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Perceived Social Support of Pregnant Adolescents
Attending School-Based Pregnancy

Programs: A Pilot Study

By

Sharon E. Plutko Long

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing

1989

(C)

[51"
a).c

ABSTRACT
PERCEIVED SOCIAL SUPPORT OF PREGNANT ADOLESCENTS

ATTENDING SCHOOL-BASED PREGNANCY
PROGRAMS: A PILOT STUDY

By

Sharon E. Plutko Long

Adolescents who become pregnant may attend a supplemental school—
based pregnancy program, which allows them to stay in their regular
school, offering special classes related pregnancy and parenting, or,
transfer to an inclusive school-based pregnancy program located in a
separate facility which offers academic and pregnancy/parenting
coursework.

The purpose of this study was to compare two groups of pregnant
adolescents who attend alternative school-based adolescent pregnancy
programs (APPs) as to the perceived supportiveness provided by teachers,
counselors, social workers and nurses. This study represents a pilot to
test a new tool, the Adolescent Pregnancy Program Social Support Source
Scale (APPS4). Perception of general support, as measured by the
Inventory of Socially Supportive Behaviors, was entered as a control
variable.

Data.was collected on the perceived support from school personnel
from 10 pregnant adolescents, age 15 to 17 years old. The APPS4 appears

to be related to social support concepts and personnel classifications.

ACKNOWLEDGEMENTS

To my thesis committee for, their words of encouragement, advice and
vision to see me complete this work and my degree: Barbara Given,
Ph.D., chairperson, Patricia Peek, M.S.N., Jacqueline Wright, M.S.N.,
and Cheryl Lauber, M.S.N. To Dr. Manfred Stommel, Ph.D., for his
guidance and patience with the design of this study and statistical
analysis.

To my nursing supervisors at Children’s Hospital of Michigan, both
present and past, for their support, words of encouragement, empathy and
willingness to listen to my frustrations and successes: Mary
Renkiewicz, M.S., Director, Clinical Nursing, Joyce Penn, M.S.N,
Clinical Nurse Manager, NICU, and Mary Lou Simi-Rudner, M.S., previous
Clinical Nurse Manager, NICU.

To my special friend, Christine Newman, M.S. for her support, ideas,
and role modeling of successful completion of a graduate degree.

To my special friend and literature review partner, Kay Shaw, B.S.N.
for her time, effort, support and willingness to listen. Go for it Kay,
you can do it too!!

To my families: Charles and Carlene Long for their love and
support, and especially, the IBM word processor; to Frank and Delcy
Plutko, for my constitution to strive for success and who consistently

demonstrated that faith in the Lord will give guidance and strength.

iii

And finally, to my best friends: Jim Long, my understanding, at
times impatient but always steadfast husband, for his love, support and
help; and to Winchester, our dog, who repeatedly dragged me away from

the computer for a walk to realize the rest of the world still exists.

iv

TABLE OF CONTENTS

LIST OF TABLES.. ...... . .......................................... vii
LIST OF FIGURES .................................................. viii
Chapter Page
I. THE PROBLEM ................................................ 1
Introduction.... ....... ...... .................... . ........ 1
Purpose of the Study ...................................... 8
Statement of the Question ............ . ..... . .............. 8
motheSiSOOOOOOOOOOOO OOOOOOOOOOOOO OOOOOOOOO OOOOOOOOOOOOOO 9
Definition of Concepts ..... ... ............................ 9
Pregnant Adolescent........ ............................ 9
SOCial support. O O O O O O O O O O O O O O O 0000000000000000000000000 10
Adolescent Pregnancy Programs .......................... 12
Limitations of the Study................ ....... ...... ..... 12
Assumptions of the Study.. ....... . ....................... . l3
overViw Of the Chapters O O O O O O O O O O O O O O O O O O O 0000000 O O O O O O O O 13
II. CONCEPTUAL FRAMEWORK................. ...................... 14
Introduction....... ...... . ................. . .............. 14
Nursing Theory........... ................................. 14
Adolescent Developmental Theory .............. ..... ........ 22
Educational Theory................. ..... . ................. 28
SOCial supportO O O O O O O O O O O O O O O O O O O O O O O O O ....... O ........... 35
Integration with Nursing Theory... ........ . ............... 39
Schematic Representation of the Conceptual Model .......... 41
III. LITERATURE REVIEW ..... . .................................... 44
IntrOductionO O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O OOOOO O OOOOOOOO 44

Impact of Pregnancy on Adolescent Growth and
DevelomntO O O O O O O O O O O O O O O O O O O OOOOOOOOOOOOOOOOOOOOOOOOOO 44
Health Care Needs... ...................................... 50
Social Support................. .......................... 58
School-Based Adolescent Pregnancy Programs ................ 67
conc1usions. O O O O O OOOOO O O O O O O O O O O O O O O O O O O O O O OOOOOOOOOOOOO 71

Chapter

IV.

VO

VI.

METHODOLOGY........

OOOOOOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOO

Overview ..................................................
Variables....... ............ ..... .........................
Operational Definition of Concepts ........................
Sample............................... ............ .........
Instruments.................... ...........................
Coding and Scoring of Data... .............................
Data Collection Procedures.... ............................

Analysis P1an.....

Protection of Human Rights ................................

Summary...........

DATA PRESENTATION AND ANALYSIS .............................

Overview..........

Descriptive Findings...... ..... ....... ....................
Reliwility 0f the scaleSOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
Data Presentation of Research Questions and

HypotheSis OOOOO O O O O O O O O O O O O O O O O O O O O O O O O O OOOOOOOOOO O OOOOO
Research Question 1. ...................................
ReseRCh Guest ion 2 O O O O O O O O O O O OOOOO O O O O O O O O O O O O O O O OOOOO

HypotheSisOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

Other Research Findings ...................................
Methodological PrOblems ...................................
Summary.. .......... . .............. . .......................
SUMMARY AND IMPLICATIONS .................. . ...... . ........ .
0verview........ ...... ............. .......................

Summary and Interpretation of Findings ....................

Descriptive Findings of the Study Sample...............
Measures of Perceived Social Support..... ..............
Research Questions and Hypothesis.... ..................

Modifications of the Conceptual Modes Based on

Study Findings..........................................
Implications for Nursing Practice....... ..... . ....... .....
Implications for Nursing Education... ..... . ......... . .....
Implications for Nursing Research .........................

serOOOOOOOOOOOOO

vi

Page
72

72
73
73
75
77
80
81
85
85
86

87

87
87
93

95
97
99

99
101
105

106

106
106

106
116
118

124
130
138
141
142

APPENDICES Page

Appendix

A. Background Data Questionnaire ............................ 143
B. Adolescent Pregnancy Program Social

Support Source Scale (APPS4) .......................... 146
C. Inventory of Socially Supportive

Behaviors (ISSB)..... ......... . ....................... 149
D. Proposal to Data Collection Sites ........................ 152
E. Screening Questionnaire .................................. 155
F. Cover Letter and Consent.. ...................... . ........ 156
G. Questionnaire Cover Sheet............. ................... 158

H. Approval from University Committee on
Research Involving Human Subjects ...................... 159

BIBLIOGRAPHY..... ................................................ 160

vii

LIST OF TABLES

Table Page
1. Comparison of Data Collection Sites................. ....... 76

2. Educational Levels of Pregnant Adolescents, their Mothers
and FatherSOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 91

3. Group Mean Scores for Adolescent Pregnancy Programs
Social Support Source Scale and Inventory of Socially
Supportive Behaviors..................................... 96

4. Analysis of Covariance Controling for the Effect of
Perceived General Support on Group Means Scores for
Adolescent Pregnancy Program Social Support Source
Scale............................................. ....... 98

viii

LIST OF FIGURES

Figure Page
1. Schema of Rogers’ Conceptual Framework ..................... 16

2. Interrelationship between Rogers’ Theory of Nursing and
Dewey’s Theory of Education .............................. 41

3. Modification of Rogers’ Theory of Nursing and Dewey’s
Theory of Education related to Perceived Social
Support of the Pregnant Adolescent Attending a
School-Based Pregnancy Program.... ......... . ............. 125

ix

CHAPTER I

THE PROBLEM

Introduction

 

During the 1960’s pregnant students were dismissed from school as
soon as authorities became aware of their condition (Mercer, 1979). In
1972, a change was made to the Federal Education Amendments, Title IX,
stating teenagers who are pregnant or who have a child, regardless of
marital status, are entitled to the same education as other students
(Zelean, 1982, Mercer, 1979). School districts are encouraged to set
up alternative school programs for pregnant adolescents to help them
continue their education, support them through this stressful time and
promote the health of the mother and fetus. It is at this point in
their lives, adolescents have the most frequent contact with the school
system. Because of this, schools, and those employed by school
districts, have become a major source of support to adolescents from the
outset of their pregnancy and on to parenthood (Rogeness, Ritchey, Alex,
Zuelzer & Morris, 1981, St. Pierre & St. Pierre, 1980).

The purpose of this study is to compare two groups of pregnant
adolescents who attend alternative school-based adolescent pregnancy
programs (APP) as to the perceived supportiveness provided by teachers,

counselors, social workers and nurses to pregnant teens in these

2
programs. The pregnant adolescents either attend an inclusive APP,
which by definition are those based within the high school, or a
supplemental APP, those based in a facility outside the high school.
The results of this study will be analyzed to answer two questions: Are
select school personnel who provide services in inclusive APP perceived
by the pregnant adolescent to be more supportive as compared to the
school personnel in supplemental APP; and, knowing that the pregnant
adolescent may also receive support from her family, friends, neighbors,
etc., what impact does this perceived support received from people, in
general, have on the perception of support from her school program?
Thus, the independent variable in the study is the type of school
program, the dependent variable is the perception of social support from
her school program and the control variable is the perception of social
support in general.

Schools are playing a larger role in the health and developmental
care of pregnant adolescent. In 1982, births to adolescents accounted
for 14 percent of all births and 26 percent of all first births
(National Center for Health Statistics, 1984). Young women who become
mothers before completing high school are more likely to drop out of
school and are less likely to complete their education after delivery
(Moore & Wertheimer, 1984, Population Information Program, 1985).
Adolescent mothers have lower education levels, poor occupational
aspirations and lack of resources. Once out of the school setting, they
have lower paying jobs which provide less income (Population Information
Program, 1985) and increase their dependence on public assistance while

living in poverty (Moore & Burt, 1982, Flick, 1986). Therefore, the

3
education system in the United States has become an essential resource
to the pregnant adolescent in terms of future economic aspiration and as
a provider of health care education.

The content of the special programs developed by school districts
for pregnant adolescents varies adapting it to meet their own needs and
resources (Roosa, 1984). Many local school districts remain unclear
about what school responses are needed, expected or tolerated in
providing services to pregnant adolescents (Zellman, 1981). The Office
of Adolescent Programs (O.A.P.P.), located within the Department of
Health and Human Services, funds service projects for pregnant and
parenting teens at risk of pregnancy (Ascher, 1985). In 1980, the
O.A.P.P. conducted a review of state policies and programs which
resulted in a proposal for clearer state level policies. However, state
Boards of Education lack data, funds and intra-agency coordination to
take the lead (Zellman, 1981). This lack of direction and support from
the state has prevented comprehensive, equitable school-based pregnancy
programs for pregnant adolescents from school district to school
district.

By 1984, 72 Michigan school districts had established educational
programs for pregnant students (Michigan Department of Social Services,
1985). Money was first appropriated for alternative in—school programs
in 1969 when Michigan law P.A. 242 mandated each school district provide
educational opportunities for the pregnant student. Today, an
Inter-Agency Task Force for High Risk Children and their Families
consisting of representatives from the Michigan Departments of

Education, Public Health, Mental Health, Social Services and Management

4
and Budget work together to address the changing needs of pregnant and
parenting teens in Michigan (Epstein, 1986).

The "Comprehensive Model of Services for Pregnant, School-Age
Parents and their Families” was endorsed by the Departments of Public
Health, Mental Health, Social Services and Education in 1978 (Michigan
Department of Education, 1979). The Model states that a school district
may either provide an adolescent pregnancy program or contract with
another district operating a program for services. Funds for the
program are distributed by the Michigan Department of Education. Six
(6) categories of services are to be provided by the school district
sponsoring a program.

1. Education: Counseling, regular curricula, education for
parenthood, pre— and post-natal education, nutrition
education, health education, educational services to children
of school age parents, and home visits.

2. Health: Develop a) service contracts with the local
health department or b) utilize a combination of local
health department and qualified school program personnel.

3. Mental Health: Where the capability exists, (limited
number of areas in the state have community Infant Mental
Health Specialists), a contract between agency and school for
part-time services.

4. Social Services: Include services to individuals, group
counseling and community resource mobilization. Services can
be provided by social workers or may be provided by other
professional groups, such as educators or health personnel.

5. Child and Day Care: Arrangements shall be made for school
age parents via the school district or through a contract with
a licensed/certified day care center.

6. Other Services: School meals and home visits are
required; transportation and outreach activities to teens

not enrolled in school are optional (Michigan Department of
Education, April, 1979, p. 10-25).

5

Interpretation of these guidelines by the school districts has
resulted in creative programs designed to meet the criteria. Most of
the school programs have a comprehensive one or two hour course dealing
with increasing the pregnant adolescent’s knowledge in the areas of
sexuality, contraception, pregnancy and parenting, exploring values and
improving decision-making skills (Moore, Erickson, Wurgel, 1984). The
class includes exercises that help clarify feelings and thoughts,
explore options available and the possible consequences of various
decisions.

A school district may opt to develop one of two basic types of
adolescent pregnancy programs: an inclusive curriculum programs or
supplemental curriculum program. The "inclusive curriculum" program
offers a general education core and a range of coursework relevant to
childbearing. In this type of program the students do not attend
regular high school classes. Many of the inclusive programs are housed
at a different site, often an under utilized elementary or middle
school. The program provides basic academic courses which are required
for graduation plus courses dealing with pregnancy and preparation for
parenthood for which the teens receive academic credit (Zellman, 1982).
The student usually returns to regular classes after the delivery. Some
programs offer options for the student to continue on in the APP for a
short time after delivery or they may remain until they graduate from
high school.

The "Supplemental curriculum” program is the second type of
alternative pregnancy program which provides one to two hours of credit

for courses related to pregnancy, health and parenting. The students

6
remain in their regular classes four to five hours of the day.
Counselors adjust class schedules of the pregnant girls to encourage
attendance. The girls are responsible for work in regular classes and
receive credit for attendance in the special program. The main feature
of this program is students are allowed to remain in their high school
with their friends and teachers throughout the pregnancy (McAfee &
Geesey, 1984).

Ideally, the six areas of services listed earlier represent a
comprehensive adolescent school-based pregnancy program. The reality is
that many of the community linkages may not be in place or may be weak.
The guidelines detail the services to be provided. However, the concept
of supportiveness is not mentioned, and, thus, remains an undefined
dimension of the services provided by these programs. This research
will attempt to evaluate the presence of social support as perceived by
the pregnant adolescents in these school-based programs.

APPs are intended to provide multidisciplinary services: academic,
health information and referral and supportive services, i.e., referral
to appropriate resources and contact with other teens in the same
situation. Supportive services also means developing a safe and caring
environment. Providing an environment which allows for feedback via
contact with similar and valued peers is a form of social support
(Gottlieb, 1985). Cassel (1976) provided research on social support
which revealed the need for feedback from a primary group may be a
preventative measure to decrease susceptibility to disease. Several
authors report adolescent pregnancy programs provide this feedback from

a primary group via peer—to—peer contact (Zellman, 1982, St. Pierre &

7
St. Pierre, 1980, Sung & Rothrock, 1980, McAfee & Geesey, 1984).
However, empirical research has not been done to evaluate the perception
of social support by the pregnant adolescent who is enrolled in a
specially created school curriculum.

Social support can be a protective mechanism to help a person cope
with life’s continuous stresses and strains (Chinn, 1983). Several
theorists have reported social support is beneficial to promote health
and well-being either directly or as a moderator of the negative effects
of stress (Cobb, 1976, House, 1984, House & Kahn, 1985). The presence
of social support has the potential to positively influence health
outcomes of the pregnant adolescent and her infant, prevent repeat
pregnancy and reduce pregnancy complications.

There is lack of consensus about how social support should be
defined (Wortman, 1984). House & Kahn (1985) define three domains of
social support:

1. The the structure of a person’s social relationships, or

social network.

2. The functional content of relationships such as expression

of affect or emotional concern, material aid, or

information, and,

3. The mere existence or quantity of relationships related to

integration versus isolation. (p. 85).
Social support is most commonly used to mean the functional aspects of
social relationships (House & Kahn, 1985). For this research, this
author will utilize the functional domain of social support which, also,
includes appraisal support.

In summary, the federal and state governments have taken notice of

the multifactorial problems surrounding teenage pregnancy. The school

district’s and county’s level of concern and financial investment in the

8
care of the pregnant adolescent varies from very comprehensive programs
(including provision of education about health, meals and child care) to
limited services (requiring referral to other community resources).
Some teens do have more options and resources than others depending on
their school district. But are these programs supportive? This
research will be evaluating the presence of social support as perceived
by the pregnant adolescent who is enrolled in a school-based APP. Only
the pregnant adolescent can reveal if these programs actually do provide

social support.

m

The purpose of this study is to compare two groups of pregnant
adolescents who attend different alternative school-based APPs as to the
perceived supportiveness provided by teachers, counselors, social
workers and nurses to pregnant teenagers. Evaluation of the presence of
social support in school-based programs can assist professionals, both
health care and education, who care for and have contact with pregnant
teens to modify and enhance their individual interactions. Maximizing
social support components of inclusive and supplemental APPs may lead to

better infant outcomes, prevention of drop-out and pregnancy recidivism.

Statement of the Question
This research will attempt to measure the perceived social support
provided by personnel teaching and counseling pregnant teenagers who
attend two types of specially created school curriculums. The results

of these measures will then be analyzed to answer two questions: 1) Are

select school personnel who provide services in inclusive APP perceived

9
by the pregnant adolescent to be more supportive as compared to the
school personnel who provide services in supplemental APP; and,
2) knowing that the pregnant adolescent may also receive support from
her family, friends, neighbors, etc., what impact does this perceived
support received from people in general have on the perception of

support from her school program?

Hypothesis

The following hypothesis will be tested:

Pregnant adolescents enrolled in inclusive adolescent pregnancy
programs will perceive more social support from selected school
personnel as compared to those pregnant adolescents enrolled in the
supplemental adolescent pregnancy programs.

Definition of Concepts

The following definition of concepts utilized in the research
questions will be employed in this study.
Egggggnt Adolescent: Adolescence extends for a period of 8 to 10 years
when a person is physically and psychologically mature, ready to assume
adult responsibilities and be self sufficient because of changes in
intellect, attitude and interests (Whaley & Wong, 1983). Mean age of
menarche is at 12.9 years and ranges from 12.5 to 13.5 years (Block,
Saltzman & Block, 1981, Rallison, 1986). Most girls are biologically
and physically mature women capable of becoming pregnant within one to
two years after menarche. Adolescence is, also, a time of curiosity
about sexual relations. Lack of knowledge of sexual function and

contraception leads to experimentation and risk taking behavior which

may result in pregnancy.

10

In this study, the pregnant adolescent is defined as a female
between the ages of 14 to 16 who is equal to or greater than 24 weeks
gestation.
Social Support: For the purposes of this study, social support will be
defined as: emotional support, instrumental aid, information support and
appraisal support (House, 1984). Emotional support can be described as
the results of a relationship, with select persons, which promotes
perceived feelings of empathy, caring or concern within the pregnant
adolescent. Instrumental aid is the feeling that one could obtain goods
(for example, money or clothes) or services (for example, being driven
somewhere or child care) from select persons. Information support is the
feeling that one could obtain information or advice about a situation
from select persons. Finally, appraisal support is being able to share
personal feelings or thoughts with someone in order to receive feedback
(positive or negative) or social comparison relevant to a persons
selfeconcept.

