambivalent or supportive of teen pregnancy noted this prevalence. The majority of prevalence statements were impersonal, such as, "Everywhere I look in high school, either someone is pregnant or has had a kid." Other participants wrote about peers, sisters, or cousins who were pregnant or parenting, and one teen shared that she was a parent. The teen-pregnancy prevalence was emphasized for some by seeing infants at school, since daycare is provided as a strategy to encourage teen parents to complete high school. Consequences Many participants wrote about the consequences of teen pregnancy. Consequences to teens were noted most often, but effects on children, parents, and society were also mentioned. These consequences were the primary reasons some teens believed pregnancy was problematic. Consequences to teens Both females (34) and males (7) wrote that pregnancy could "mess up" or "ruin" teens lives. Some participants wrote about the kinds of consequences pregnant teens face. The most important consequence noted by both females (32) and males (12) was disruption of school. Many wrote that school disruption would be a barrier to getting a good job, making money, or being able to support a baby. One male explained, "Usually the parents

quit school because they have to get a job to support the baby. Then they don't graduate, so they can't get a good job." The second most prevalent consequence cited by females (13) was "compromise of future success." One female explained, "People don't realize how a baby can ruin your plans for a future." For males, the next most prevalent consequence was financial constraints, "so your friends have all this money and you're broke." Both females and males noted the likely consequence of desertion by the infant's father. One male wrote: "The girls are in the house all day being boring, while guys are still having fun and doing another girl." According to one female: "The girls that get pregnant most likely will lose the baby's father because the male is scared or is lazy and doesn't want to be tied down." Consequences noted less frequently were related to other losses, including parental rejection, social losses (social contacts, position among peers), and rejection by peers. Consequences to others Consequences to infants were noted by 16 females and 14 males. "It's not fair to the child" or a similar sentiment was expressed by many of the participants. In addition, 8 females and 4 males noted teens' lack of financial resources to provide for their children. One male wrote: "It's not fair to the baby to bring it into this world if you can't provide for it." Another participant echoed the sentiments of many adults: "A child being raised by another child is never a good thing." A few teens wrote more abstractly about social consequences. One female wrote that the high teen-pregnancy rate "makes the whole town look bad." One male noted teenage pregnancy is a "burden on the welfare system." Explanations Some participants offered explanations for the high rate. According to the males, teen pregnancy occurs because adolescents disregard the risks, are irresponsible, and are having sex. Proportionally, females wrote fewer comments about teen-pregnancy causes. Some cited irresponsibility: "I find teen pregnancy to be irresponsible, stupid, and disgusting." Both genders wrote about living in a small town with "nothing else to do." According to 1 female, "Some students feel sex is the only thing to do in this small town." Several participants were less critical, noting that sometimes pregnancy is desired or intentional. According to 1 female, "I know some girls that want babies, just so they have somebody to love them." One male wrote, "Kids are doing it on purpose." Some participants cited "accidents" as the cause, "Accidents happen, I understand that." Other explanations included lack of parental oversight, partner pressure, and "protection" (condom) failure. Prevention Suggestions Both male and female participants wrote that pregnancy prevention is needed, and many offered suggestions. Some suggestions were directed toward adults, but the majority were directed toward teens, primarily that teens should be responsible, use contraception or "protection," focus on school and future success, and wait to have sex or children. One student summed up many of the prevention comments: Schools and other parts of the community should issue condoms to teens from age 12. They should also have classes about teen pregnancy to teach kids that it is not easy to be a young parent, not having a job, not able to go to school, or not even enjoying life like you would. The suggestions directed toward adults include increased parental influence, education, and communication about sexual issues, and greater accessibility of protection (condoms, contraceptives). Some participants thought more activities in their small town would help prevent teen pregnancy. A few students provided insight into why teens do not use protection. One female wrote, "I think girls are scared to ask for birth control." According to 1 male, "Almost every student I know is sexually active, and half the time they don't use protection because you're not going to stop the intimacy for something and totally blow it off." Another male wrote, "Teens don't really care or like to use protection."