Adolescent pregnancy programs are intended to provide academic,
pregnancy and parenting preparation courses in a caring atmosphere. It
is, also, intended, no matter the structure, for the APP to create an
environment where students can freely discuss their situations and
problems within a peer group setting (Zellman, 1982). Some adolescents
feel more comfortable attending an alternative school program developed
for teenagers who are pregnant. Others choose to remain in their own
schools throughout pregnancy with medical passes for prenatal care.

(Bongiovanni, 1983). A comprehensive program should offer emotional,

11
physical and informational resources to the adolescent while pregnant
and continuing on into parenthood.

The participants will be describing their perception of social
support provided by selected school personnel. Although the school
personnel are not a variable in this study, it is felt that the
classifications be defined. School personnel are identified school
employees hired or contracted to provide services to pregnant
adolescents enrolled in an APP. For the purposes of this research,
these personnel include:

-Teachers: persons designated by the school district to provide
education. This can include the APP program coordinator

-Counselors: persons designated by the school district or APP to
perform the role of a counselor

-Nurses: persons designated by the school district to practice as a
Registered Nurse. This can be a school nurse or a public health nurse

-Social Workers: persons designated by the school district to
provide social services, either employed by the school district or by
contract via a community agency

The control variable for this study is the pregnant adolescent’s
perception of social support from persons other than school personnel.
Perception of general social support may influence the perception of
support received from the school program. Sources of general support
may include, but are not limited to, members of her family, friends,
spouse, schoolmates, neighbors or any other person she believes has been
supportive to her at this time while she is pregnant. Eliminating the

influence of perceived general social support on the perceived support

12
from school personnel may add clarity in identifying the true
supportiveness of the school program. Without specifically identifying
the general sources of support, examples are given to help the
adolescent relate her thoughts and feelings about general support
received.
Adolescent Pregnancy Programs: An APP is a composite of learning
activities and experiences within the school setting that are directed
toward developing an environment that protects and promotes the health
of pregnant and parenting students (Michigan Department of Social
Services, 1985). Services include academic education, health education,
health services and life skill competency courses. Both inclusive and
supplemental APPs, which have been defined earlier, offer a general
education core and a range of course work relevant to child-bearing all

for credit.

Limitations of the Study

The limitations of the study are:

1. The population included only those pregnant adolescents actively
attending an adolescent pregnancy program eliminating those who may have
delivered prematurely or who may be at home on bed rest although
receiving services from the program.

2. Participation in the study is voluntary. All persons who chose
to participate and meet the criteria were allowed to do so.

3. The time of enrollment into the adolescent pregnancy program
and, thus, exposure to the program personnel and services varied and may

systematically differ between adolescent pregnancy programs.

l3
4. Because the student may have other support systems within the
school personnel, i.e. coaches, the personnel included in the study may
not represent the total support provided by the school personnel.
5. The instrument was administered in a classroom setting. This

environment may impact the responses of the participants.

Agggmptiongggf the Study

In this study, the researcher is making the following assumptions:

1. It is assumed that pregnancy and childbirth are stressful life
events.

2. It is assumed that the answers to the questions on the
instrument reflect honestly and accurately the pregnant adolescents’
perception of social support from the school program personnel.

3. It is assumed that the pregnant adolescents’ perception of
social support can be identified related to the selected school
personnel in the adolescent pregnancy programs.

4. It is assumed that the pregnant adolescent’s perception of
social support can be identified related to other persons, excluding

school personnel, in general, at this time.

Overview of the Chapters
The description of this study has been organized into six chapters.
Chapter I, included the introduction, the purpose of the study, the
statement of the question, hypothesis, conceptual definitions,
limitations and assumptions underlying this study.
In Chapter II, the conceptual framework is presented based on

Rogers’ theory of nursing practice, growth and development theory,

14

Dewey’s philosophy of education and the concepts of social support as
defined by J.S. House.

In Chapter III, the pertinent literature and research on the problem
are reviewed.

In Chapter IV, methodology and procedures of the research are
described.

In Chapter V, data are presented and analysis of the results of the
research are given and discussed.

In Chapter VI, the research findings are summarized and conclusions

and nursing implications are presented.

CHAPTER II

CONCEPTUAL FRAMEWORK

Introduction

In this research, two groups of pregnant adolescents who attend
alternative school-based pregnancy programs will be compared related to
the perceived supportiveness provided by the school personnel.
Nursing’s role in supporting these adolescents includes promoting
health, preventing illness and helping the teens continue with their
education. In this chapter, the theories of nursing, adolescent growth
and development, education and social support will be described. The
concepts and theories relevant to this study are integrated into a

conceptual scheme for this research.

Eggers’ Theory of Nursigg

Based on the systems theory framework, Rogers’ theory emphasizes
the "wholeness" of man or the human field. "Unitary Man", the main focus
of her theory, is a ”four-dimensional, negentropic energy field
identified by pattern and organization and manifesting characteristics
and behaviors that are different from those of the parts". (Rogers,
1980, p. 332). The wholeness of man and human behavior means it is
indivisible denoting unity and synergy. Synergy represents the

unpredictable behavior of the whole system (Fawcett, 1985).

14£1

15

Rogers’ theory is based on five assumptions:

1. Man is a unified whole possessing his own integrity and
manifesting characteristics that are more than and different from the
sum of its’ parts (p. 47).

2. Man and environment are continuously exchanging matter and
energy with each other (p. 59).

3. The life process evolves irreversibly and unidirectionally along
the space-time continuum (p. 59).

4. Pattern and organization identify man and reflects his unique
innovative wholeness (p. 65).

5. Man is characterized by the capacity for abstraction and
imagery, language and thought, sensation and emotion (p. 73).

A schematic diagram of Rogers’ theory is shown in Figure 1.

There are four building blocks underlying these five assumptions.
First, energy fields are identified as both animate and inanimate,
having no boundaries and which are indivisible and extend to infinity
(Falco and Lobo, 1985). Second, the energy fields are open, constantly
exchanging energy and materials between the environment (Rogers, 1970).
Third, the interchange between energy fields exhibit pattern and
organization which are observable properties of human behavior (Fawcett,

1985). The final building block, Unitary Man, exists in space and time

 

exhibiting four-dimensionality characterized by continuously fluctuating
imaginary boundaries. Patterning and organization are not fixed; man
exists in the ”relative present” (Fawcett, 1985). Unitary Man is always
in the process of ”becoming" rather than "is” at any point (Meleis,

1985).

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Describing nursing theory requires the definition of four concepts:
Man (previously defined), environment, nursing and health. Environment
is represented by: ”an irreducible, four—dimensional, negentropic
energy field, identified by pattern and manifesting characteristics
different from those of the parts and encompassing all that is other
than any given human field" (Rogers, 1980, p. 332). The environment
consists of all the patterns existing external to the individual.

Man and environment interact continuously by patterning and
repatterning. Rogers defines three principles of homeodynamics as
fundamental concepts describing man and environment interaction.
Originally, she developed the principle of complementarity to define
this interaction: ”the interaction between human and environmental
fields is continuous, mutual and simultaneous" (Rogers, 1980, p. 333).
Refining her theory to gain greater accuracy and clarity, integrality

replaced complementarity. Intergrality is the continuous mutual human

 

field and environmental field process (Rogers, 1986). This process of
man-environment interaction can be seen daily displaying unique patterns
and rhythms. In Figure 1, this can be seen as the environment forms a
repetitive pattern around each phase of growth and movement.

Helic , the second principle, describes the nature and direction of
the man-environment interaction. This interaction is creative and
innovative, manifesting increasing diversity and complexity of field
pattern characterized by non-repeating rhythmicities (Ference, 1986).
The center arrow in Figure 1 depicts movement in one direction with the

outcome of health and continued growth.

18

The third principle, resonanc , represents continuous change from
lower to higher frequency wave patterns in human and environmental
fields (Rogers, 1986). This principle describes the composition of the
human and environmental fields which both change in pattern and
organization as they interact. In Figure 1, resonancy is represented by
the increasing number of arrows to and from Unitary man who moves along
the life continuum. Rogers (1970) describes resonancy when man is in
rhythm and symmetry with the world via thought, feelings and
perceptions. Thus, the three principles of homeodynamics, integrality,
helicy, and resonancy, define the characteristics of the human and
environmental field pattern focusing on continuous change, mutuality and
diversity.

Nursing is a learned profession; a science of Unitary Man (Meleis,
1985). Conceptually, the act of nursing "is the utilization of
nursing’s body of abstract knowledge in service to man" (Rogers, 1970,
p. 121). Nursing goals focus on health promotion and the interaction
between the human and environmental energy fields (Fawcett, 1985).
"Professional nursing seeks to promote symphonic interaction between man
and environment, to strengthen the coherence and integrity of man, and
to direct and redirect patterning of human and environmental fields for
realization of maximal health potential (Rogers, 1970, p. 122).

Nursing practice is both a science and an art. The science of
nursing, according to Rogers, studies the nature and direction of human
development with the environment (Fawcett, 1985). The art of nursing is
the creative use of nursing knowledge in service to the human being.

The field of nursing is the outgrowth of concern for human health and

19
welfare. The mission of nursing is to serve people via health
prevention, promotion and maintenance, through the practice of safe
nursing care and to increase theoretical body of nursing knowledge
(Rogers, 1986). Rogers’ description of the mission of nursing is
congruent with the philosophy of primary care.

Finally, Rogers (1970) views £22119 as "an expression of the life
process" (p. 85). Health and illness, ease and disease, normal and
pathological, maximal well-being and sickness are dichotomous terms
"arbitrarily defined, culturally infused and value-laden" (Rogers, 1970,
p. 85, Fawcett, 1985). The "state of health" is very subjective and
varies from person to person and culture to culture. Health and illness
are part of a continuum involving multiple events to which man achieves
his maximal health potential (Rogers, 1970).

Rogers (1970) believes nurses assist persons to achieve their
maximum health potential. Through research on various phenomenon that
impact health, nurses are able to empirically identify relationships
between events. Discussion about the meaning and importance of health
with the client along with mutual goal setting can integrate the
subjective interpretation of health into the plan of care. It is
through development of creative nursing interventions that clients can
then be assisted in re-patterning themselves with their environment
leading to their maximal health potential.

Pregnancy, although stressful, is considered a healthy alteration
in the normal life process of a woman. Pregnant adolescents have the
added stressors of behavioral and emotional immaturity and limited

resources. They are, therefore, at a higher risk for potential

20
alterations in their health and the health of their infants (Population
Information Program, 1985).

According to Rogers’ theory, the pregnant adolescent represents
"Unitary Man" who possesses her own integrity and manifests
characteristics which are more than and different from the sum of her
parts (Rogers, 1970). Physical health, social, emotional and
psychological characteristics of the adolescent are integrated parts
impacting on the well-being of the whole person. Thus, the assessment
of the adolescent includes identification of those internal and external
factors, or events, impacting her life situation.

The environment represents those factors external to the pregnant
adolescent. The adolescent and her environment are both open systems
constantly exchanging materials and energy (Rogers, 1970). Interactions
with school teachers, counselors, social workers and nurses represent
aspects of the environment. Social support is a perceived dimension of
the environment. Each adolescent, manifesting individual personality
and maturity, will bring to this research a different perspective. The
teenager is in a unique school environment individualized specifically
because she is pregnant.

Rogers’ theory stresses the ecological relationships between man
and the environment. The environment surrounding the pregnant
adolescent includes the school system, family system and the health care
system. Assessment and evaluation of the interaction patterns between
systems and the availability of services to pregnant teens needs to be a

continuous process. Nursing needs to assess the patterns between these

2,1
systems. As the environment and needs of the adolescent change, so to
should the patterns and designs of services to deal with these needs.

Nursing research needs to be done to describe the life events
surrounding the pregnant teenager who remains within the school system.
This research includes health care provided by nurses delivering
specialized care in the school setting. Research describes the
phenomenon of interest which nurses utilize to shape future nursing
actions in response to the same or similar phenomenon. Rogers’ theory
can provide a structure for the interpretation of pregnant adolescents’
perception of supportiveness (the phenomenon of interest) received from
school personnel in adolescent pregnancy programs.

In sum, Rogers’ theory of nursing practice supports the use of
nursing process stressing assessment of life patterning related to the
client’s health. She believes nurses are creative and unique in their
ability to communicate with clients encouraging independence, decision
making, selfrcare and self‘control. Rogers’ theory offers a special way
of looking at the nurse/client interaction with the goal of promoting
healthy outcomes.

Rogers (1970) believes that "the life process evolves irreversibly
and unidirectionally along a space-time continuum”. This assumption of
her theory is applicable to research involving pregnant adolescents as
they grow and develop into adulthood and parenthood. Following is a
description of the physical, social and emotional develOpment an
adolescent experiences including the impact of pregnancy on these

processes.

22
Developaental Theory

The process of life dictates that man exists with the environment
in a four-dimensional space (height, width, depth). The process
implied, is the movement of man through time (the fourth dimension) as
he/she grows and develops (Rogers, 1970). Adolescence literally means
”to grow into maturity” and is generally regarded as psychological,
social and maturational processes initiated by pubertal changes (Whaley
& Wong, 1983). Developmental time is complimentary to Rogers’
definition of time as a continuum of past, present and future.

The development of life moves in a negentropic and unidirectional
fashion meaning movement in one direction which gains increased order,
complexity and heterogeneity (Rogers, 1970). With time, patterns occur
as man develops and increases interactions with his environment. The
pattern and organization displayed is unique to each human being.

The unidirectionality of life described in Roger’s theory
correlates with the developmental theory of the human being. This
section describes the development of the adolescent including: a) basic
physical growth, b) psychological and emotional development, and c) a
description of adolescent social development focusing on the sexual
behavior and experimentation leading to the occurrence of pregnancy.

Adolescence is a period of intense payaical changes beginning with
puberty and ending when the male and female sex organs mature. In the
female, this period occurs between 12 and 14 years of age and, in the
male, between 14 and 18 years of age (Whaley & Wong, 1983). Adolescence
extends for eight to ten years when changes in intellect, attitude and

interest signal the person is physically and psychologically mature and

23
ready to assume adult responsibilities and be self-sufficient (Whaley &
Wong, 1983). Basically, adolescence represents the male and female ages
from 10 to 20 years of age.

Various authors describe the transitional period of adolescence by
stages delineated by various age ranges which frequently overlap.
(Murray & Zentner, 1985, Adams, 1983, Whaley & Wong, 1983). The
development of the adolescent, aged 13 to 17, will be described
encompasses the age range of the sample for this research. From age 13
to 17 the female reproductive organs become functionally operative and
physical growth is completed (Murray & Zentner, 1985, Forbes, 1981).

Neinstein (1984) discusses four areas of physical growth in the
female adolescent. First, changes occur in the endocrine system,
specifically increases in the sex hormones (estrogen, progesterone,
testosterone and their derivatives), gonadotropins (luteinizing hormone
& follicle stimulating hormone) and adrenal hormones. Second, the
physical size of the adolescent increases due to growth spurts which
account for 20 to 25% of final adult height and about 503 of final adult
weight. Third, there is development of secondary sex characteristics:
pubic hair and breast development and characteristic distribution
patterns of adipose tissue and skin changes (Whaley & Wong, 1983).
Finally, the major female developmental landmark of adolescence:
menarche. Menarche occurs, on the average, at age 12.3 years, after
peak height growth has occurred. The age of menarche depends on such
factors as race, socioeconomic status, heredity, nutrition and culture

(Neinstein, 1984, Bongiovanni, 1983).

24

As the adolescent moves along the space-time continuum,
paychological tasks are achieved in preparation for adulthood. Erik
Erikson (1963) states the adolescent is in a phase of acquiring identity
while overcoming a sense of identity diffusion. Acquisition of identity
is essential for making adult decisions, such as choice of a vocation
or a marriage partner. The adolescent is concerned about her "becoming"
her own identity and questions herself, "Which way can I be?" (Maier,
1965). Rogers (1970) describes this four dimensional becoming of man in
her theory as the person moves along the space-time continuum.

Man is ”characterized by the capacity for abstraction and imagery,
language and thought, sensation and emotion" (Rogers, 1970).
Development from an infant to an adolescent occurs physically in space
and cognitively from concrete to abstract (Adams, 1983). The adolescent
is just beginning to develop and test a form of abstract thinking
requiring judgements about social and sexual responsibility. Her
ability to predict the consequences of actions involves the intuition of
looking to the future. Risking pregnancy demonstrates the adolescent
has not thought through the consequences of her sexual activity.

The assumption in Rogers’ theory related to abstract thought can
only be partially applied to the psychological development of the
adolescent. The teen may have developed various levels of abstract
thought, i.e., to perform advanced science or math. However, new
experiences with personal relationships create changes in thoughts about
which way she should act. Thoughts become entwined with new emotional
feelings, peer pressure and limited experience in decision making.

Because of these mixed emotions and experiences, even the adolescent who

25
has developed academic-related abstract thought processes can become
pregnant.

antional development, during adolescence, includes dealing with
feelings and behavior which becomes more complex with age. Previous
trust in her body and mastery of its function are suddenly shaken and
must be regained gradually by re-evaluating herself (Maier, 1965). Body
image becomes established while coping with changes in physical
appearance, accepting one’s physique and using the body effectively
(Havighurst, 1972). David Mechanic (1983) describes normal
physiological changes that increase the adolescents’ awareness of her
body include developing an identity, focusing inward and increasing
one’s sense of self-awareness.

Selfrawareness is a prerequisite to successful handling of stressful
life events (Pender, 1982). Lack of identity and self-awareness, at
this time, along with the interplay of confusing emotional swings
translates into her need to explore, experience and search for an
identity. It is patterning with the environment (specifically peer
influence) which helps the adolescent interpret new feelings and
sensations and possibly guide or give advice about her decisions
(McCubbin, Needle & Wilson, 1985).

Nurses can utilize Rogers’ theory to describe the development of
body image, self-concept and identity. Continued assessment involves
observing adolescents over time and seeing patterns of growth and
organization. The adolescent and her world are considered energy fields
which interact. It is the pattern and organization of man’s

interactions with the environment that develops his unique identity

26
(Rogers, 1970). The patterning takes place over time demonstrating a
rhythmicity between the adolescent and her world. Social development of
the adolescent, both in the family and within the peer group, will be
discussed next as she continues to interact with her environment.
Cochran and Brassard (1979) identify five areas of social development of
the child. First, is the concept of social and cognitive attachment.
Achievement of mature relationships with age-mates of both sexes are
tasks for the adolescent. Erikson (1963) states that parents have lost
their role as the essential support and value-giver being replaced by
the peer group. The adolescent becomes increasingly involved in
heterosexual relations manifested by dating activity, sexual
experimentation and intercourse (Havighurst, 1972, Neinstein, 1984).
Gaining independence from parents and other adults is the second

developmental area (Cochran and Brassard, 1979, Havighurst, 1972).
Conflicts may arise as the adolescent exhibits less interest in the
parents devoting more of her time to peers (Neinstein, 1984).
Successful transition through this phase should result in less
dependency on the family and integration into society as an adult. The
pregnant adolescent, however, experiences identity diffusion. By
experimenting with independence, she becomes pregnant which forces her
back into a dependent relationship with her own mother or family
(Buchholz & G01, 1986). Thus, the teen remains in the mother-daughter
dyadic relationship.

Self-regulation is an aspect of independence which involves making
decisions about and having control of one’s life. The need for some

control of one’s environment is critical to feelings of personal

27
competence and self-esteem (Pender, 1982). According to Rogers (1970),
man uses rational thought as a control mechanism to organize his
experiences and to make sense of them, then knowingly makes choices.
The adolescent, as she travels through life, learns how to make choices
through emotional and rational thought and through the feedback from the
results of her decisions. The adolescent actively participates in
determining her life pattern through decision making.

The third area of social development is experience with social
roles. Erikson (1963) defines this time as role experimentation versus
negative identity. Social experimentation involves "trying out ” adult-
like behavior, vocational behavior, preparing for intimacy, and being
accepted into ”the gang or clique" with its rituals and group conformity
(Maier, 1965, Adams, 1983). Identity depends on successful
experimentation with many roles.

Cochran and Brassard (1979) define child rearing attitudes and
behaviors as an area of social development. They believe these
attitudes are learned from persons in social and family networks which
may facilitate maternal competence. Pregnant adolescents need to have
role models who exhibit socially responsible behavior who, also, will
support them as a new mother. Young adolescents may not have the
ability to achieve or recognize acceptable behavior and, thus, flounders
in role and identity diffusion.

The fifth, and final, area of social development is self—concept.
The child develops a conceptualization of self through interaction with
significant others, first with parents and then by identifying with a

peer group. The adolescent has a feeling of omnipotence and immortality

28
leading to risk taking behaviors (Neinstein, 1984). Such behaviors may
lead to suicide, accidents, drug use and pregnancy. Self-concept is a
struggle as the pregnant adolescent may feel negative about her body,
fear rejection, and be over-sensitive to the opinions of others (Whaley
& Wong, 1983).

In summary, the developmental process is generally predictable,
however, the environmental influences are not. Pregnancy has altered
the adolescents’ physical, emotional and psychological development.
Changes occurring within and around her are irreversible and move in one
direction. The rate of change in life varies but remains on a time
continuum. Although human growth and development has a predictable
nature, environmental influences have impacted the adolescents’
developmental pattern.

The next section describes the school environment of the pregnant
adolescent. The APP she attends is yet another energy field which
continuously interacts with the human field. The constant give and take
across the abstract boundaries of energy fields is an important aspect
of the team’s life. It is the quality of the interactions between human

system and environment which is the focus of this research.

Educational Theory

 

Like nursing, education literature is filled with different theories
and philosophies of education (Wynne, 1963, White & Duker, 1973). Also,
like nursing, educators have difficulty defining what education is, who
are educators and what is their role. For the purposes of this
conceptual framework, the educational theory of John Dewey will be

utilized. Dewey has written vastly on his philosophy of education.

29
This section will be a selective description of continuity, experience,
democracy, methods and motivation in education according to Dewey.

Dewey’s educational philosophy has roots in the theory of growth and
development stressing continuity of physiological and environmental
experiences for the learner. Being a progressive theory, the student
should be educated according to his or her interests or needs. As a
pragmatic theory, education is based on the interaction of the
individual with the environment or experience; this interaction is
always changing (Ornstein & Levine, 1984).

According to Dewey, sound educational experience involves continuity
and interaction between the learner and what is learned. "The principle
of continuity of experience means that every experience both takes up
something from those which have gone before and modifies in some way the
quality of those which come after." (Dewey, 1938, p. 27). The quality
of education the pregnant teen has received needs to be continued or
improved to promote her advancement to the next grade or experience. It
is up to the APPs to ensure a standard of education is maintained for
students with special needs.

Dewey believes that life is a process that renews itself and then
reorganizes as interactions with the environment occur.

Continuity of life, another concept of Dewey’s theory, is the
"readaptation of the environment to the needs of living organism" to
promote experiences for learning and growth (Dewey, 1916, p.2). This is
seen by the various philosophies and standards school systems have

related to experiential activities of the students. Some systems are

30
more structured or controlling while others are more flexible and
creative.

The school culture has become more experiential to address the needs
of pregnant students. The APP becomes an environment where the students
begin to learn about present realities of pregnancy, growth and
parenting. Schools have become more responsive to these students with
special needs by creating a unique environment to assist in reorganizing
their lives.

The APPs attempt to help the pregnant adolescent deal with this
stressful situation and assist in preparing for the future. Dewey
(1938) believes the main purpose or objective of education is to
"prepare the young for future responsibilities and success in life, by
means of acquisition of the organized bodies of information and prepared
forms of skill” using a variety of teaching methods (p. 3). The APPs,
in this research, provide the students with the basic academic courses
required for graduation (math, english, history, vocational training)
stressing the need for basic intellectual skills and knowledge.

However, the programs, also, focus on meeting specific knowledge needs
of the adolescent during pregnancy and in preparation for the challenges
of parenthood.

To achieve the objective of education, Dewey (1897) defines four
methods in the educational process. First, is focusing on the child’s
own nature or activity. Potentiating activities and abilities will lead

to increased learning and growth. Second, the imagination of the child

 

should be used in the formation of proper images of the content. Images

31
make the content real and vivid enhancing the experience; thus, the
retention of content.

Third, interests in various subjects, topics or activities are the
signs and symptoms of growth. Observation of the child will lead to
understanding the stage he/she is in or progressing to. Furthermore,
interest is untapped personal power. To promote power, the teacher and
environment encourages growth and makes experiences permanent (Dewey,
1897).

Finally, Dewey (1897) stresses utilizing the emotional side of the
child to promote learning. Emotions are the result, or reflex, of
actions. Guiding actions and thoughts will lead to appropriate
emotional responses to life experience which enhances fulfillment and
growth.

Dewey’s (1897) four methods can be applied to the description of
Rogers’ (1970) Unitary Man. Unitary man possesses sensations
(interests), language (activity), thought, abstraction and imagery
(imagination) and feelings and emotions (emotions). Stimulating all
dimensions of the child will promote meaningful experiences for the
purpose of achievement and growth.

Teachers, Dewey (1938) describes, "are the agents through which
knowledge and skills are communicated and rules of conduct enforced"
(p.3). The teacher is skilled in selecting influences, or experiences,
which affect the child and assist him/her in properly responding to
these influences (Dewey, 1897). The APPs employ teachers for academic
instruction and child guidance. Social workers, counselors, and nurses

are employed, or contracted, to instruct in the areas of life sciences

32
(prenatal and child care) and life processes (decision making and self
awareness). Teachers focus on creating learning environments while
nurses work with the pregnant adolescent who is responding to social,
emotional, psychological and environmental changes.

Both the teacher and the nurse, the school and the health care
system.are environments external to the pregnant teen. The focus of the
teacher in educating the pregnant adolescent is different than the
educational role of nursing. Dewey defines educators role as creating
meaningful experiences and modifying the environment which impacts on
the person. Nursing interventions, according to Rogers, focuses on the
person who is responding and interacting with the environment. The
philosophies of education for nurses and teachers are different
but compatible providing a variety of potential experiences and learning
environments.

Dewey’s educational theory is based on the democratic ideal which is

 

characterized by two elements: mutual interests and social habit.
Recognition of antual interests of the group as a factor in social
control where many and varied points of view are shared (Dewey, 1916).
This aspect of democracy is seen in the APP as the teens gather as a
group to share problems and find support. The teacher, as a
facilitator, assists the students experience growth through
understanding of their present situation and the future implications.
The teacher selects and guides present experiences that "live fruitfully
and creatively in subsequent experience" (Noll, 1983).

Group interaction provides a form of social support via sharing

feelings of affirmation - "I’m OK", sharing advice and exchanging

33
information. Dewey (1916) states, democracy is a "mode of associated

" made

living and learning, of conjoint communicated experiences...
available to all and "for the good of all its members" (p. 101). Thus,
selected group contact within the APP attempts to provide a democratic

education ideal.

The second element of democracy, social habit, occurs as increased

 

participation in the community/group causes a change with "continuous
readjustment through meeting new situations produced by varied
intercourse" (Dewey, 1938, p. 100). This reflects the longitudinal
effects of experiences to deal with the present but, also, to form a
foundation to prepare for the future. The APP attempts to educate the
pregnant teens via experience with other peers, who are in or may have
been in the same situation, and by interactions with supportive school
faculty. Dewey (1938) succinctly states, "What the student has learned
in the way of knowledge and skill in one situation becomes an instrument
of understanding and dealing effectively with the situations that
follow." (p.42).

The structure of the APPs, including interactions with school
faculty and the presence of the programs in the high school and the
community, attempts to provide awareness of the need for a change in
social habits. Creation of legislation to promote easier access to
programs, prevent drop-out, decreased discrimination of the pregnant
student and increased awareness of teen sexuality by the community has
slowly caused a change in social habits to expand services to these

students.

34

Dewey has been called the "philosopher of growth" because of the
concepts of continuity and building on experiences. The concept of
ggagta can be a theory itself in education. J. P. Wynne (1963), in
discussing Dewey’s philosophy, states "growth is it’s own end, not
merely a means to some other ends outside the process of human
experience." (p. 188) Dewey (1916) states education is development;
that life is development and that "developing and growing is life" (p.
59). Translated into an educational perspective:

1) the education process has no end beyond itself, it is it’s own
end, and,

2) that the educational process is one of continual reorganization,
restructuring and transforming (Wynne, 1963, p.188).

In this analogy, neither Dewey nor Wynne define growth tasks or
levels. Dewey’s theory is based on what each adolescent is doing at
that time and how the educational process can enhance and create
experiences to promote growth. The emphasis is on the experiences the
pregnant adolescent encounters, interpretation of and response to the
situation and the changes or reorganization that will occur as the
result of her involvement in an APP. Thus, growth comes from within.
Dewey (1916) states, "Growth is not something done to them, it is
something they do." (p. 50)

A weakness in Dewey’s theory is the lack of measurable outcomes.
The theory individualizes education to each student. Measurement of
growth, therefore, is subjective based on the teacher’s interpretation
of the student. His theory relies on a continuous, interactive

environment between student and teacher. Some APPs are designed with

35
limited class/counseling time on pregnancy and parenthood which impacts
evaluation in the areas of emotional, psychological and behavioral
growth important in preparation for parenthood. Ideally, the theory is
appropriate for the structure of the APP which provides an environment
for experiences to prepare the pregnant adolescent for parenthood and
adulthood.

In summary, Dewey’s theory stresses growth of the teenager as the
result of life and school experiences. Growth is seen in the
adolescent’s ability to understand the experience, respond to it via
adaptation or reorganization and be able to utilize the knowledge in
future situations. Rogers’ theory 1970) echoes the same themes stating
the pregnant teen organizes experiences, makes sense of them and learns
how to make rational choices about her life; she is an active
participant.

The structure of the APP involves unique classes for the pregnant
student and contact with teachers and other support faculty, i.e. social
workers, counselors and nurses. The quality of the experience depends
on a comfortable environment and the supportiveness of the staff. In
the next section, supportiveness will be defined using the theory of

social support.

Social Support
Definitions of social support vary between researchers who emphasize
different concepts (Cobb, 1976, Kaplan, Cassel & Gore, 1977, Kahn &
Antonucci, 1980, House, 1981, Gottlieb, 1985). For this research, the
definition of social support as developed by J. S. House will be

utilized focusing on the stress buffering effect of social support.

36

J. S. House bases his philosophy of social support on stress
producing situations at work. He believes most people invest time and
importance in their work which has an impact on their health and well
being (House, 1981). The time spent at work and in corporation or
organizations "constitutes the most structured and organized aspects of
most adults lives. This can, also, be applied to the role of school in
the lives of children" (p. 8). The stress that work or school (or play)
produce has the potential to alter the health of the person.

Social support, as defined by House (1981) involves four broad types
of supportive behaviors or acts which includes giving or receiving
aaotional sapport. This means providing empathy, caring, love and
trust. Examples of emotional support include talking, airing or
ventilating general concerns; providing reassurance and/or
encouragement; listening; reflecting understanding, concern, respect,
trust or interpersonal intimacy; providing companionship, especially
during stressful situations; and providing a supportive relationship
over an extended period of time (Gottlieb, 1978).

The second category most commonly identified is instrumental support

 

(House, 1981). This includes behaviors that directly help the person in
need. Cobb (1976) describes these activities as "instrumental, active
or material” support; Hahn and Antonucci (1980) describe it as ”aid".
Instrumental support might be the simple act of loaning someone money or
by helping someone with a task or helping care for someone.

Instrumental support represents a physical action having positive

psychological impacts.

37

Inforaation support means providing a person with information that
the person can use in coping with personal and environmental problems
(House, 1981). This represents a type of very common, indirect support
people rarely identify. It is support that allows the person to help
themselves. Gottlieb (1978) defines these behaviors as ”problem-solving
behaviors": talking; providing clarification or discussion of a problem
to promote new understanding; providing suggestions, directions, orders
or cemmands about the means of problem solving or providing information
about sources of stress. Information support behaviors are not
inclusive as providing information may be perceived as a form of
emotional support or as instrumental support if information is the major
need for the person.

The last category House (1981) labels as appraisal support. This is

 

similar to informational support because it involves the transmission of
information. The distinguishing characteristic of appraisal support is
its relevance to self-evaluation. Cobb (1978) describes this as
information that one is valued or esteemed; it reaffirms one’s sense of
personal worth. This category causes the person to compare him/herself
with others, evaluate feedback received from others and then make a
judgement or decision as to whether they like/dislike,
approve/disapprove of themselves. This process is the least concrete
because of the individual variability. Social comparison may come from
a person telling another person they are "doing a good job’ or by
describing to them requirements to successfully complete a task, i.e.

requirements for a grade (House, 1981). Persons can validate feelings

38
of peers or the appropriateness of behavior through feedback which may
be painful at times, but beneficial in the long run.

Social support is a variable which facilitates coping with major
life events, stressors and adaptation to change (Cobb, 1976, Barrera,
1981). Kaplan, Cassel and Gore (1977) believe that absence of adequate
social support increases the susceptibility of the organism to various
form of disease; social support provides protective effects to buffer
the person from stress or disease.

In their research, Kaplan, Cassel and Gore (1977) suggest that
stress causes a release of chemical transmitters from the hypothalamus
which, via the anterior pituitary, causes a general protein catabolic
effect. With appropriate social stimulus, however, a second center
within the hypothalamus releases its own chemical transmitters which
moderates the stress stimulus. Thus, social support is an external
stimulus which can buffer stress impacting the pregnant adolescent.

Investigations have been undertaken to examine the positive effect
of social support in pregnancy. Nuckolls, Cassel and Kaplan (1972)
measured the rate of pregnancy complications related to perceived social
support. They reported that pregnant women exposed to high life stress
and low psychological assets, including social support, had three times
as many pregnancy related complications than women with equally high
levels of stress and high psychological assets. Brown (1986) collected
data from 313 expectant couples on stress experienced during pregnancy.
The data suggested that pregnant mothers preferred various types of
support (from family, friends and spouse), that stress is an important

force in provoking illness (reports of chronic illness by couples during

39
pregnancy) and that "support is a balancing force in mediating health"
(p. 75).

Cobb (1976) describes research done across the life cycle. He
asserts that social support is a moderator of stress associated with the
major transitions in life (e.g. growth and development phases) and
unexpected crises (e.g. pregnancy, hospitalizations, bereavement,
unemployment). Social support, therefore, is an aspect that touches all
aspects of life from infancy to adulthood and from wellness to illness.

Measuring social support involves identifying categories of specific
behaviors or feelings and then identifying the flow, or paths, of this
behavior as modifying stress. This research involves pregnant
adolescents’ subjective, or perceived, feelings of social support from
school personnel. The support, or lack thereof, is an aspect of the
environment which may not be observable to the researcher because of the
research design. It is important to stress that behavior and activities
are ultimately designed to be supportive. However, social support is
likely to be effective only to the extent to which it is perceived
(House, 1981). To be as objective as possible, questions are asked
about the level of satisfaction with or ask "how much support’ one feels

they receive.

Integration with Nursing Theory
True empirical research involves the development of social support
interventions used with random controlled case studies. The intent of
this research is to measure a quality of the interactions between the
pregnant adolescent and the school personnel. Specifics of the school

environment, teachers, counselors, social workers and nurses, can be

40
perceived as a stress or as a stress-buffering factor. This research
will be describing the perceived supportiveness of teachers, counselors,
social workers and nurses as reported by the pregnant adolescent.
Figure 2 illustrates the conceptual scheme for this research. In this
chapter, a comparison of concepts in Rogers’ theory of nursing and
Dewey’s theory of education is discussed. The comparison shown in
Figure 2 shows nursing’s role and the use of social support as a tool to
caring for pregnant adolescents.

Growth and development is the process which describes helicy and
continuity of life. The pregnant adolescent will continue to grow into
adulthood following a unique pattern, via her own nature and within her
own time frame. Nursing intervention can provide a reference for the
adolescent to help her understand the changes occurring within her body,
in the surrounding environment and to prepare for the future.

The adolescent gives to and takes from the life process. This
exchange is reflected in the principles of integrality and the
continuity of experiences. Her experience of pregnancy results in
unique psychological and physical experiences and changes in her
environment. The APP encourages and supports her to care for herself,
for the growing fetus and to plan for the future. Development of
interest in health, prenatal care, nutrition and sexuality are all
important at this time. Social support becomes a tool nurses and school
faculty can use in promoting interest in herself and the educational
process.

As the adolescent develops, thoughts and actions become more

complex. Pregnancy increases the social, emotional and physical

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42
complexity in the life of an adolescent. The principles of resonancy
and democracy reflect the pattern of life for the adolescent who is
pregnant. Life changes rapidly and the adolescent has to be flexible in
order to maintain health and life. Social support provided by the
school faculty and nursing personnel may become a resource to help her
adapt to these rapidly occurring changes.

The dashed perpendicular line in Figure 2 represents the place where
this research ends. Outcomes for pregnant adolescents include:

1) health promotion and health maintenance for the adolescent and
her fetus during pregnancy,

2) detection and treatment of potential health complications in
pregnancy a

3) continuing academic study until delivery,

4) psychological maturation to deal with present stresses and in
preparation for delivery, and finally,

5) identification of support services within the school systems for
pregnant and parenting teenagers.

All five outcomes have longitudinal implications for patterning
and repatterning as the adolescent grows into adulthood and
parenthood.

Finally, outcomes after delivery have a dual focus. First, Dewey
hopes the experiences provided in the adolescent pregnancy program will
motivate interest within the student to finish high school. A
reciprocal process needs to occur here. If the school shows true
interest in this high-risk student, it is hoped that she will maintain

interest in continuing her education. Second, Rogers hopes the

43
adolescent will continue to grow and develop as a person and an adult,
assuming responsibility for both her own health and the health of her
child. Both theories stress the process of adaptation between the
person and the environment in the handling of stress and life. Pregnant
adolescents need help and guidance from both education and nursing to

promote symmetry between man-environment interactions.

CHAPTER 3

REVIEW OF THE LITERATURE*

Introduction

 

The review of the literature will focus on four areas: first,
changes in adolescent growth and development because of the pregnancy,
second, identified health care needs of the pregnant adolescent, third,
identified social support for the pregnant adolescent, and finally,
identified social support to the pregnant adolescents attending school-
based adolescent pregnancy programs. Although this research involves
the measurement of perceived social support by pregnant teens, it is
felt that select research about the impact of pregnancy be described.
Social support is a factor that can impact the health, growth and
development and well-being of the pregnant adolescent.

lapact of Pregnancygon Adolescent
Growth and Development

Are children bearing children? Several researchers have explored
the effects of pregnancy on the potential competition between the
growth of the pregnant adolescent and her fetus. In comparing the
growth spurts of male and female adolescents, G.B. Forbes (1981) found
that females reach their maximum lean body mass (LBM, this excludes

*Written in collaboration with Kay Shaw, RN, Master’s Candidate,
Family Clinical Nurse Specialist Program, MSU

44

45
all lipid tissue and includes muscles, viscera and skeleton) by age 16.
He found that growth of body size related to gynecologic age
(chronologic age at time of last menstrual period prior to conception
minus the age at menarche) are close to their maximum by about one year
post-menarche. Thus, pregnant adolescents > 16 years of age are
practically mature related to LBM. Forbes believes the fertile teenager
is able to sustain a pregnancy both physiologically and anatomically and
is not likely to be in a growth spurt which competes with the growth of
her fetus.

Garn, La Velle, Pesick and Ridella (1984) followed 1,609 adolescents
age 13 to 19 through two successive pregnancies who, on the average,
were pregnant within two years after menarche. Using a control group of
11,464 non-pregnant teenagers, the authors show that, l) the pregnant
teenagers, especially the youngest ones, were small and remained small
throughout two pregnancies and that, 2) pregnancy weight gain decreased
with advancing age at pregnancy. A separate analysis looked at 50 girls
with the largest pregnancy weight gains revealed that "weight gains were
not associated with greater statural growth and vice versa" (Garn,
et.al., 1984, p. 33).