Positive Pregnancy Reflections Some teens provided more positive reflections about teen pregnancy. One female wrote, "I know I'm not ready for kids right now, but if it were to happen I wouldn't be completely upset...I don't frown upon teenage mothers. I actually kind of envy them." Several wrote that teen pregnancy might be good because it could teach teens to be more responsible. Others wrote that teen pregnancy was not a problem and gave both positive and negative reasons. Several males and females wrote that they either had no opinion or teen pregnancy was not their concern. Some females noted that pregnant or parenting teens need help, not criticism. Others noted that pregnancy itself is good, but becoming pregnant as a teen is not--timing, not the pregnancy, is problematic. Sexual Activity Acknowledged Even though not requested, some participants acknowledged adolescent sexual activity. Both females and males wrote that teens are having sex, some with multiple partners. One female wrote, "Boys and girls are going to have sex regardless of the consequences." Another wrote, "I'm not a virgin myself." A male stated, "You can't stop kids from having sex. I mean that's what they think about 90% of the time." Many of these participants recommended using "protection." Explanations for adolescent sexual activity include peer or partner pressure, fear of partner loss if refused, and sex is expected in "long-term" relationships: "After a lengthy period of time, that's what you're supposed to do." Some participants disagreed with adolescent sexual activity. Ten females and one male wrote that teens should wait until they are older to have sex. One male wrote, "It's really not that hard to be celibate. I'm 16 and still a virgin. I've had plenty of chances but still resisted." Three females and 2 males wrote that sex before marriage is wrong. Discussion As indicated by these participants, and in current literature, there are many reasons for the higher teen- pregnancy rates in rural communities, some socioeconomically based. Rural adolescents are more likely to have younger, less educated parents and less likely to have health insurance. They are more likely to live in mother-only families and in poverty, especially in the rural South. 13,14 As suggested by some participants and other researchers, limited activities and decreased parental monitoring may contribute to increased risky behaviors.15 In rural communities or "small towns with nothing to do," where everyone "knows each other," some parents may feel a false sense of security and less need to monitor their children. Even if rural teens believe that becoming pregnant is wrong or has negative consequences, without education about pregnancy prevention or financial support to become involved in afterschool activities, or health insurance to obtain birth control, pregnancy may be more likely. NPs, especially those who work in these environments, must be creative in helping teens and parents overcome these barriers. While 68% of the participants believed teen pregnancy is bad or wrong, more than 32% believed teen pregnancy is good or OK or were ambivalent. As indicated in the TASDM and identified by other researchers, positive or ambivalent teen pregnancy attitudes promote risk taking. 16,17 This ambivalence was not explained but could be related to living in environments where many adults were teen parents and did not complete high school or education beyond high school. The most important consequence noted by these participants was the disruption of school but without parental examples of educational success, pregnancy might seem equally desirable. As health promotion experts, nurse practitioners (NPs) could enquire about future plans and promote success in the context of their usual teen-pregnancy prevention strategies. Nearly 66% of participants commented about the prevalence of pregnancy among their peers. Without being asked, many also noted that teens are sexually active. This, too, could contribute to high teen-pregnancy rates since sexually active adolescents influence non-sexually active peers to engage in risky behaviors. 18

Recognizing the prevalence of teen pregnancy and sexual activity could lead some teens to view pregnancy as normal or even desirable.10 Limited activities and resources in rural communities, the high prevalence, and the

pregnancy ambivalence of some teens are identified problems that NPs may recognize and could address with teens. Many participants noted the importance of using "protection" if engaging in sexual activity. Some desired more information about sexual matters, and researchers have shown that providing information in schools about sexually transmitted infections and pregnancy risks can decrease risky behaviors. 19 However, many rural community leaders and educators prefer abstinence-only education, which restricts this desired instruction. Abstinence is an essential component of sexuality education as postponement of sexual debut is clearly associated with decreased risky behaviors. 20 However, abstinence-only education is often ineffective in preventing teen pregnancy21 because it often results in minimal or no sexuality education. NPs, unlike other educators, have opportunities for open conversations about sexual issues and must use these opportunities as much as possible. This research indicates that many rural adolescents are very aware of teen pregnancy, understand the causes, consequences, and means of prevention, which correlates with evidence-based recommendations. However, limited activities and resources of many rural teens, combined with high teen-pregnancy prevalence (suggesting normalcy) and the ambivalence of some, may be overriding forces. These findings, which are helpful in understanding high teen pregnancy rates, resonate with many NPs and provide guidance for care strategies. Limitations These data were obtained from a timed writing exercise to help students prepare for state testing. Since this was an in-class assignment, students did not have the opportunity to opt out of the exercise. The pressure of a writing assignment to prepare for state testing and being asked to write about a "problem" could have biased the participants to write negatively about teen pregnancy. However, because the essays were written anonymously, students might have shared their feelings more candidly. While the essays provide a snapshot of insight from rural high school students, individual interviews or focus groups using probing questions could have generated more comprehensive qualitative information. While data were collected in a nontraditional manner, insightful information resulted that would have been difficult to obtain any other way in this population. While difficult to ensure in qualitative research, several measures were used to determine the validity and significance of this project. The data were analyzed separately and jointly and relevant themes identified with a research assistant. The findings were shared and clarified with other adolescents, educators, and researchers during and after data analysis to ensure significance. Conclusions These results indicate that teens have significant insight about teen pregnancy, including explanations, consequences, and prevention suggestions. The recognized prevalence of pregnant or parenting teens and ambivalence of some suggests that teen pregnancy could be seen as a rural norm. Based on the insight and recommendations of these teens, NPs could be bolder in initiating conversations about the consequences of pregnancy and need for safe sexual practices. Hearing this "cry" from the teens themselves could be persuasive to community and school leaders who prefer abstinence-only education. These findings could improve efforts to decrease rural teen pregnancy. The greatest need cited by these participants is for more sexual information, while the greatest teen-pregnancy consequence they noted is school disruption and decreased future success. NPs are on the front line in their efforts to promote safe sexual practices while parents and educators focus on school success. It's time to join forces in these efforts!