In conclusion, the authors found no evidence that pregnant teenagers
were in a period of rapid growth with little statural growth or
permanent weight gain attributable to the pregnancy period. This data
supports Forbes study which showed that growth was virtually complete in
females within one year of menarche. At the time of pregnancy, weight

and stature changes will not be marked by large increases or decreases.

46

Another study looked at the stature of the 650 pregnant, Peruvian
adolescents at delivery and compared them to the stature of their
parents as an estimate of completion of growth. Frischancho, Matos,
Leonard and Yaroch (1985) did an extensive statistical analysis
involving pregnancy weight gain, adolescent maturity and the role of
adolescent growth status as compared to the height of the pregnant teens
parents. In this study, 59% of the teens completed their statural
growth and delivered infants who weighed more (3.1 Kg) than those
considered not mature (2.9 Kg). This supports the previous two studies
which state if the pregnant adolescent has completed her growth, she
should not be in competetion with the growth of her fetus. However,
those teens who had not completed their growth delivered smaller infants
and, thus, may be competing for nutrients.

Naeye (1981) believes that there is competition for nutrients
between the pregnant adolescent and fetus. In a large prospective
study, the author gathered data pertaining to maternal pre—pregnancy
body weight for height and pregnancy weight gain on 13,830 mothers
between the ages of 10 and 32. He believes that pre-pregnancy weight is
an indirect reflection of nutritional stores and pregnancy weight gain
is a reflection of calorie intake during pregnancy.

Results revealed that mothers age 10 to 16 who were normal sized or
underweight before pregnancy had growth-retarded neonates in comparison
with older mothers who were normal size or underweight. Findings were
similar when this same data was stratified by gynecologic age. This was

not seen in the neonates born to young mothers who were overweight.

47
Parity had no effect on the birth weight of the infants of the mothers
who were normal or overweight.

In summary, this author found that 10 to 16 year old mothers produce
smaller infants than older women. Also, younger teens with lower
gynecologic ages (<1 to 2 years) produce smaller infants. This may
indicate that the growth needs of the young mothers are competing with
the growth needs of their fetuses for available nutrients. Obese
teenage mothers appeared to spare their infants from this same
competition.

Classic research done by Erkan, Rimer and Stine (1971) and Zlatnic
and Burmeister (1977) identified the impact of gynecological age (GA)
versus the chronological age (CA) as parameters for adolescent maturity
when compared to the incidence of low birth weight (LBW, <2,500 gm).
Erkan, Rimer and Stine (1971) showed that adolescents, age 12 to 15, who
become pregnant within two years post-menarche have twice the chance
(31.4%) of having a low birth weight infant than those adolescents who
become pregnant two years after menarche (16%, p <0.01). In the study
by Zlatnic and Burmeister (1977), there was a statistically significant
increase in low birth weight infants born to teens less than 15 years
old (12%) versus the 16 to 17 years old (7%, p (0.05).

The study by Zlatnic and Burmeister went on the describe adolescents
with GA’s of 1 and 2 have a significantly higher rate of delivery of
low-birth weight infants (13%) than those teens with GA’s of 3 to 9 (7%,
p (0.05). The authors show l3, l4 and 15 year olds with a GA > 2 had
the same percentage of low birth weight infants as 16 and 17 year olds

who become pregnant at a GA < 2. In their study, adolescents < 15 years

48
and with a GA < 2 have the highest risk of delivering a low-birth weight
infant (chi-square=3.94, p<0.05). Thus, the results from these two
studies provide support that teenagers are fertile within one year after
menarche and that lower gynecological age, no matter the chronological
age, has a greater impact on the outcome of pregnancy related to
delivering a low birth weight infant.

The multidimensional impact of social, economic and environmental
factors is also illuminated in research done by Frischancho, Matos,
Leonard and Yaroch (1985). Frischancho, et. al., do not agree that low
gynecological age is a risk factor. In their study, involving 412
Peruvian, primiparous adolescents, no statistically significant
difference in birth weight could be associated with gynecological age
differences. However, younger mothers with the same weight gains as
older mothers delivered infants who, on the average, weighted 97 to 142
gm less than those born to older women of similar nutritional status.
Results from this research suggest that the impact of GA or CA cannot be
viewed in isolation and, again, raises the questions about the
possibility of competition for nutrients.

The Frischancho, et. a1, research looks at multiple variables that
impact teen pregnancy and their outcomes. Their population, however, is
Peruvian teens, where teenage pregnancy is more of a norm. Their
results may not be generalizable due to the socially acceptable status
of teen pregnancy and the difference in economic and social variables of
the Peruvian lifestyle.

In summary, teens who have a gynecological age of >2 and who are >

15 years old appear to be physically mature and capable of delivering a

49

normal size infant. Nutrition status of the adolescent, as measured by
the mothers pre-pregnancy weight, pregnancy weight gain, height and the
infant’s birth weight has become an important variable identified in the
more recent literature. The multidimensional characteristic of
nutrition status shows that pregnant adolescents who have gained weight
appropriately, have a better chance of delivering a larger baby.

Research in the area of adolescent pregnancy demonstrates weaknesses
and strengths in methodology and theory. Weaknesses identified include
minimal theoretical frameworks and no hypothesis testing (Baizerman,
Sheehan, Ellison & Schlesinger, 1974, Mercer, 1985). Utilizing more
variables with larger populations shows many more sides to this complex
picture. However, there is lack of standard variables and standard
definitions for terms, i.e. what is low—birth-weight or poor/good
nutritional status and age groupings of the populations (Baldwin, 1981,
Mercer, 1985). The research describing the multidimensional
characteristics of teenage pregnancy and the outcomes as documented in
the literature could be improved by consistency in definitions and
basing the research on theoretical frameworks.

In this section, literature was reviewed which described several
areas of concern for the practitioner in the caring for the pregnant
teen — nutrition, gynecological age as a risk factor and monitoring of
maternal and fetal well-being. Identification of supportive activities
and interventions and evaluation of the same are important dimensions to
care for this high-risk group. In the next section, health care needs
will be described in an effort to promote healthier outcomes for

pregnant teens and their infants.

50
Health Care Needs and the Pregnant Adolescent

Health care needs of the pregnant adolescent includes assessment of
their physical, social, emotional and cognitive growth and development
prior to and during pregnancy. This section includes a select review of
literature describing health care needs of the pregnant adolescent.

Health risk behaviors of an adolescent are those activities which
may be considered "at risk” to the health and well-being of the
adolescent or be considered as social problem behaviors to a health
conscious society (McCubbin, Needle & Wilson, 1985). Adolescents
characteristically take risks as they experiment with advancing
adulthood. Risk taking behaviors such as drinking liquor, smoking
cigarettes or marijuana, taking drugs or becoming sexually active, can
impact their health and well-being. Negotiating these behaviors are
part of the the social and psychological development of the adolescent:
gaining independence, self-regulation and decision making. Becoming
pregnant is the result of taking risks that have a lasting impact on the
adolescent and her future.

Davis, Fink, Yesupria, Rajegowda and Lala (1986) identified risk
taking behaviors of 475 pregnant hispanic and black women, age 23 and
younger, and the impact of the pregnancy on changing these behaviors.

In this study, substance abuse was identified as a major health risk
behavior for pregnant adolescents. Prior to the pregnancy,
approximately 50% reported smoking cigarettes before the pregnancy and
25% used alcohol. During the pregnancy, 30% continued to smoke and 10%
continued to use alcohol. These results suggest substance abuse to be a

major concern in caring for pregnant adolescents.

51

Research done by Miller and Merritt (1979) support this concern for
the incidence of health risk behaviors in pregnant teenagers. They
identified maternal "behavioral" conditions associated with pregnancy
which include low pre-pregnancy weight for height, low pregnancy weight
gain, lack of any prenatal care, cigarette smoking, use of addicting
drugs or consuming large volumes of alcohol during pregnancy. Their
sample of 770 white, pregnant adolescents aged 13 to 19 demonstrated
more risk behaviors as compared to a control group of 20 to 34 year
olds.

Pletch (1988) identified substance abuse activities and health
activities of pregnant and nonpregnant teens in four inner city high
schools. Results of questionnaires completed by females under 19 years
old revealed that most subjects thought that the baby was put at greater
risk if its mother used a substance during pregnancy. In this study,
the pregnant and nonpregnant subjects reported similar use of most
substances. The pregnant teens appeared to be smoking more cigarettes
than nonpregnant subjects but, also, reported better health habits
related to nutrition and sleep. The non-pregnant teens exercised more
and consumed more cola and caffiene than the pregnant teens. The
authors hypothesised that the pregnant teens who stay in school may
possess qualities which may contribute to some positive health
activities.

Adolescent health risk behaviors frequently are not identified soon
enough. The adolescent who becomes pregnant finds herself in a
situation where she has to consider how these risk behaviors impact the

health of her fetus. Prenatal care and maintaining contact with health

52
care providers becomes a major support for the adolescent during her
pregnancy.

Routine, frequent prenatal care can address the health care needs of
the pregnant adolescent. How soon prenatal care is started and the
number of visits attended have shown to impact the outcome of pregnancy.
Research by Zuckerman, et. a1, (1983), Elster (1984) and Davis, et.al.
(1986) found a strong correlation between maternal age and the trimester
that prenatal care began. Davis, et.al. (1986) found the likelihood of
pregnant teens receiving prenatal care in the first trimester increased
with age. In Elster’s study, only 50% of all women 12 to 16 years old
who became pregnant began prenatal care in the first trimester. This
percentage, again, increased with age, 67% of women aged 17 to 18 up to
91% of women aged 25 to 29. Results were similar in the Zuckerman, et.
al. study, 60% for teens age 13 to 18 and 74% for females age 19 to 30.

For primiparous women, Elster (1984) found that the risk for having
a small-for-gestational (SGA) age infant was significantly related to
late prenatal care and to very young maternal age with late prenatal
care having a stronger influence. If the young adolescent began
prenatal care during the first trimester, their rates for SGA infants
(5%) was similar to those rates for older adolescents (6%) who began
prenatal care early. For multiparous mothers both prenatal care and
maternal age were significantly related to the risk of having an SGA
infant, with young maternal age exerting a stronger influence.
Zuckerman, et. a1. (1983) showed similar results in that the adolescents

delivered smaller infants than nonadolescent mothers.

53

The results of these studies suggest that the risk of having an
small-for—gestational-age (SGA) infant is increased for the young
adolescents (<15 years) and for adolescents who receive late prenatal
care. Elster’s study showed parity, also, had an influence. Young
primiparous adolescents who received early prenatal care were not at
risk for having SGA infants when compared to adults, while young
multiparous adolescents, regardless of when prenatal care began, were at
increased risk. Thus, both parity and prenatal care appear to be key
variables mediating the relationship between young maternal age and
suboptimal outcomes.

Several other comparison studies evaluating the effectiveness of
routine prenantal care versus specially designed, clinic-based, prenatal
programs have shown similar results. Pregnant teens enrolled in special
comprehensive prenatal programs had a reduced incidence of low birth
weight (LBW, (2,500 grams) and premature infants, higher hematocrits and
lower incidence of infections and difficult delivery as compared to
teens of the same age receiving routine prenatal care (Perkins,
Nakashima & Mullin, 1978, Neelson, Patterson, Mercer & May, 1983,
Scholl, Decker, Karp, Green & DeSales, 1984, Hall & Fisch, 1984).
Several of the studies used a comparison group of older women, >19 years
old. The older women consistently had the best infant outcomes of both
groups of teens (Perkins, Nakashima & Mullin, 1978, Neelson, et. al.,
1983, Scholl, et. al., 1984). Thus, it appears that pregnant teens have
improved pregnancy and infant outcomes with specially created prenatal

care programs.

54

Two interesting studies deserve mention of their results related to
evalution of special prenatal care programs for pregnant teens. First,
research by Leppert, Namerow and Barker (1986), in their work with
teenagers attending clinics in Harlem and South Bronx, New York, believe
the incidence of low birth weight infants born to these teens are
related to multi-causal factors. Their statistics show teen mothers,
age 13 to 19, enrolled in a comprehensive prenatal care program had a
15% rate of low birth weight ((2,500 grams) versus the mothers age 20 or
older (9.5%), enrolled in the same program. When separating the results
for the younger teens, the authors found that teens age 13 to 15 years
had a 22% incidence of delivering a low birth weight infants ((2500
grams) compared to 14% of the 16 to 19 year olds. In this research,
both maternal age and the number of antenatal visits were significant
predictors of gestational age and birth weight. These results suggest
that younger adolescents remain at greater risk of adverse outcomes than
older adolescent mothers even when both attend the same comprehensive
prenatal program.

Second, a special teen pregnancy program evaluated in the Neelson,
et al. (1983) research utilized nurse practitioners and nurse midwives
as primary care givers. The positive results of this study confirm
that, 1) adolescents can benefit from specialized prenatal care programs
and, 2) nurses practicing in extended roles can achieve patient outcomes
comparable to low risk populations.

Overall, it appears that younger teens, (15 years old, remain to
have poorer outcomes with or without interventions. Pregnant teens

older than 15 have improved outcomes with special prenatal programs.

55
Furthermore, the pregnant teens who receive only routine prenatal care
are at the highest risk. Further evaluation related to the qualities of
special teen prenatal programs, specifically provision of social support
and the need for programs focusing on the (15 pregnant teen, needs to be
done to identify the factors that may promote better outcomes.

Assessing the teens interests at this time of rapid change is a way
to identify pertinent prenatal care issues important to the teen which
should be included in a prenatal program. Taking this approach, Giblin,
Poland and Sacks (1986) sought to find out what information was
important for pregnant adolescents to learn during her pregnancy. The
authors assessed the health information needs of 142, predominately
black, urban, low-income pregnant adolescents (mean age 16.9 years). A
subset of this group (n=57) was used to look at the relationship of
these needs to adolescent’s self—esteem as a predictor of use of post—
partum services.

Interest areas cited most frequently by the pregnant teens for
prenatal education focused on birth, personal health and somatic
complaints. Topics such as drugs and substance abuse, physical
symptomatology and problems with school and family should be considered
for inclusion in prenatal programs for adolescents. In this study,
adolescents who attended fewer prenatal and post-partum follow up visits
scored higher on the depression scale and had lower self-esteem scores
than those with high health care utilization. The authors state that
prenatal programs need to be sensitive to the developmental limitations
of adolescents related to health information needs and counseling

methods. Programs should include ”discussions about depression, self-

56
worth and the value of seeking health care" (Giblin, Poland & Sachs,
1986, p. 172).

Research done by Dr. L Held (1981), also, looked at self-esteem of
the pregnant adolescent and at her social network. This sample of 73
women, 17 years or younger, had normal self—esteem scores similar to
other populations. Self-esteem was higher for those women attending a
day school for pregnant teenagers, and for black teens who plan to both
keep their baby and return to school. These results were compared with
responses from white teens who had the lowest self-esteem scores and
whose mothers were the most disapproving of the pregnancy. Overall, the
perspective grandmother was identified by the pregnant adolescent as the
most important person to her but the most disapproving; yet, the
adolescent turns to her the most for support.

Self-esteem in pregnant adolescents was also researched by Ralph,
Lochman and Thomas (1984) to determine if select psychosocial
characteristics indicate poorer family or personal adjustment. A
convenience sample of 19 pregnant and 20 nulliparous 15 and 16 year old
black teenage women were enrolled into this case control study. The
pregnant group was found to have less well-defined vocational goals, a
mother who is less educated and who felt greater security within the
home and with family-related roles. Significant characteristics for the
nulliparous group revealed they were less comfortable with family life,
were more interested in vocational opportunities and had mothers with
more education.

In this sample, adolescent pregnancy was not associated with a

pattern of significant psychological or familial disturbance. The

57
authors believe the pregnant adolescent is not using pregnancy as a
coping mechanism to deal with threats to her self-esteem and do not view
experiences with family, school and peers as devaluing.

In their discussion, the authors state that their convenience sample
is small and homogenous. However, the wide variation found in the
pregnant adolescents psychological and family characteristics are much
different from the ”deviant behavior” with which pregnant adolescents
have been labeled. Weakness in this study is the statistical analysis.
The authors performed a number of tests on multiple variables to the
point that the charts in the text were not correlated to the
descriptions and the reader could not follow where the figures were
derived from.

Health care needs of the pregnant adolescent can only be partially
provided within the health care setting. The authors cited previously
support the need for special prenatal programs for adolescents to
provide them with information, health care and supportive services.
Identifying social and emotional issues surrounding the pregnant
adolescent has been illuded to several times. The multidimensional
characterstic of adolescent pregnancy includes looking at social support
and approval from the teen’s family and friends.

The reasons why pregnant adolescents are placed in a high risk
category for adverse obstetrical and neonatal outcomes have been
described in the previous studies. Health care provided to pregnant
adolescents needs to focus on both the health of the teen and the health

of her growing fetus.

58
The pregnant adolesCent often has difficulty accessing the health
care system because of her lack of resources, transportation and
guidance. She may have difficulty being able to problem solve and make
the decision of when to seek health care. The next section will address
the research done to identify sources and types of support pregnant
adolescents have available and how they impact pregnancy and infant

outcomes.

Social Support and Adolescent Pregnancy

 

The social support theory for this research is taken from J. House
who developed his philosophy based on evaluation job stress as perceived
by the worker related to identification of perceived social support from
their supervisor, their spouse, other workers at the job and relatives
or friends. His underlying belief is that social support is a resource
which can "buffer" people against the deleterious impact of potentially
stressful situations and events. "The presence or absence of social
support can modify or condition the relationship between potential
stressors and individual health and well-being" (House, 1980, p. 146).

Although most of his research has been done on adult populations,
House relates that his research is applicable to children because the
role of school is similar to the role of work, i.e., the amount of time
one spends in a structured environment or participating in organizations
or clubs. In the next few paragraphs, House’s research and philosophy
of social support will be described.

The major work by House (1980) was completed over many years dealing
with a large manufacturing plant located in a small Michigan city. All

levels of workers were sent questionnaires with an overall response rate

59
of 67.6%. Participants were asked two questions about four types of
significant people in their lives: supervisors, other people at work,
their spouse and their friends and relatives. (The author does
acknowledge that coworkers can also be friends.) The questions were:

1. ”How much can each of these people be relied on when things get
tough at work?" (Instrumental support)

2. ”How much is each of the following people willing to listen to
your work-related problems?" (Emotional and instrumental support)

A third question was asked about their immediate supervisor and
other people at work:

3. ”How much is each of the following people helpful to you in
getting your job done?" (Instrumental support)

Three additional questions were asked about supervisor support
related to the supervisor’s competence (instrumental and informational
support), concern about the workers (emotional support) and the amount
of praise they give for good work (appraisal support).

In this study, the type of work performed was very weakly related
perceived social support. Support from the supervisor has two to three
times the ability to buffer stress. Support from friends and relatives,
who probably overlap with coworkers, has weaker positive effects on
perceived job stresses. Thus, work-related sources of support are most
likely to affect perceived occupational stress.

The overall emphasis of perceived social support both at work and
non-work situations, has an impact on the ability of the individual to
perform their job and to modify stress that may arise related to work.
Workers experiencing high levels of social support are less affected by

the characteristics of their jobs. Likewise, the effect of objective

60
job characteristics on perceived stress are lessened by social support.
0n the other hand, persons who perceive low social support report
positive effects of objective characteristics of their job on their
ability to handle occupational stress.

Translating this research to the work of the pregnant adolescent,
school personnel who provide supervisory functions for the student,
whether it is related to education, health care or resource acquisition
and maintenance, can exert an impact on the adolescent’s perception of
their ability to perform school work successfully and assist them in
handling the stresses of school related to both growth and development
and the impact of pregnancy. Research related to school support will be
described later in the last section of this chapter.

In the research by House, support from supervisors made an impact to
buffer work related stress. Family and friends were, also, important in
modifying stress if their supervisors were not supportive. Friends and
family, also, are sources of support who assist the adolescent in
handling the functional tasks of school work and the normal psychosocial
pressures of adolescence. As previously stated in the research by Held
(1981), the pregnant teen considers her mother as the most important
person to her. Becerra and deAnde (1984), in their research, compared
subgroups of white non-Hispanics and Mexican American (MA) adolescents
to measure their perception of support from parents, family and friends
and attitudes about their pregnancy. Their convenience sample consisted
of 122 adolescents between the ages of 13 and 20 who were either
pregnant at the time or who had delivered a child within the previous 12

months.

61

In this study, the 80% teens identified their mother as an important
source of support. "Peers (as support) were notably absent from the
support network of the adolescent mothers in the sample." (Becerra &
DeAnde, 1984, p.113) Approximately 15% of the overall sample indicated
that they had no girlfriends with the MA teens having fewer friends than
the white teens. Cultural factors partially explain these differences
in that "friends who are not blood relatives are less likely to be
sought out" (p.113). In general, it appears that adolescent mothers are
relatively isolated from their peers during a developmental stage when
significant peer relationships are usually increasing. Therefore, the
effects of peer pressure for pregnant or parenting teens at this time is
less because of stronger involvement and dependence their families.

There was a significant difference noted in frequency of marriage
between the white and MA teens. Of the 13 to 17 year olds, none of the
white adolescents were married while almost 50% MA teens were married.
The percent of married teens increased with age in both groups. Of the
white adolescents, 70% lived with their parents. The research by Davis,
et.al. (1986), also, supports the higher rate of marriage in hispanic
teens as compared to black teens. Their data showed that the younger
the adolescent, the more likely she is to live with her parents. Becerra
and deAnde (1984) state that the traditional Mexican norm of marriage,
particularly if the female becomes pregnant, is adhered to more strongly
with the spouse/father accepting responsibility for their child.

Attitudes the teen as about the pregnancy is an indirect reflection
of her self-esteem and support she may be receiving to deal with the

stressor of pregnancy. Qualitative research by Horn (1983) described

62
the attitudes about pregnancy of American Indian, white and black
pregnant teens. The American Indian placed a high value on becoming a
mother at an early age while white and black teens valued education more
highly than early pregnancy. Hollingsworth, et.al., (1983) research
with black and white teens revealed that the teen (16 years of age
reported feelings of being "happy" or "afraid" and those >16 years of
age "mixed up" or "depressed”. The literature describing differences in
culture highlights the need to assess these beliefs as they may
influence their acceptance of the pregnancy.

In summary, these studies identified various social and cultural
influences on the pregnant adolescent. Becarra and deAnde describe the
MA adolescent in the process of becoming acculturated, thus, being
caught between two world views-the Mexican culture and the American
culture. The social support environment of these adolescents, both
white and mexican, described in this research places the adolescent’s
mother as a major influence and that peers are reported to provide less
support or influence. The teens’ attitudes about being pregnant are
generally positive, however, ambivalent feelings continue to surface.
These dynamics retard the process of the adolescent developing
independence and positive self-esteem via interactions with peers and
beginning separation from parents. White pregnant teens appear to be at
a higher developmental risk because the majority continue to live with
their parents while marriage and responsibility for the infant has a
higher cultural value for the MA teen.

The impact of adolescent pregnancy as ramifications on the

educational achievement and economic future of the teen. Health care

63
and education systems have attempted to reach out to the teen via
special clinics and programs in the community and at school. In the
remainder of this section, some of these programs and their impact
related to the providing support to the pregnant teen will be described.
Some of the studies to be described do not conceptually define social
support. Furthermore, most of the studies use pregnancy and infant
outcome variables as the evaluation mechanism to demonstrate the
presence of social support. This continues to be a weakness in the
research literature describing the impact of social support.

Heins, Nance, and Ferguson (1987) report evaluation research of a
social intervention program designed to reduce the risks associated with
adolescent pregnancy. The Resource Mothers Program provides prenatal
education and social support to rural pregnant teenagers in South
Carolina. The program employed and trained 100 lay women from the
community who made monthly home visits to the teen, daily visits during
the hospital stay and regular home visits during the infant’s first year
of life.

The study population consisted of 575 pregnant 13 to 18 year olds
93% single, 89% black and 11% white. These teens were matched with a
control population of 565 women under 19 years. Data was collected from
Vital Records and Health Statistics files in the county.

Evaluation of this program on various maternal and infants variables
showed that 36% of the controls received inadequate prenatal care as
compared with 18% of the study cases (p=.000001). The controls had a
significantly higher percentage of small-for—gestational age infants

than the study cases (p=.002). Study participants had significantly

64
fewer low birth weight infants ((2,500 grams) than the controls
(p=.006).

The results from this study suggests the effectiveness of supportive
intervention in improving prenatal care and birth weight. The authors
state they are not sure if the improved perinatal outcomes are due to
improved prenatal care only or to something special about the Resource
Mother’s supportive role. This program and study demonstrates the
potential impact of supportive behaviors provided to adolescents who are
pregnant. A limitation of this study relates to the authors fail to
define their concepts of social support related to activities of the
Resource Mother's nor do they tell if this program was a supplement to
other programs in the county, i.e., school or hospital programs already
established.

Another program was evaluated to determine the impact of an on-going
comprehensive antepartum, psychosocial education program on the medical
outcome of pregnant adolescents. Smith, et a1. (1978) looked at two
groups of low income adolescents matched for parity, month of delivery,
age and race. At 13 weeks gestation, a randomly selected experimental
group of 126 adolescents were enrolled in weekly, three hour group
classes to provide education on routine prenatal care, contraception,
child deve10pment, labor preparation and psychosocial aspects of
pregnancy. Of the experimental group, 73% attended at least five or
more classes.

Evaluation of this prenatal program showed that the experimental
group as compared to the control group attended more prenatal visits

(mean of 6.25 versus 5.13), had fewer number of admissions for false

65
labor (mean of .01 versus .41), and delivered larger infants (3105 grams
versus 2931 grams) who had higher apgars (mean 8.60 versus 8.14). Two
other significant results of this program was the reduction of urinary
tract infections and a higher return rate to the four week postpartum
examination.

The authors suggest that based on the results of this study,
prenatal educational programs can positively impact maternal and infant
outcomes in the care of the pregnant adolescent. More prenatal visits
allows for closer monitoring of the adolescent patient which will
ultimately benefit the fetus as well. Regular group participation can
provide the adolescent with a forum to learn about and discuss health
care practices which may be a motivator for better medical care
utilization. Meeting with peers who are in similar situations provides
social support to the pregnant adolescent. The concept of social
support, however, without definition and specific measurement, can only
be implied in programs like this.

Barrera & Balls (1983) conceptually defined amd measured three
social support variables of network size, satisfaction with support and
frequency of supportive behavioral transactions as predictors of birth
complications at delivery. In the prospective study, 74 pregnant teens
(mean age 17.2 years) were enrolled prenatally from either an
”alternative" school for pregnant high school students or a county
health department clinic.

In this study, both total support network size and support
satisfaction emerged as significant (p(.Ol, p(.001, respectively)

predictors of birth outcome. Support satisfaction, however, showed the

66
strongest relationship to scales of psychological adjustment and emerged
as the best predictor of birth complications. According to these
authors, support satisfaction appears to be the most relevant yardstick
for measuring the adequacy of a preventative intervention for these
adolescents.

Classic social support research completed by Nuckolls, Cassell and
Kaplan (1972) looked at the relationship between psychosocial assets and
social stresses as measured by a cumulative life change score and the
prognosis of pregnancy in 170 adult pregnant women. Psychosocial assets
were found to have a buffering effect on life stress related to multiple
life changes. Specifically, it was found that women who reported high
life stress and low levels of psychosocial assets had three times more
birth complications than those women who reported high levels of
psychosocial assets. Therefore, by strengthening the psychosocial
assets of an individual (i.e. social support), the incidence of illness
could be reduced and the quality of life would improve.

Norbeck and Tilden (1983) performed research examining anxiety,
depression and selfeesteem related to pregnancy complications in a
convenience sample of 117 low risk, adult women. A secondary goal of
this study was to examine the differential effects of these psychosocial
variables on specific types of complications.

The authors found from their results that high-life stress and low
social support were significantly related to high emotional
disequilibrium (p(.01). Only emotional support was significantly
related to emotional disequilibrium (p(.01). One psychosocial variable,

high life-stress from the prior year, was significantly related to

67

overall complications (p(.01). Data from this study provides evidence
that there are certain psychosocial variables which have an impact on
the occurance of specific infant and pregnancy complications. These
findings are consistent with the stress—buffering effect found for
”psychosocial assets" in the Nuckolls, Cassel & Kaplan (1972) study.

Research about social support related to it’s impact on pregnancy
has focused mostly on adults. Only Berrera (1981, 1983) and associates
have conceptually defined social support and measured it’s impact on the
pregnant adolescent. Several of the programs described included
activities that stronly suggest social support is a positive factor.
However, social support was not identified and measured conceptually.
Further research on the specific psychosocial qualities of special teen
programs is needed.

Research describing the sources and types of social support pregnant
teens receive from their school programs is limited. In the next
section, a description of school-based adolescent pregnancy programs

will be provided related to their role in supporting the pregnant teen.

School-Based Adolescent Pregnancy Programs

The qualitative aspect of social support provided by school—based
adolescent pregnancy programs has not been documented. As with the
evaluation of specially designed community based prenatal programs,
evaluation of school-based programs do not define and measure social
support as an outcome. The programs are evlauated by the number of
pregnant adolescents who graduate and the pregnancy recidivism rate.

For 17 years, Michigan has been involved in developing and

administering resources to address the needs of pregnant and parenting

68
teens. Three model school-age parent programs were piloted in 1979—1980
which were funded by the state. By 1983, eight model programs were in
operation. Ann S. Epstein, Ph.D. (1986), with the support from the
State Department of Education, evaluated the eight sites over a three
year period to determine how well the programs were addressing the needs
of pregnant and parenting teens related to education and health outcomes
and reduction of repeat pregnancies.

Over 2,700 students were served by the eight programs. Population
characteristics revealed more than 50% were 16 or 17 years old, black
and on Aid to Families with Dependent Children. Few were supported by
their families even though 75% continue to live with their parents.
Nearly three-quarters of the students enter the programs during
pregnancy and over 95% of the adolescents choose to keep their infants.

Educational outcomes of students attending these programs showed 82%
enter the model sites from their regular school programs, 75% are high
school students and 25% are junior high students. Of the senior level
students in the programs, nearly 66% graduate at the end of the school
year and the same percentage of younger students choose to continue
their education the following year. Most students return to their
regular schools (52%) while 43% choose to remain in the model program.

Several parameters of maternal and infant outcomes were evaluated:
43% began prenatal care in the first trimester, attendance to prenatal
visits averaged 10.9 out of a recommended 12 prenatal visits and the
infant mortality for the model site programs was 1.4% as compared to the
State wide infant mortality for teens of 2.4%. Prematurity and low

birth weight have been reduced to "half that of the state figure for

69
infants born to adolescents" (p.30). The author estimates that good
prenatal care in the model programs saved over $900,000 in medical costs
for infant intensive care over the three-year evaluation period.
Immunizations for these infants born to adolescents is at a 94% rate.

Repeat pregnancy rates among the students enrolled in the model
programs was 2.4%. Epstein (1986) states that this rate is
significantly below national figures which indicate that 33% of
all teenagers will become pregnant again before their adolescence is
over (p. 57).

This evaluative study indicates that these eight school-based
pregnancy programs have been successful in addressing some problems
associated with teenage pregnancy. The author feels the programs are
meeting the needs of pregnant adolescents by supporting them to continue
and complete their education, insuring healthy pregnancy and infant
outcomes and reducing the incidence of repeat pregnancies among the
adolescent school population. Improvement in the identification of
pregnant teens and referral to prenatal care earlier remains to be a
concern.

Roosa (1984) studied the short—term effect of parenting program on
pregnant teens knowledge about child development and human reproduction
and their attitudes and emotional responses to various aspects of
mother-child interaction. Three pretest questionnaires were
administered to a convenience sample of 79 pregnant students who were
enrolled in an inclusve school-based pregnancy/parenting program. The
same questionnaires were completed by 31 students of the original sample

five months later at the end of the term.

70

Results from the pre-test questionnaire showed a high level of
knowledge (percent correct) about child development and human
reproduction at pretest. The scores on the attitude scales revealed a
relatively low level of anxiety about childrearing but neutral feelings
related to maternal satisfaction. The teens were somewhat more likely
to feel hostility toward children than encourage positive interaction
with them.

The results from this study showed a relaxed group of pregnant teens
who demonstrated significant knowledge about child development and human
reproduction. The scores evaluating maternal attitude about
childrearing from pretest to posttest did not reflect a change in
attitude. Thus, the programs did not have an effect upon the parenting
attitudes held by the teens. The author suggest that further evaluation
of how the teenage mother rears her child after she leaves the special
program is needed.

Rogeness, et a1, (1981) interviewed a convenience sample of 28
pregnant adolescents in a special school program (TAMS) with 27 pregnant
adolescents who were not in the special school program (NTAMS) to
compare their social support network and their ability to parent. This
study revealed that those teens not involved in the special program
reported more feelings of isolation and more dependent upon their
mothers than the teens in the TAMS program. The girls in the special
school program viewed school and work more positively with 96% planning
to find work or an career. The mother of the pregnant teens not in the

special program continued to be a primary source (67%) of learning about

71
childcare while school played a significant role in learning about
childcare for the TAMS (36%).

A screening profile of parenting was done on both groups to identify
mothers with known problems interacting with their children. The NTAMS
group demonstrated a high likelihood of a having difficulty related to
maternal/child interactions. This supports Roosa’s findings related to
potential child rearing difficultities of the teen mother.

The results of the Michigan study are impressive on impacting the
educational and health outcomes of the pregnant teens and their infants.
Other research shows the impact special school-based programs have on
attitudes, parenting skills and preventing adolescent isolation. There
is a concern about potential rearing practices of the adolescent mother
related to poor maternal/child interactions. Social support provided by
these programs is probably a factor, however, is not defined or measured
as a research variable. This continues to be a weakness in education

literature as well as nursing, social work and health care literature.

Conclusions

 

In this chapter, the literature has been reviewed related to the
impact of pregnancy on growth and development of the adolescent and her
fetus with a description several potential adverse outcomes. Health
care needs have been described because of this impact on the pregnancy.
Various types of social support received by the pregnant adolesent from
family, friends, community programs and school have been described. The
overall drawback in the literature is the lack of identification and
definition of socially supportive behaviors and the measurement of their

impact on the pregnant adolescent.

CHAPTER IV

METHODOLOGY AND PROCEDURES

Overview

The purpose of this study was to compare two groups of pregnant
adolescents who attend different alternative school-based adolescent
pregnancy programs (APP) as to the perceived supportiveness provided by
teachers, counselors, social workers and nurses to pregnant teenagers
enrolled in these programs. One hypothesis has been developed to answer
two research questions: 1) Are the selective school personnel who
provide services in inclusive APP perceived to be more supportive by the
pregnant adolescents as compared to the school personnel who provide
services in supplemental APP, and, 2) Knowing that the pregnant
adolescent may also receive support from her family, friends, neighbors,
etc., what impact does this perceived support received from people in
general have on the perception of support from her school program? The
following hypothesis will be tested:

Pregnant adolescents enrolled the inclusive adolescent pregnancy
program will perceive more social support from selected school personnel
as compared to those pregnant adolescents enrolled in supplemental
adolescent pregnancy programs.

In this chapter, the methods and procedures will be presented to
test the hypothesis. Two tools will be used: The Adolescent Pregnancy
Programs Social Support Source Scale (APPS4) and the Inventory of

Socially Supportive Behaviors (ISSB). The history of these tools will

72

73
be given along with a description of the variables, sample, data
collection procedures and analysis plan including reliability and

validity measures.

Variables

Prior to the administration of the research instruments, background
data was collected, via a written questionnaire, on each participant to
gain further insight into the characteristics of this sample (see
Appendix A). In the literature, attribute variables have been described
to help researchers understand basic characteristics of adolescents who
become pregnant, their situation and their behavior. For this research,
these background variables include: age, ethnic background, living
arrangement, education level of teen’s mother and father, when the
teen’s mother had her first baby, age at menarche, if the pregnancy was
planned, involvement of father of the baby, estimated date of delivery,
month when prenatal care started and number of prenatal visits to date.
Variables about the school program and the education of the girls
included: grade level, amount of time at school, how the school system
found out about their pregnancy or their referral to the program and how

long the teen has been involved in her program.

Operational Definition of Concepts

 

The independent variable for this research was the type of program

 

the pregnant adolescent is enrolled in, either inclusive or
supplemental. The operational definition of the APP is: A composite of
learning activities and experiences within the school setting that are

directed toward developing an environment that protects and promotes the

74
health of pregnant and parenting students (Michigan Department of Social
Services, 1985). Services include academic education, health education,
health services and life skill competency courses. Basically, APPs
offer a general education core and a range of course work relevant to
childbearing, all for credit.

School-based APPs can be classified as either an inclusive program
or a supplemental program. An inclusive APP is defined as a teenage
pregnancy program which offers a general education core and courses on
pregnancy and parenting, all for credit. The program is not held in the
regular high school building but is usually held in another facility
designed for use by the teenaged pregnancy and parenting programs.

The supplemental APP is defined as a teenage pregnancy program which is

 

housed in the regular high school where the teen may stay in regular
academic classes and attend specialized classes related the pregnancy
and parenting.

There was one dependent variable in this research - the perception

 

of social support by the pregnant adolescent. Social support is
operationally defined as a four dimensional concept which includes:
feelings about emotional support, instrumental aid, information support
and appraisal support (House, 1984). Although four dimensions will be
assessed, the concept of social support will be viewed as a whole for
the purposes of this study.

The school personnel are being evaluated as to whether they are a
supportive part of the school environment. Although the school
personnel were not a variable in this study, it is felt that this

concept be defined. The operational definition of the school personnel

 

75
is: those identified school employees hired or contracted to provide
services to pregnant adolescents who are attending the designated APPs.
For the purpose of this research, these personnel include teachers,
counselors, social workers and nurses.

In this study, a control variable was used because of the inability
to randomly assign subjects to a school-based program. The perceived
social support received from people in general, other than school
personnel, i.e., family, friends, neighbors, was the control variable.
It is assumed that most pregnant adolescents have persons in their life
who are supportive to them, but are not part of the school system.
Perception of general social support may influence the perception of
social support received from the school program. Specifically,
eliminating the influence of perceived general social support on the
perceived support from school personnel may add clarity in identifying
the true supportiveness of the school program.

In the next section, a description of the sample used for this
research will be provided. This will be followed by a description of
the instruments to be used including their development, prior validity
and reliability measures, and modifications made for the purposes of

this research to measure type and source of social support.

Sample

This research was a cross-sectional survey design utilizing two
questionnaires to collect data. The sample consisted of 20 pregnant
adolescents, ages 14 to 16, who are 24 weeks gestation or greater. Age
of gestation was based on their reported date of confinement (EDC) at

the time of the data collection. Of the students enrolled in the APPs,

76
10 of these students were enrolled in an inclusive program and 10 were
enrolled in a supplemental program.

Three data collection sites were selected: Two suburban school-
based adolescent pregnancy/parenting programs, one which is inclusive
and one which is supplemental, and a large urban obstetrical clinic with
a teen pregnancy program. Permission was obtained from either the
school superintendent or program directors for access to the sample.
Selection of these sites was based on ease of access to students and the
number of students in each program to obtain an appropriate sample from
each type of school program. This represented a non-random, convenience
sample. Participation by the students was voluntary.

Table 1. Services to be Provided Districts Implementing Adolescent
Pregnancy Programs (Michigan Department of Education, 1979)

 

 

 

Guidelines Site Site

1 2

School Counseling + + +
Regular Curricula + + +
Education for Parenthood + + !
Nutrition Education + + !
Health Counseling + + !
Child Health + + !
Mental Health Intervention* + + R
Social Service Counseling + + +
School Transportation + - +
School Meals + + +
Home Visits** + + +

 

* The provision for funding limit the underwriting of this component to
those areas of the state where community health/mental health agencies
can provide required expertise.

*tHome visits as needed and appropriate to address education, social

services, health and mental health.