Boys (n) Boys % Girls (n) Girls % Total (N) Total %

Bad, wrong, stupid 39 73.58% 46 63.89% 85 68%

Ambivalent 13 24.52% 23 31.94% 36 28.8%

References 1 SD Hoffman, By the numbers: The public costs of teen childbearing, 2006, The National Campaign to Prevent Teen Pregnancy, Washington, DC 2 K Kost, S Henshaw, L Carlin, U.S. teenage pregnancies, births and abortions: national and state trends and trends by race and ethnicity, Accessed September 10, 2012. 3 E Terry-Humen, J Manlove, KA Moore, Playing catch-up: how children born to teen mothers fare, Accessed September 10, 2012. 4 VJ Hotz, SW McElroy, SG Sanders, Consequences of teen childbearing for mothers, SD Hoffman, RA Maynard, Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy, 2008, Urban Institute Press, Washington, DC, 51-118 5 B Wolfe, EM Rivers, Children's health and healthcare, SD Hoffman, RA Maynard, Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy, 2008, Urban Institute Press, Washington, DC, 221-247 6 MJ Brien, RJ Willis, Costs and consequences for the fathers, SD Hoffman, RA Maynard, Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy y, 2008, Urban Institute Press, Washington, DC, 119-160 7 Florida Charts, Florida Department of Health Office of Health Statistics &Assessment. 2011. Florida Birth Query System, Accessed September 10, 2012. 8 US Census Bureau, State &County QuickFacts, Accessed October 27, 2010. 9 Weiss JA. Decreasing teen pregnancy in vulnerable adolescents. Poster presentation, National Academies of Practice Forum 2011, Washington, DC, March 2011. 10 JA Weiss, ML Jampol, JA Lievano, SM Smith, JL Wurster, Normalizing risky sexual behaviors: a grounded theory study, Pediatr Nurs, Vol. 34, 2008, 163-169 11 JA Weiss, Preventing teen pregnancy by avoiding risk exposure, American J Health Studies, Vol. 25, 2010, 202-210 12 MAXQDA, VERBI Software. Consult. Sozialforschung, 2007, GmbH, Marburg Germany 13 US Department Health &Human Services, Health Resources &Services Administration, Maternal &Child Health Bureau. 2011, The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation 2007, 2007, The Department, Rockville, MD 14 C Rogers, Rural children at a glance, Accessed September 10, 2012. 15 BE Molnar, AL Roberts, A Browne, H Gardener, SL Buka, What girls need: recommendations for preventing violence among urban girls in the US, Soc Sci Med, Vol. 60, 2005, 2191-2204 16 JC Abma, GM Martinez, CE Copen, Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006-2008. National Center for Health Statistics, Vital Health Stats, Vol. 23, Iss. 30, 2010 17 C Stevens-Simon, J Sheeder, S Harter, Teen contraceptive decisions: childbearing intentions are the tip of the iceberg, Women Health, Vol. 42, 2005, 55-73 18 R Sieving, ME Eisenberg, S Pettingell, C Skay, Friends' influence on adolescents' first sexual intercourse, Perspect Sex Reproduct Health, Vol. 38, 2006, 13-19 19 D Kirby, BA Laris, L Rolleri, Sex and HIV education programs for youth: their impact and important characteristics, Accessed February 16, 2008. 20 TG Sandfort, M Orr, JS Hirsch, J Santelli, Long-term health correlates of timing of sexual debut: results from a national US study, Am J Public Health, Vol. 98, Iss. 1, 2008, 155-161

Good, right, OK 1 1.89% 3 4.16% 4 3.2%

Total 53 100% 72 100% 125 100%

21 KF Stanger-Hall, DW Hall, Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S., PLoS ONE, Vol. 6, Iss. 10, 2011, e24658 Subject: Teenage pregnancy; Teenagers; Writing; Pregnancy; Teachers; Qualitative research; Secondary schools; Secondary school students; Decision making; Mothers; Data analysis; Teenage parents; Community; Rural areas; Publication title: The Journal for Nurse Practitioners Volume: 8 Issue: 10 Pages: 804-809 Publication year: 2012 Publication date: Nov 2012 Year: 2012 Publisher: Elsevier Limited Place of publication: Philadelphia Country of publication: United States Publication subject: Medical Sciences--Nurses And Nursing ISSN: 15554155 Source type: Scholarly Journals Language of publication: English Document type: Journal Article DOI: http://dx.doi.org/10.1016/j.nurpra.2012.02.028 ProQuest document ID: 1507211795 Document URL: http://search.proquest.com/docview/1507211795?accountid=458 Copyright: Copyright Elsevier Limited Nov 2012 Last updated: 2014-03-21 Database: ProQuest Central

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  • Who Will Listen? Rural Teen Pregnancy Reflections