+ Services provided by the school program

- Services not provided by the school program

R Referral to outside agency

! Offered in regular academic classes

77

Instruments

 

The Adolescent Pregnancy Program Social Support Source Scale (APPS4)
was developed for this research study to evaluate perceived social
support by the pregnant adolescent within the school setting (see
Appendix B). The APPS4 is a 32 item tool containing two sections that
are hypothesized to measure four dimensions of social support:
emotional support, practical assistance, companionship and advice. The
tool is modeled after the Support Dimension Scale (SDS) developed by
Caldwell and Reinhart (1988). The SDS is designed to examine four
dimensions of social support within the same questionnaire: a) source,
b) type, c) amount, and d) satisfaction (Caldwell and Reinhart, 1988).
The authors identified four types of social support: emotional support,
practical assistance, companionship and advice and information. The
sources of support delineated on the APPS4 tool are different from the
SDS. Furthermore, the terminology of the APPS4 tool has been modified
for use with adolescents.

Caldwell and Reinhart administered SDS to 373 college freshman to
define sources and types of support these students relied on while
dealing the normative psychological task of young adulthood, i.e., home
leaving. Reliability scores for the Support Dimension Scale were not
calculated by the authors (R. Caldwell, written communication, July, 26,
1988). In this research, scores on amount and satisfaction dimensions
of social support will be calculated along with the total support score.

In the first section of the APPS4 tool, the pregnant adolescent is

asked about her perceptions of the amount of social support received at

78
school from teachers, counselors, social workers or nurses. For
example:

a) If you wanted to talk to someone at school about things that
are very personal and private, in general, how much comfort,
concern or caring do you receive from:...

b) If you needed to borrow something or needed help with something
(clothes, food, money, help with finding housing or
services), in general, how much help or assistance do you
feel you receive from ...

c) How much positive feedback, (meaning when they like your ideas
or the things that you do), do you feel you receive from...

d) In general, how much advice or information do you feel you
receive from ....

Almost None A Small An Average A Large A Great
Amount Amount Amount Deal
1 2 3 4 5

Scoring for this section of the tool was on a five point Likert-type
scale.

The second section, contains questions about the pregnant
adolescent’s level of satisfaction with the social support she has
received from teachers, counselors, social workers or nurses. For
example:

a) In general, how satisfied have you been with the concern or
caring (for example, the opportunities to talk about things
that are personal and private) you have received from...

b) In general, how satisfied have you been with the amount of
help or assistance (opportunities to borrow or receive
money, food, clothes, etc.) you have received from ...

c) In general, how satisfied have you been with the amount
of positive feedback (letting you know they liked your
ideas or things that you did) you have received from ...

d) In general, how satisfied have you been with the amount
of advice or information you have received from ...

Very Dissatisfied Satisfied Largely Greatly
Dissatisfied Satisfied Satisfied
l 2 3 4 5

Scoring for this section of the tool is on a five point Likert-type

scale.

79

The second questionnaire used in this research was the Inventory of

 

Socially Supportive Behaviors (ISSB) which was developed by Berrera,
Sandler, and Ramsay (1981) to assist in the identification of the
dimensions of social support and to determine if specifically supportive
behaviors are predictive of satisfactory adjustment of certain
individuals under certain life conditions (see Appendix C). Berrera and
Ainlay (1983) derived four types of social support from the factoring of
the ISSB: directive guidance, nondirective support, positive social
interaction and tangible assistance.

The ISSB is a 40 item tool rated on a 5-point Likert-type scale that
ranges from "Not at all" to "About every day". The initial study was
done with 71 university students who completed the ISSB in two
assessment sessions that were separated by a two-day test interval.
Internal consistency reliability yielded coefficient alpha of .92 and
.94 for the first and second administration of the tool, respectively.

The authors did an additional study using 43 university students to
evaluate validity via comparison with the Cohesion subscale of the
Family Environment Scale, developed by Moos, to compare perceived
supportiveness. Results confirmed these two tools were significantly
correlated (r-41)=.359, p(.Ol). The author identified that each tool
was measuring unique aspects of social support.

Berrera (1981) conducted a study using the ISSB to examine the
relationship between social support and the well-being of pregnant
adolescents. The sample consisted of 86 pregnant adolescents with a

mean age of 17.2 years who had been pregnant a mean of 6.6 months. The

80
coefficient alpha for the ISSB in this study is .92 which represents
high internal consistency.
The scale for the tool is based on an interval scale to reflect a
frequency rate based on a 30 day time period. The pregnant adolescent

is to reflect the amount of social support received "over the past

month”. Scoring for this tool was on a five point Likert-type scale.
Not At 1 to 2 Times in 1 Time Several Times Once A
All the Past Month per Week per Week Day
0 l 2 3 4

In summary, the APPS4 is a new tool patterned after a tool that has
not been tested extensively. The authors who originally developed and
tested the SDS used an adult population and where not evaluating
perceptions of total social support but were interested in measuring the
dimensions of social support. Thus, the results obtained from testing
the APPS4 will not be compared with results from the study using the
SDS.

On the other hand, the ISSB has been used with several different
populations, including pregnant adolescents. It has proven, thus far,
to be a reliable and valid tool for the measurement of perceived social

support by the pregnant adolescent.

Codingiand Scoring the Data

 

The data collection sites were coded as nominal categories:
l=inc1usive , 2=supp1ementa1 and 3=clinic. The APPS4 contains 32 items
which was coded on an interval scale with ranges from one (1) to five

(5). A total score for perceived social support was obtained by

81
averaging the 32 items. The code of "9" was used to reflect "no
answer". Coding of the ISSB included obtaining a score of zero (0) to
four (4) for each of the 40 items. A total score was then averaged from
the 40 items. The code of "9" signified "no answer".

Scoring for the two questionnaires was done using a total support
score. There were eight (8) questions measuring the perceived social
support from select school personnel (8 x 4 school personnel = 32
items). For the APPS4, each of the questions could have a maximum score
of 20 (one to five point scale multiplied by four school personnel).

The maximum score for the 32 item APPS4 is 160. Each participant had
one score reflecting the average of the 32 items measuring perceived
social support from their school program.

Scoring for the 40 item ISSB was based on a maximum score of 160.
The five-point Likert-like scale has an absolute factor zero, "Not at
all", and ranged from zero to four (four multiplied by 40 =160). A
total score from all 40 items was obtained.

Data Collection Procedures

 

Contact was made with the two school—based APPs. One director
verbally gave permission for data collection at her site. The
superintendent of the school district was the approval body for the
other site. A meeting was held with the director of the obstetric
clinic to describe the research and get approval. All approval persons
were written a letter of introduction which included the research
proposal and copy of the tools (see Appendix D).

After approval, determination of the eligible participants was made

via discussion with each site contact person. At the clinic site, a

82
Teen Time Program is held weekly which the girls have to sign in and
indicate their age. Eligibility was based on age (14 to 16 years) and
estimated date of delivery (EDC, greater than or equal to 24 weeks
gestation). The participant sample from the clinic completed a pre-
screening questionnaire if they had been in school from January, 1988 to
June, 1988. If they had not been in school, they checked "no" for the
first question on the pre-screening questionnaire, and are not eligible
to participate in the research (See Appendix E). If they had been in
school, they complete the remainder of the screening questionnaire
asking about their school program to determine if it is an inclusive or
supplemental program:

1. Did you attend a special school program, because you were
pregnant, which was not located in your regular school building?

2. Did you remain in you remain in your regular school and
attend special classes at your school during the day that taught
you about pregnancy, childbirth and how to stay healthy while
you were pregnant?

3. Did someone in the school system (a teacher, a counselor,
the nurse or other school personnel) know about your pregnancy?

Arrangements were made with the school-based APP site contact to
meet with eligible participants after the parental/guardian consent
forms are distributed to the eligible teens (see Appendix F). The teens
were reminded by the site contact to bring in the forms the day before
or day of the scheduled data collection day.

The eligible participants at the clinic site were asked if their
parent/guardian was with them that day. If they were, the research was
explained to the parent and student. The cover letter was reviewed with
them and they were asked to sign the consent if they chose to have their

daughter participate (see Appendix F). The student was then given the

83
tool to complete. If their parent/guardian was not with them, the
letter explaining the research and consent was be sent home. The
researcher obtained the participants name and phone number and the date
when she would be attending the next Teen Time session. The researcher
provided a reminder phone call to the student the day before her clinic
appointment/Teen Time session to remind her to bring the completed
consent.

Time and room arrangements were made with the help of each site
contact. Questionnaires were administered in a "classroom" style
setting depending upon the number of participants and space available in
the facility. Need for repeat data collection times was determined by
the number of participants, their stage of pregnancy, and their
progression to 24 weeks.

This researcher was the sole data collector. At each data
collection time, parental/guardian permission forms were collected prior
to distribution of the questionnaire. The researcher then read through
the written cover sheet on the tool with the pregnant teens which
explained the research, the tool and the basic procedures of the data
collection (see Appendix G). These instructions included:

1. Giving an overview of the purpose of the research:

”Thank you for volunteering to participate in this research study. This
research will be looking at how supportive your school program is to you
while you are pregnant."

2. Assurance of confidentiality:

"Your answers will not be shared with your school teachers or clinic

staff. Answers to the questionnaire you agreed to fill out will be seen

84

by myself and my advisors at Michigan State University. No one from
your school program or the clinic will have access to these answers."

3. Consent to participate:
”Signing the consent form indicates your interest to participate. You
can discontinue your participation in the study at any time."

4. Give an overview of the questionnaire and tools:
"The questionnaire you have agreed to fill out has three parts. The
first is background data about your self and school. Most questions

require only a 'check mark’ or short answer, i.e. your birth date. Part

two, or 'B’, asks for your feelings about specific school personnel with

whom you have contact. There is a scale provided with each question for

which you circle a number under your response. Part three, or 'C’, asks

for your feelings about the amount of support you feel you have received
in general from persons other than school personnel, for example, your
family, friends or neighbors, etc., during the past month. Again, a
scale is provided with each question for which you circle a number."
”Please answer each question as honestly as possible. There are no
right or wrong answers, just what you feel. I expect you will be able
to complete all parts within 20 to 30 minutes. More time will be
allowed if you need it. I will be here to answer any questions while
you complete the questionnaire."
5. Clarify for the participants any terms or concepts as
needed. The tools have been constructed at a comprehension level to

prevent the need for lengthy discussions.

85
6. Report of Findings:

"If you request, you can receive a copy of the results of this study.
My name and phone number are printed below for you to keep if desired."
7. Assure a quiet, comfortable atmosphere for the participants.

Collaboration with the site coordinators was done prior to the

administration of the tools.

Analysis Plan

 

Data analysis began with establishing the reliability of the
modified scales and subscales using Cronbach’s alpha as a measure. A
high value indicated that respondents have similar response patterns to
all the items included in a scale or subscale. In this study, an alpha
of 0.7 was accepted as sufficient evidence of internal consistency.

To test the hypothesis, an analysis of co—variance was conducted.
Using the data obtained from the APPS4 tool, this test described the
mean effect of the independent variable, type of APP and school
personnel, on the dependent variable, perceived social support. The
intervening variable, support from persons other than school personnel,
measured by the ISSB, was used to factor differences between the two
groups of pregnant adolescents. The background variables were not

used as co-variates in this research.

Protection of Human Rights
Approval to perform this research was received from the University

Committee on Research Involving Human Subjects (see Appendis H).

86
Summary
In summary, the research process has been described for this study.

The two tools used have been described highlighting any changes, prior
use and reliability and validity statistics. A description of the
variables and sample has been given. Procedures to conduct the research
have been described including gaining approval from and coordination at
the data collection sites and time frame. Analysis of co-variance was
the statistical procedure used to determine relationships between the
variables identified for this research. The test results will be

reported in Chapter V on data analysis.

CHAPTER V

DATA PRESENTATION AND ANALYSIS OF RESULTS

Overview

The data presented in this chapter will be used to describe the
sociodemographic characteristics of the subjects as well as their
responses to the instruments. The focus of the presentation will be to
answer the two research questions: 1) Are the selective school
personnel who provide services in inclusive adolescent pregnancy
programs (APP) perceived to be more supportive than the school personnel
who provide services in supplemental APPs, and 2) Knowing that the
pregnant adolescent may also receive support from her family, friends,
neighbors, what impact does this perceived support received from people,
in general, have on the perception of support from her school program?
A convenience, volunteer sample of ten (10) pregnant adolescents was
obtained from two school programs (one inclusive and one supplemental)
and an urban teen pregnancy clinic. This research is a pilot study to
determine the reliability of a newly developed tool, the Adolescent

Pregnancy Program Social Support Source Scale.

Descriptive Findings of Study,Sample
The sample for this study consisted of five pregnant adolescents who
attended inclusive APP, three pregnant adolescent who attended a
supplemental APP and two adolescents who attended school but were not
enrolled in a school-based pregnancy program or special classes about

87

88
pregnancy at school. All participants, who volunteered to be in the
study, were asked the gestation of their pregnancy. At the time of the
instrument administration, all were pregnant for 24 weeks or more which
made them eligible to participate in the study.

Aga The age of the study sample ranged from 15 to 17 years. The
mean age overall was 16.2. The age distribution consisted of one 15
year old (10%) six 16 year olds (60%) and three 17 year olds (30%).

Race of ethnic background Seven students in the sample were black
(70%) and three students were white (30%).

Living arrangements Data about living arrangements for the sample

 

showed that 60% (n=6) were living with their mothers only and 30% (n=3)
were living with both parents. One participant selected the ”other"
category but checked living with her mother and indicated "her" husband.
This was interpreted to mean she was living with her mother and
stepfather.

Gestation The participants were requested to provide the estimated
date of confinement (EDC, delivery date). All were at least 24 weeks
gestation: 30% (n=3) were between 24 to 28 weeks or 36 to 40 weeks, 20%
(n=2) were between 32 to 36 weeks and 10% (n=1) were between 28 to 32
weeks.

Age at menarche All participants were asked to indicate their age
at menarche. The range for age at menarche was 11 to 15 years. The
mean age was 12.8 years. The distribution between the earliest and
latest onset was fairly even with 30% (n=3) starting at age 12, 20%
(n=2) starting at each of the ages 11, 13 and 15 and 10% (n=1) starting

at age 14.

89

Father involvement Each participant was asked to indicate the
amount of involvement the father of the baby would likely to have in the
care of the infant after the birth. Half of the girls (n=5) anticipated
the father to be involved "alot". The rest of the sample anticipated
less involvement of the
father: 20% (n=2) indicated "somewhat" involved, 10% (n=1) indicated ”a
little” involved and 20% (n=2) indicated "not at all".

Plannedgpregnancy The majority of the participants (n=9) reported
that this pregnancy was not planned. Only one teen indicated that it
was planned.

Prenatal care Each participant was asked to indicate what month

 

they first went to the doctor to find out if they were pregnant.
Responses ranged from the first to the fifth month. Thirty percent
(n=3) of the teens sought care during the second month and 30% (n=3)
sought care during the fifth month. Only 10% (n=1) sought care in
either the first or fourth month with 20% (n=2) making their first
prenatal visit in the third month.

The participants were, also, asked to indicate the approximate
number of prenatal visits they had attended at the time of instrument
administration. The sample selected included subjects from three
categories: five or less visits - 40% (n=4), six to 11 visits - 40%
(n=4), and 12 or more visits - 20% (n=2). Ninety percent (n=9) of the
teens in this sample were at least 28 weeks gestation indicating the
minimum number of prenatal visits to be six.

Mothers’ firstgpregnancy The sample was asked to indicate the age

at which her mother had her first baby. The ages ranged from 16 to 26

90
years, with two participants failing to write in an age. The ages and
frequencies included: two mothers were 16 years old, one each was 17,
20, 23 or 26 years old and two were 24 years old.

Parental education level All participants were asked about the
highest grade of education completed by both their mother and father.
Educational attainment for the subjects’ mothers ranged from 11th grade
to two years of college, with the half (n=5) completing high school (see
Table 2).

Educational attainment for the subjects’ fathers ranged from high
school graduate to completing four years of college. Two participants
failed to check a response. Half of the teens’ father (n=5) completed
high school (see Table 2).

Adolescent grade level The present grade level was obtained from

 

all participants which ranged from 10th to 12th grade. Grade level
distribution of the pregnant adolescents are presented in Table 2.

School attendance The attendance at school was obtained by having
each teen indicate the number of days per week she attended school over
the past two months and by the number of hours per day she spent at
school. The majority of the teens (70%, n27) attended school five days
per week with 20% (n=2) attending three to four days per week and 10%
attending one to two days per week.

The participants selected one of three categories identifying hours
spent at school. Half of the teens (n=5) spent five to six hours at
school per day while 30% (n=3) spent more than seven and 20% (n=2) spent

three to four hours per day.

91

Table 2: Educational levels of the pregnant adolescents, their
mothers and fathers (n=10).

 

 

 

 

Education Mother Father Adolescent
Level
No. % No. % No. %

10th grade 0 0 0 0 4 40
11th grade 1 10 0 0 4 40
12th grade 0 0 0 0 2 20
High School

Graduate 5 50 5 50 - -
Some College 3 30 1 10 - -
Two Years

College 1 10 0 0 - -
Four Years

College 0 0 2 20 - -
Missing 0 0 2 20 0 0
Total 10 100 10 100 10 100

 

Months in the program All participants were requested to report how
many months they have been attending classes in their school program.
The months in the programs ranged from one month to five months with 30%
(n=3) attending for three months and 30% (n=3) attending for four
months. The remainder of the sample was fairly equally distributed with
20% (n=2) attending for five months, 10% (n=1) enrolled for one month
and 10% (n=1) for two months.

School awareness All participants were asked to indicate how their
school system found out about their pregnancy. Of the 11 situations the
teens could choose from, they identified only four which described how
the school system became aware of their pregnancy: 40% (n=4) confided
in a counselor, 30% (n=3) confided in a teacher, 10% (n=1) indicated

friends told, 20% (n=2) indicated "other" as a response.

92

In summary, the data presented in this section described the
sociodemographic characteristics of the subjects including a focus on
the amount of contact with their school program. Given that there were
only ten (10) subjects in the sample, responses indicate a large degree
of variation with respect to the variables in question. In the next
section, data from this pilot study will be used to determine whether
further study is indicated to answer the research question and the
hypothesis and determine the reliability for further use of the

instruments.

Reliability of the Scales

 

The Adolescent Pregnancy Program Social Support Source Scale (APPS4)
and the Inventory of Socially Supportive Behaviors (ISSB) were subjected
to reliability tests (coefficient alpha). The APPS4 (measuring school
support) was divided into two subscales, one measuring the 'amount of’
support and the other measuring 'satisfaction with’ the support. Four
items (questions 7, 11, 14 and 39) were deleted from the ISSB because of
missing answers. Due to the very small sample size, missing values
would have caused an acceptable reduction in the total number of cases
from ten to seven.

For this research, an alpha of .7 is considered evidence of a high
degree of internal consistency. The reliability coefficient for the
APPS4 is .94 which represents a high internal consistency among the
items measuring support perceived from teachers, nurses and social
workers. The "counselor" items were deleted from the APPS4 because the
results showed a small negative correlation to the rest of the items.

This correlation indicates that the support from counselors is not

93
necessarily related to the support coming from the other three
classifications of school personnel. Thus, the following data results
for the APPS4 consists of responses evaluating the perceived support
from school teachers, nurses and social workers.

In reviewing the counselor items, most of the teens (n=8) reported
they perceived an average to large amount of support from the
counselors. Comparing this to a total mean score calculated for the
other three classifications of school personnel (2.59, representing a
small to average perception of support), it appears the counselors are
perceived as more supportive as compared to teachers, nurses and social
workers. Therefore, support from counselors may be perceived as 'in
addition to’ or 'independent of’ the other support and, thus, a possible
reason for the negative correlation. Because of the small sample size,
these inferences are considered strictly tenative. It appears, however,
that there is no "general" school support but there are different
sources of support that should be considered separately.

The subscale measuring the 'amount of’ perceived social support from
select personnel had a coefficient alpha of .84, which represents a high
internal consistenCy among the items. The subscale measuring
'satisfaction with’ the social support received had a coefficient alpha
of .90, which, again, shows high internal consistency among the items.
After deletion of the counselor items, the coefficient alpha for both
subscales increased to .87 and .92, respectively, which further
strengthened the internal consistency among the school teacher, nurse

and social worker items.

94

The ISSB had a reliability coefficient of .96, which represents a
high internal consistency among the items for the scale. Four items
were not answered on this scale and were deleted resulting in a new
coefficient alpha of .98, which again demonstrates a high internal
consistency.

In summary, both the APPS4 and the ISSB exhibited a high degree of
internal relatedness among the items in the scales as a whole. The ISSB
has been tested extensively prior to this research and the reliability
results are similar. Because of the small sample size, this study is
considered a pilot study to test the APPS4. It is very likely that the
values of this small sample may deviate from the values of the general
population of pregnant adolescents. Furthermore, the inability to
randomly select the sample limits the representativeness and may bias
the results. From the results of this study, it appears the APPS4 may
be reliable for evaluating the perceived supportiveness of school
teachers, nurses and social workers. More testing needs to be done to
further evaluate the measurement of perceived support of counselors
using the APPS4.

Data Presentation for Research the
Questions and Hypothesis

To answer research question one, the mean scores of the APPS4 will
be presented to determine if there are differences in perceived support
by teens enrolled in two types of APPs. Pearson product-moment
correlation coefficient will be used to answer research question two to
determine the degree of relationship between the variables (school

support and general support). _Using analysis of covariance to control

95

for general support, the hypothesis will be tested. However, because of
the extremely small sample size, these results are not statistically
"significant". Thus, the results can only be taken as descriptive of
the sample and no inferences to the larger population of pregnant
adolescent are possible.

The sample included three groups of pregnant adolescents. Group one
(1) are the adolescents in the inclusive program (n=5), group two (2)
are those adolescents in the supplemental programs (n=3) and group three
(3) are those adolescents who remained in school but were not enrolled
in any special classes related to pregnancy (n=2). Although the
research question and hypothesis do not include this third group,
results will be discussed at the end of the analysis section pertaining
to the contrast between this group and groups 1 and 2.

Research Question 1

 

Are selected school personnel who provide services in inclusive
adolescent pregnancy programs (APP) perceived by the pregnant adolescent
to be more supportive as compared to the school personnel who provide
services in a supplemental APP?

The mean scores on the 24 items APPS4 measuring total perceived
support from the school personnel was 2.59 on a scale from 1 to 5, with
a range of 1.41 to 3.54. The total mean scores for the subscales were
similar with 'amount’ of support mean 2.53 and 'satisfaction’ with the
support mean 2.65. Thus, the total sample of pregnant adolescents
perceived the amount of support received to be less than average

(average represented by a score of 3.00) and they were less satisfied

96
with the support they did receive (satisfied represented by a score of
3.00) from their school program (see Table 3).

Mean scores for group one on the APPS4 was 2.54 and for group two
2.88 (see Table 3). Therefore, the pregnant adolescents attending the
supplemental APP perceive more support from and more satisfaction with
the support they received from their school program than the pregnant
adolescents attending the inclusive programs. This result does not, of
course, show a difference in the expected direction. However, given the

very small number of cases involved, the hypothesis cannot be rejected.

Table 3. Group mean scores for APPS4 and ISSB

 

 

 

 

Group APPS4* (n=9) ISSB**
Total Amount Satisfaction (n=10)
1 2.54 2.52 2.55 2.02-
2 2.88 3.08 2.67 2.14
3 2.44 2.00 2.87 2.47
Total 2.59 2.53 2.65 2.15

 

* APPS4 range 1 - 5

** ISSB range 0 — 4

The subscale mean scores for group one shows they perceive less
support in both amount of (2.52) and satisfaction with (2.55) than group
two (3.08 and 2.67, respectively, see Table 3). Thus, the pregnant
teens enrolled in supplemental APPs (group 2) report perceptions of
receiving more support from their school
program and are more satisfied with the support than the teens in the

inclusive programs.

97
Research Question 2

Knowing that the pregnant adolescent may also receive support from
her family, friends, neighbors, etc., what impact does this perceived
support received from people in general have on the perception of
support form her school program?

The degree of relationship between the variables, school support and
general support, was measured by the Pearson product—moment correlation
coefficient. The size of the correlation coefficient indicates the
degree of the relationship. A relationship was defined as: l) slight
or weak if the a >.10 or (.30, 2) moderate if >.30 to (.50, and 3) high
or strong is >.50 (Burns & Grove, 1987).

There was a moderate to strong relationship (a =.48, p =.08) between
total scores on the APPS4 and the total scores on the ISSB. This
correlation indicates that pregnant adolescents’ perception of school
support is related to their perception of general support. However,
school support and general support appear to be sufficiently distinct in
the minds of the pregnant adolescents. After all, the two variables
share only 25% of the variance in common (r =25). Because general
support does have an impact on the pregnant adolescents’ perception of
support from the school program, it will be introduced as a covariate to
answer question two.

Employing analysis of covariance involves removing the possible
effects of a control variable (or covariate) which may affect the
differences between two groups. In this study, the effect of the
control variable, perceived general support, was removed allowing for

clearer identification of the main effect, the perception of support

98

received from the school program. If the difference between perceived
school support in the two groups declines after the effects of the
covariate is taken into account, this would indicate that it is not the
school programs per se that differ in support provided to the pregnant
teen. If the difference in perception increases after the effect of the
covariate is taken in to account, this would indicate that differences
between the school programs cannot be simply attributed to differences
in student perceptions of general support. Statistical significance was
not computed because of the small sample size.

The pregnant teens enrolled in the inclusive program (group one) had
a mean score of 2.54 which was adjusted to 2.58 after the effect of the
control variable was factored (see Table 4). In this group, the
perception of support received from school personnel increased slightly
after the effect of perceived general support was taken into account.
Thus, one reason why students in the inclusive APPs reported lower
school support is that they differed with respect to their perceptions
of general support.

Table 4. Analysis of Covariance controlling for tha

effect of perceived general support on group mean (X)
scores for APPS4.

 

 

 

Groups E before E after
adjustment adjustment
1 2.54 2.58
2 2.88 2.88
3 2.44 2.32

 

Total 2.65 2.59

 

99

There was no change in the mean scores (2.88) for those teens
enrolled in supplemental APP (group two) when the effect of the control
variable (general support) was taken into account (see Table 4). The
teens in the supplemental APP perceive school to be supportive whether
or not general support is a factor.

Hypothesis: Pregnant adolescents enrolled in inclusive adolescent
pregnancy programs will perceive more social support from selected

school personnel as compared to those pregnant adolescents enrolled in
supplemental adolescent pregnancy programs.

 

Comparing the adjusted means of the two groups, the teens attending
the supplemental APP (group 2) perceive more support from their school
program (2.88) than the teens attending inclusive APP (group one, 2.58),
although the difference between the two groups narrowed slightly. Even
though the results from this analysis of covariance cannot be used to
reject or accept the hypothesis because of the small sample size, it
points, if anything, towards a rejection of the hypothesis.

In summary, the interpretation of the data analysis reveals that
pregnant adolescents who attend supplemental APPs perceive
their school program to be more supportive than the teens who
attend inclusive programs. Furthermore, the pregnant teens’ perception
of general support received from family, friends or neighbors has an
impact on the teens perception of support from the school program.

Thus, controlling for general support helped to clarify the true support

provided by their school program.

Other Research Findings

 

The ISSB was used to measure the perception of general support as

perceived by the pregnant teens. The mean score on the 36 item ISSB

100
measuring perception of general support was 2.15 on a scale of 0 to 4,
with a range of .59 to 3.64 (see Table 3). Group two reported
perception of slightly more general support (2.14) than group one
(2.02). Overall, the pregnant adolescents perceived they received
general support, of various types, ranging from at least four (4) times
during the past month (approximately one time per week) to several times
per week, (however, not every day).

Another finding involved data was collected from a third group of
pregnant teens who remained in school but who received no special
intervention from the school setting, i.e. course work or classes. This
group completed both the APPS4 and the ISSB.

The mean score on the APPS4 for group three was 2.44 (see Table 2).
This score was lower than group one (inclusive) by .10 and group two
(supplemental) by .44. The teens in group three perceive less support
from the school personnel than both groups one or two.

The subscale scores on the APPS4 for group three were 2.00 for the
’amount of’ support received and 2.87 for ‘satisfaction with’ the
support (see Table 2). Comparing these results to groups one and two,
the teens in group three perceived that they received less support from
their school program but were more satisfied with the support that they
did receive than either group one or group two. Thus, the pregnant
adolescent who remains in school but who receives no special
intervention perceives school to be less supportive than those enrolled
in special programs. However, pregnant teens not enrolled in APPs

perceive the support received as satisfactory.

101

Measurement of general support for group three showed a mean score
of 2.47 on the ISSB (see Table 2), which is higher than either group one
(2.02) or two (2.14). Thus, support received outside the school setting
is perceived to be more important for the pregnant teen not enrolled in
an APP as compared to those teens in APPs.

Computing analysis of covariance for group three shows a mean score
of 2.44 which is adjusted to 2.32 when the influence of perceived
general support is factored out (see Table 4). In this group, their
perception of support from the school program is reduced when the effect
of general support is removed. Thus, the teens in school but not in an
APP perceive less support from the school, an effect that is
strengthened once general support is taken in to account.

In summary, the teens in this study report receiving general support
at least weekly to several times each week. Furthermore, the pregnant
teens who choose to remain in school but not attend a special program
related to pregnancy or parenting perceive the least amount of support
from their school program than either of the groups of teens enrolled in
inclusive or supplemental APPs. It appears these teens receive more of
their support from persons external to school which may positively

influence how they perceive support from school personnel.

Methodological Problems

 

Several methodological problems occurred during this research.
Because of the small sample size and the modification of a new tool,
this research must be considered strictly exploratory. In this section,

evaluation the APPS4, ISSB and a description of methodological

102
limitations of this study related to the use of the school sites and the
clinic site will be discussed.

Difficulties in attaining an adequate sample relate to timing of
data collection and sociodemographic factors. Initially three school
programs were to be utilized. Because data collection was conducted
during the last month of school prior to summer vacation, the
teachers/site contacts reported many of their students had delivered or
were receiving home education services. Referrals to the program
decrease as students do not want to switch classes close to the end of
the term. Thus, one site was not utilized because of no students; the
other two school programs had three students who were eligible and
agreed to participate.

The clinic site posed separate date collection difficulties.
Students attended Teen Time voluntarily, usually when they also had a
prenatal visit. If the teen did not come to the clinic with their
parent, she was asked to take the consent form home, have it signed and
return it at their next visit. The data collector obtained the teen’s
phone number and called her the morning of her next anticipated clinic
visit to remind her about the consent form. Several of the teens who
were contacted were not attending Teen Time as their appointments had
been changed or they switched to another prenatal care site. Thus, they
were lost as a potential candidate because of the parental consent
requirement.

Another stumbling block was the number of pregnant teens who dropped
out of school. The clinic is located at a large inner city hospital

where no one is turned away for health care. Over the past three years,

103

the Teen Time program has had contact with over 400 pregnant teen who
on the average attend approximately six of the ten Teen Time sessions;
only 10% complete the full program (personnal communication, 11—22—88).
The average attendance at a Teen Time session ranges from four to 15
pregnant teens, who may bring their parents, the father of the baby or
any other support person. Eligibility to participate in the study
required that the teen had been in school from January to June, 1988 at
least three days per week. Over the seven week data collection period
(part of June and July), 15 prescreening questionnaires were returned
from teens who dropped out of school during the six month time period,
and, thus, could not participate in the study.

Evaluation of the APPS4 revealed that nine of the ten teens answered
all the questions on the tool. All missing answers were located on a
tool completed by one participant. Further evaluation of this showed no
consistent pattern related to personnel categories or inability to read.
(This participant completed the 40 item ISSB which followed the APPS4
with only one missing answer). The average administration time to
complete the three sections of the questionnaire (background data, APPS4
and ISSB) was 20 minutes. Observation of the teens showed they spent
most of the time on the ISSB section.

The APPS4 appears to be easily understood related to concepts and
personnel classifications. Development of the tool included terminology
modeled after other adolescent support tools. The personnel
classifications are generic within the school systems. The teens were

encouraged to ask the data collector questions, if needed, should they

104
not understand any part of the tool. No questions were asked during any
of the data collection times.

The APPS4 allows for the identification of groups or classifications
of people to evaluate their supportiveness. The analysis of this study
tenatively identified counselors as a group who provides a different
type of support to pregnant teens. Through more research, further
discrimination of sources of support to pregnant adolescents can be
identified and strengthened.

Pregnant teens may have contact with a variety of school personnel
or be enrolled in an APP which offers a variety of experiences. It is
possible that the interaction with the personnel identified on the APPS4
may be minimal, which would be identified by the marking the lowest
ranking on the tool. Development of a more specific tool containing
classifications identified by the teen (i.e., coaches, secretaries) may
individualize the tool for the evaluation of a specific program while
remaining to collect data on personnel classifications. On the other
hand, guidelines recommend specific personnel be available to the
pregnant teen to provide services. If they are not available, this tool
may need a column indicating 'no contact with’, which identifies a
weakness in the APP structure.

This tool could be used to collect data about perceived sources of
social support with larger sample sizes. However, it could, also, be
used to measure support at select intervals to detect changes in the
perception support received from specific sources. Modifications to the

tool could include expanding the ranking selection for answers and

105
allowing the teen to select specific personnel classifications to

evaluate as sources of support.

Summary

A description of the study sample in relation to sociodemographic
and academic status was presented in Chapter V. Reliability of the
scales designed to measure the study variables were reported and
correlations between the variables presented. Additional findings
related to teens in school without the benefit of special APP
intervention were described. A discussion of study findings and the
implications for nursing practice, nursing education and further

research will be presented in Chapter VI.

CHAPTER VI

SUMMARY AND IMPLICATIONS

Overview

A summary and study findings is presented in Chapter VI.
Conclusions and recommendations for future research, nursing practice

and nursing education are also presented.

Summary and Interpretation of Findings
Descriptive Findings of the Study Sample

This section will include a discussion of demographic information
and findings.

Age; The mean age of the sample was 16.2 years. The adolescent growth
spurt for females is virtually complete by age 16 (Forbes, 1981, Garn,
LaVelle, Pesick & Ridella, 1984). Thus, the pregnant adolescents in
this study can be considered physically mature by virtue of their
chronological age.

This study was designed to include pregnant adolescents who were 14
to 16 years of age. However, no 14 year olds participated. This could
be anticipated because of the small sample size. Other studies using
large samples of pregnant adolescents (n =>500) average less than 10% of
the sample as 14 year olds as compared with their numbers of 15, 16 and
17 year olds (Frischancho, Matos & Flegel, 1983, Merritt, Lawrence &

Naeye, 1980, Garn & Petzold, 1983).

106

 

107

Reasons for the lack of 14 year olds in this study may be their
inability to seek help because of psychological insecurity and
immaturity. Many young adolescents continue to deny the pregnancy until
later months and up until delivery. Fear of punishment, lack of
resources and limited knowledge about bodily changes that occur during
adolescence may promote the denial of pregnancy and thus, reduce her
exposure to the health care system. Furthermore, as discussed later in
this chapter, the school dropout rate of pregnant adolescent may include
many of these younger teens

Seventeen year olds were included in this study because of their
availability and agreement to participate. Overall, this creates a
more mature sample which could impact the questionnaire responses.
Rage. The sample for this study was 70% black and 30% white. This
could be expected as the clinic was located is a large urban medical
center serving a 65% black population. One school site was located in a
suburban community where the population was 34% black; the other school
site has an enrollment of only 10% black students. Selection of data
collection sites and the sample was by convenience based on
accessibility and availability. Analysis of responses by race was not
computed because of the small sample size. The lack of racial
equivalence in the sample (as well as the small sample size) would limit
the generalizability of the findings to other groups.

Another possible explanation for the lack of racial equivalence is
the overall incidence of pregancy between black and white teenagers.
Nationally, the incidence of pregnancy in black teenagers is

approximately nine times the incidence for white teenagers (Miller,

108
1986). In Michigan, the ratio is 86% to 18.5% per one thousand for black
and white teens, respectively (Epstein, 1986). Because the clinic
serves the inner city, Medicaid population, which is predominately
black, and has a reputation for long waiting periods, teens who have
insurance would opt to be seen by a private practitioner.
Living arrangements. More teens in this study (60%) reported to be
living with only their mother with 30% living with both parents. Thus,
a total of 90% actually lived with their mother. Zuckerman, et. al.
(1984) reports that 88% of the pregnant teens continued to live with
parents or relatives during the pregnancy. This is consistent with the
research by Held (1981) and Becerra and deAnde (1984) who reported that
the prospective grandmother has a great influence on the teens who,
also, identified their mother as the most important person to her.

Gestation. The sample was limited to pregnant adolescents who were

 

actively attending school and who were at least 24 weeks gestation.
Once pregnant, the adolescent is faced with the decision to continue the
pregnancy. Purposeful interruption of a pre-viable pregnancy is done
before 24 weeks gestation (Jensen & Bobak, 1985). Therefore, the
adolescent had made the decision to continue the pregnancy at the time
she participated in this study.

Age at menarche. The mean age of menarche for the sample was 12.8.
Considering the mean chronological age for this sample was 16.2, the
gynecological age becomes 3.4 for this group. Forbes (1981) and Garn,
LaVelle, Pesick & Ridella (1984) both report that teens who become
pregnant after one year (gynecological age of >1) have completed their

growth. Erkan, Rimer & Stine (1971), Zlatnic & Burmeister (1977) and

109
Naeye (1981) identified teens with gynecological ages of 1 to 2 as being
at higher risk to deliver a low—birth weight (LBW) infant. The group
represents teens who, on the average, have completed their growth who
will be at a lower risk to deliver a LBW infant.
Father’s involvement. Only 50% of the teens in this study anticipated
the father of the baby to involved "alot" in the care of the baby. The
father of the baby is often stereotyped as not wanting to be involved
with the infant (Panzarine, S. & Elster, 1982). The fathers are often
adolescents themselves having to deal with their own adolescent needs
(Hardy & Duggan, 1988). The prospective father can provide support for
the pregnant teen, as with the Hispanic adolescents where the incidence
of marriage is higher (Becarra and deAnde, 1984). Involvement of the
baby’s father through marital commitment is not the norm. A recent
report from Hardy and Duggan (1988) demonstrates only one in four white
teens and very few black teens were married to the teen mother at the
time of the birth. This sample represents teens who 'on the average’
perceive the of father of the baby will be involved with the child after
delivery.

A limitation to this question is the subjective interpretation of
the selection of answers. What one teen feels is 'alot’ of involvement,
others may feel is 'somewhat’ involved or 'a little’ involved. Specific
activities or determination of time may increase the objectivity of this
question.

Planned pregnancy. The majority of the participants (90%, n=9)
indicated that the pregnancy was not planned. Prevention of pregnancy

for the adolescent involves knowledge about and use of contraceptives.

110
It is not known if any of the pregnancies in this sample were the result
of contraceptive failure.

Developmentally, adolescents feel they are immune from pregnancy and
do not have the maturity to foresee the future consequences of risk
taking behavior, i.e., unprotected intercourse. In the study by Becarra
and deAnde, 25% to 44% of the pregnant teens indicated they used
contraceptives most of the time while 77% of older teens and 45% of
younger teens in the study by Hollingsworth, Kotchen & Felice (1983)
reported they had "some or extensive" information about contraceptive
methods. In another study by Levenson, Smith & Morrow (1986), 98% of
the physicians polled felt information about contraceptives was
extremely important while only 43% of the pregnant teens felt the same
way. Prevention of pregnancy and family planning through instruction on
reproductive health and use of contraceptive is a health care need with
this study sample.

Prenatal care. In this study, 60% (n=6) of the teens sought prenatal

 

care during the first trimester (prior to 12 weeks gestation) and 40%
(n=4) during the second trimester (between week 13 and week 28). During
adolescence, the development of independence and self control is a major
task. Decision making promotes these feelings of independence and
control. The adolescent may not have attained the self confidence to
recognize and make decisions related to seeking prenatal care.

Research by Zuckerman, §t_§l, (1983), Elster (1984) and Davis, gt
al, (1986) found a strong correlation between maternal age and the

trimester that prenatal care began. Davis, et al, (1986) found the

 

likelihood of pregnant teens receiving prenatal care in the first

111
trimester increased with age. The results from this study were similar
to Zuckerman, §t_§l. (60% for 13 to 18 year olds) and Elster (50% for 12
to 16 year olds and 67% for 17 to 18 year olds) of the teens reporting
start of care in the first trimester.

The number of prenatal visits is an indicator of amount of prenatal
care received. In this sample, 40% (n=4) of the teens reported that
they attended five (<5) or less visits; 60% (n=6) attended six (>6) or
more visits. These results may be explained partially by the fact that
the overall sample is slightly older (15 to 17 versus 14 to 16).

Another reason may be the influence of the school program they attend.
Even the girls who remain in their regular school without special
'classes have increased access to school personnel, i.e., counselors,
teachers, nurses, who may help with decisions about seeking health care.

Leppert, Namerow and Barker (1986) reported that maternal age and
the number of antenatal visits were significant predictors of
gestational age and birth weight of infants born to adolescents.

Because 90% (n=9) of the teens in this study were at least 28 weeks
gestation, the minimum number of visits at this time would be six, if
care began during the second month. Thus, the majority of the teens
were attending an adequate amount of visits with 40% (n=4) not attaining
the ideal prenatal care.

Mother’s first pregnancy. Only three of eight pregnant adolescents
reported that their own mother was a teen parent. (Two students did not
complete this question). Parent role models have a strong influence as
to whether it is acceptable to initiate sexual activity, and to keep and

raise a child if pregnancy occurs (Hogan & Kitagawa, 1985). This sample

112
may not be characteristic of other research which reports pregnant teens
tend to replicate their mothers’ reproductive history (Becarra & deAnde,
1984).

It is difficult to determine an explanation for these results with
such a small sample size. This may be an area of demographics that is
changing related to identifying causative factors of adolescent
pregnancy. Depending on the age of the prospective grandmother, there
may have been increased availability and use of contraceptives or
alternative pregnancy options during their teenage years. Based on the
higher educational levels of these grandmothers, as reported by the
pregnant teens (see below), childbearing may have been delayed to
complete their education.

Parental education level: Both the mothers and fathers of the pregnant
teens in this sample have attained at least a high school diploma (90%,
n=9, of the mothers and 80%, n28, of the fathers). Of this sample, 40%
(n=4) of the prospective grandmothers and 30% (n=3) of the prospective
grandfathers had attended college. Research by Ralph, Lochman and
Thomas (1984) describe the pregnant adolescent as having role models,
especially her mother, with less education.

The connection between parental education level and adolescent
pregnancy is not clear in these research results. Research by Zelnick,
Kantor and Ford (1981) show that family values related to going to
college, choosing and career and making money are dominant influences on
the adolescent. Those teens who come from poorly educated families have
more difficulty dealing with behavior and attitudinal signals she

receives about school and work choices from both peers and family

113
members (Zelnick, Kantor & Ford, 1981). Thus, this group of teenager
appears to have had good role models related to educational achievement.
Adolescent grade level and school attendance. Eligibility to
participate in this study was based on being actively enrolled in a
school program. The majority of this sample reported that they attended
school at least five days per week (70%, n=7) and spent at least five to
six hours at school per day (80%, n=8).

At the clinic site, a prescreening questionnaire was given to all
teens to determine if they met the eligibility requirements to
participate in this research. Pregnant adolescents were eligible to
participate if they had been attending school at least three days per
week during the previous six months prior to the data collection period
(January to June). Of concern was the number of returned prescreeing
questionnaires from pregnant adolescents indicating they were not
attending school during that time period (n=15). A possible explanation
for this could be the reluctance of the teens to participate in the
research, and thus, they indicated they were not in school. More than
likely, the teens truly were not in school for which dropout rates for
pregnant teens have become a national and state concern (Epstein, 1986,
Ascher, 1985).

The literature describes pregnant teens as having less well-defined
and optimistic vocational goals; these teens have few opportunities to
participate in social activities and recreation with peers which could
provide an area for achievement and healthy competition (Ralph, Lochman
& Thomas, 1984, Mercer, 1985). Non—pregnant teens, on the other hand,

were described as vocationally oriented with strong family or school

114
ties, including many friends, hobbies and extracurricular activities
(Ralph, Lochman & Thomas, 1984, Welches, 1979). Adolescents who are
having difficulty in school, i.e., academically and with attendance,
need to be identified early and stimulated toward increased involvement
in school or other extracurricular activities to develop special or
personal interests or hobbies.

Month in school program. The majority of the teens in this study (60%,

 

n=6) reported that they had been in their school program for at least
three months. This appears to imply that the teens feel a need to
continue in school even though stressed by pregnancy. These teens who
remain in school may have been, and still are, vocationally and
educationally oriented but made the mistake of becoming pregnant and
made the decision to continue the pregnancy. With increasing support
available in the schools to help pregnant students, pregnant teens are
able to continue their education. Descriptive data about students who
enter APPs show that most will graduate or choose to continue their
schooling after delivery (Epstein, 1986).

School awareness. The teens in this study indicated that they confided

 

in a counselor (40%, n=4) or a teacher (30%, n=3) to ask for help with
the pregnancy. The process of identification of pregnant adolescents in
the school setting has not been described in the literature. Pregnant
teens in the school setting are often identified via the circulation a
”rumor" that a student is pregnant which is heard by a teacher or
counselor who matches this with other behavioral indicators, i.e.,

increased absences and decreasing grades (personal communication,

115
October, 1987). In this study, the majority of the teens appeared to
take the initiative to seek out school personnel for help.

Psychologically, the pregnant adolescent has the ”who me"
omnipotence, denial attitude and is struggling with independence yet
feeling inadequate about making decisions and taking control (Cochran &
Brassard, 1979, Whaley & Wong, 1983, Neinstein, 1984). The confirmation
of pregnancy impinges on their self-esteem and personal competence;
thus, they seek an adult for guidance. The school personnel are often
looked to for this guidance as the teens have frequent contact with the
school system and they are easily accessible. This sample appears to be
comfortable with the school personnel as a resource and turned to them
for help.

In summary, the descriptive findings of this study sample of 10
pregnant adolescents show they are between the ages of 15 and 17, at
least 24 weeks gestation and 70% black and 30% white. The majority of
the teens continue to live with their mothers who were not themselves a
teen parent. The majority of the pregnant adolescents stated they did
not plan to become pregnant and most feel the father of the baby will be
involved with the child after the child is delivered. Most of the teens
have been receiving adequate prenatal care and all have continued with
their education. The parents of most of the pregnant teens have
attained at least a high school diploma with several having attended
college. The teens identified counselors and teachers as the school

personnel they turned to to inform the school system of their pregnancy.

116

In the next section, the data from the research questionnaires will
be described and interpretations related to the research question and
hypotheses discussed.

Measures of perceived social support

The Adolescent Pregnancy Program Social Support Source Scale (APPS4)
and the Inventory of Socially Supportive Behaviors (ISSB) were used to
describe two aspects of social support perceived by pregnant adolescents
aged 15 to 17 years old. The APPS4 is a tool designed for this study to
measure perceived social support provided by school personnel to
pregnant adolescents. This study was a pilot to test the APPS4 for
internal consistency and usability with the indicated sample.

The reliability coefficient for the APPS4 evaluation perceived
support from teachers, nurses and social workers was .94, with the two
subscales measuring the amount of support and satisfaction with the
support demonstrating coefficient alphas of .84 and .90, respectively.
Burns and Grove (1987) suggest a reliability of .80 is the lowest
acceptable coefficient for a well-developed measurement tool to satisfy
the criterion of internal consistency. However, for this research, an
alpha of .7 is considered as sufficient evidence of internal
consistency. Results from this analysis indicate a high degree of
internal consistency among the items on the overall tool and subscales.
As a pilot study with a small sample size, this indicates further
testing of this tool as a reliable instrument with a larger sample would
be warranted.

The counselor items on the APPS4 were deleted from the tool because

they showed a small negative correlation to the rest of the items. This

117
raised the overall and subscale coefficient alphas. The implications
from this small sample indicates that the support perceived from
counselors is not necessarily related to the support perceived from
other three classifications of school personnel.

Counselors, historically, help the students with scholastic and
social difficulties and provide career guidance. In the case of the
adolescent who becomes pregnant, the counselor arranges for the student
to transfer into special "family life" classes within the school or
transfer to an off campus APP (Miller, 1984). The interactions with the
counselors, because of their inherent role, may be the reason for the
differences seen in these results.

The ISSB is a tool designed to assess the perception of general
support as perceived by pregnant adolescents. The reliability
coefficient for this study was .96, after deleting four items which were
not answered. The four items were from different participants and
appear to address four different concepts of social support being
measured (i.e., caring, practical aid, feedback and advice). It is felt
the lack of response to these questions is related to random omission by
the participant.

The ISSB has been used with both adult and adolescent populations.
Previous studies using the ISSB report similar coefficient alphas, (.92,
.94, .92, Berrera, §t_gl, 1981, Berrera & Ainlay, 1983). The results
from this study demonstrate high internal consistency among the items on
the ISSB.

In summary, both the APPS4 and ISSB show strong degree of internal

relatedness among the items in the scale. The small sample size limits

118

the generalizability of the results to the general population of
pregnant adolescents. From these results, it appears that the APPS4 is
reliable for evaluating the perceived supportiveness of school teachers,
nurses and social workers. Further testing to evaluate the measurement
of perceived support from counselors using a larger sample size needs to
be done. Monitoring absence of responses for patterns is indicated when
using the ISSB.
Research Questions and Hypothesis

Calculation of mean scores, Pearson-product moment correlation
coefficient and analysis of covariance (ANCOVA) was used to answer the
research question one, research question two and hypothesis,
respectively. Because of the extremely small sample size, these results
are not statistically "significant" and can only be taken as descriptive
of the sample. The sample produced three groups of pregnant
adolescents. Group one (1) are those adolescents in the inclusive
program (n=5), group two (2) are those adolescents in the supplemental
programs (n=3), and group three (3) are those adolescents who remained
in school but were not enrolled in any special classes related to
pregnancy (n=2). Although the research question and hypothesis did not
include this third group, results will be discussed and contrasted to
groups 1 and 2.

Research question 1

 

Are selected school personnel who provide services in inclusive APPs
perceived by the pregnant adolescent to be more supportive as compared

to school personnel who provide services in supplemental APPs?

119

The mean score for the 24 item APPS4 was calculated for three
groups: Group one ~ pregnant teens enrolled in inclusive programs,
2.54, group two - pregnant teens enrolled in supplemental programs,
2.88, and, group three - pregnant teens who remained in school but were
not enrolled in special classes related to the pregnancy, 2.44 (on a
scale of l to 5). Given the results from the small number of cases in
this pilot, these mean scores indicate pregnant teens in supplemental
programs perceive more support from school than the pregnant teens in
inclusive programs and those not enrolled in any special coursework.

The results above indicate that the teens in supplemental APPs find
the environment more supportive. These are the teens who remain in
their regular high school and transfer into special classes related to
pregnancy and parenting. They do not have to transfer to another school
building or to a separate program. A possible reason for the feeling of
less support by teens in inclusive programs may have social and
policital underpinnings. The supportive environment of the APP can be
politically and socially stigmatized. Although state and local school
districts realize these teens need special services, the controversy
remains over where the services are provided. Several reports reveal
that the pregnant teen who remains in the regular school setting "bring
sexuality matters to the attention of other adolescents" (Weatherley,
Perlman, Levine, Klerman, 1986, p. 76). These teens offend influential
adults in the community and, thus, special APPs are segregated and tend
to keep a low profile. These sentiments about the program, (and the

pregnant teen) isolate the teen from her peers and may generate feelings

120
within the teen of being "unsightly and immoral" (Perlman & Weatherley,
1986, McCarthy & Radish, 1983).

A difference was noticed in the subscale scores between the teens in
the two programs. The teens in the supplemental APP reported receiving
an average 'amount of’ support as compared to the teens in the inclusive
APP who report a of small 'amount’ of support. The need of specific
types of support or a description of satisfaction with the support given
to the pregnant adolescent is not described in the literature. In the
literature, evaluation of APPs are based on maternal outcome, infant
outcome and educational achievement. Although these are important
issues, these outcomes are "after the fact” and the present reality of
dealing day to day with the adolescent is left to the program personnel.
This small sample appears to show that there is a perception of more
support from the supplemental APPs than from inclusive APPs.

Both inclusive and supplemental APPs provide pregnant teens exposure
to other teens in similar circumstances. The benefits of peer to peer
contact based on what the adolescent perceives is not empirically
described in the literature. Transfering from their regular school into
an inclusive APP may promote feelings of isolation from long time
friends who are not pregnant. Furthermore, this may also increase their
stress because of having to make new friends. Isolation from long time
friends and having to make new friends may be a factor in the reduced
perception of support from the school system and school personnel in

inclusive programs.

121

Research qpestion 2

 

Knowing that the pregnant adolescent may also receive support from
her family, friends, neighbors, etc., what impact does this perceived
support received from people in general have on the perception of
support from her school program?

The results of the Pearson product-moment correlation coefficient
demonstrated that there is a relationship between the adolescents’
perception of general support and the adolescents’ perception of
specific support (school support) within the total sample. However,
school support and general support are perceived as different.
Therefore, the scores from the ISSB, measuring general support, were
introduced as a covariate to answer question 2.

The statistical analysis of the impact of perceived general
support on the perceived school support showed that the teens enrolled
in inclusive programs perceived more support from the school personnel
after general support was factored. The teens in supplemental programs
perceived school personnel to be supportive whether or not general
support was a factor. However, comparing the adjusted means of the two
groups, the teens attending the supplemental APP perceive more support
(2.88) from their school programs than the teens attending inclusive
programs (2.58).

The teens who remained in school without special classes related to
pregnancy (group 3) perceived more general support than teens in the
other two groups. Adjusting the mean score of the APPS4 for this group
by factoring the general support variable (ISSB) showed that the teens

perceive less support from the school personnel. Thus, the teens who

122
remained in school without special classes were receiving more support
from their general environment than their school environment (school
personnel).

Hypothesis

Pregnant adolescents enrolled in inclusive adolescent pregnancy
programs will perceive more social support from selected school
personnel as compared to those pregnant adolescents enrolled in
supplemental adolescent pregnancy programs.

Interpretation of the data analysis reveals that pregnant
adolescents who attend supplemental APPs perceive their school program
to be more supportive than the teens who attend inclusive programs.
These results cause the hypothesis to be rejected. Controlling for
general support received from family, friends or neighbors clarified the
teens perception of support from the school program.

The results from these three groups appears to support the need for
special involvement of the school system in the care of pregnant
adolescents. Results of one study identified support needs of pregnant
and parenting adolescents. Barth, Schinke & Maxwell (1983) compared
responses of 185 pregnant or parenting teens with non~pregnant teens,
all who were in an APP or regular school, related to issues of
adolescent parenting and childbearing. The pregnant and parenting teens
reported both needing and having more social support that non-parenting
girls and the black adolescent tended to receive more social support
than whites. Identification of specific supportive factors to the
adolescents is not part of either the Barth, Schinke & Maxwell study nor
described in this research.

Advantages and disadvantages over the type or structure of APPs the

pregnant teen attends is debatable. Zellman’s (1982) research of 12

123
APPs concludes that inclusive programs are "short-term interventions
which have little or no communication with regular school staff" (p.
20). The regular school staff feel they are not obligated to provide
special services to special needs students and that having a program in
the district, outside the regular school setting, is good enough. 0n the
other hand, supplemental programs avoid the hassle of having to transfer
to another school and school faculty would have to interact with
pregnant students on the basis of academics and attendance as they would
with any other student (Zellman, 1982).

In summary, although there is little research about the adolescents’
perception of social support from their school program, the results from
this small sample tends to show supplemental APPs programs (group 2)
are perceived to be more supportive than inclusive APPs (group 1).
Furthermore, students who remain in school but not enrolled in special
APPs (group 3), attain more support from their environment, excluding
school personnel. The literature on the school’s role in dealing with
adolescent pregnancy describes weak and unclear school policies as to
the faculty and administrator involvement with and response to the care
of these students. The response of the school system and the community
at large may have an impact on the perception of support the adolescent
feels she receives from school programs. Furthermore, identification of
the needs of these special students by asking them about their needs
during pregnancy and after delivery will assist in the creation of new
interventions to strengthen the supportive enviroment of the school

personnel and school systems.

124

In the next section, the results of this study will be applied the

conceptual frameworks’ of Rogers, Dewey and social support.
Modification of the Conceptual Model
Based on Study Findings

The conceptual scheme for this research, as shown in Figure 2
(chapter II), offers a comparison of the nursing theory of Rogers and
the educational theory of Dewey, each offering social support to the
pregnant adolescent. Social support becomes a tool for both
nursing and school personnel in the care of the pregnant adolescent.

The adolescent continues to grow and develop even as the pregnancy
progresses. The pattern of growth is altered as compared to other non-
pregnant adolescents yet she develops in unique areas not perceived by
her non-pregnant peers (responsibility for health and care of a fetus
and child). The impact of nursing care in this model appears to be
illuminated as the pregnant adolescent seeks prenatal care and health
counseling. Developing a relationship with pregnant adolescents
involves physical, social and psychological care which increases in
frequency and intensity as the adolescent nears delivery.

Nursing’s role, according to Rogers, is to promote "symphonic
interaction between man and environment . . . to direct and redirect
patterning of human and environmental fields for realization of maximal
health potential (Rogers, 1970, p. 122). Environmental interaction with
the human field is seen in Figure 3 by the increasing rhythmicities and
increasing arrows to between nursing and Unitary man depicting the

principles of integrality, helicy and resonancy.

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Nursing Interventions

 

126

Nursing, as an environmental field of the pregnant adolescent,
responds to the increasing complexity of the teen’s life helping her to
understand and deal with the ensuing stresses or strains. This research
revealed that the small group of participants were receiving adequate
prenatal care and contact with nursing personnel. Providing social
support is a nursing intervention which plays an important role in
buffering the stress of pregnancy and dealing with specific problems
that surround the pregnant adolescent (Brown, 1986). Implications for
nursing practice will be discussed later in the next section.

Dewey’s principles of education are valid and important in the
education of pregnant adolescents but difficult to recognize in today’s
educational systems. School is a place where students should be
educated according to their interests or needs via interaction with an
environment that offers experiences for the student to grow and develop.
The ability of the school system and their personnel to change with the
needs of the student is controversial related to special education for
pregnant teens. The solid, wavy line in Figure 2 depicts the
restructuring, adaption and transformation of the school system as the
teen develops prior to pregnancy. This line changes to a broken line of
varying degrees for those who remain in school while pregnant. The
amount of continuity of each line represents the perception of
supportiveness by the pregnant teens of the school personnel in the
three groups. For the pregnant teens who drop out of school, the line
stops during pregnancy and, hopefully, continues after delivery as they

continue their education.

127

For this research, two school programs were utilized: one run by a
city school district and one run by a county school district.
Establishing programs such as these emphasize the ability of the school
environment and community to adapt to the needs of the changing
adolescents. Dewey would describe this restructuring and transformation
as continuity of life. In Michigan, state and local support helped to
develop and maintain APPs which have demonstrated success in keeping the
teens in school, encouraging good prenatal care, reducing rates of
infant mortality, prematurity and low birthweight and preventing repeat
pregnancy (Epstein, 1986). Dewey’s principle of democracy is
demonstrated by the mutual interest of state and local governments in
Michigan regarding the incidence and pregnancy outcomes of adolescents
and the ability of the communities to change.

The Epstein (1986) Report on the eight model school-age parenting
programs in Michigan included the two school sites in this study and the
programs serving the urban clinic site. In the report, the dropout rate
for students who became pregnant over the three year evaluation period
was 19%. Thus, the results of this study and the Epstein report
describe a need to focus on earlier identification and intervention with
pregnant teens including outreach education and follow up after
delivery.

The objective of education, according to Dewey, is to prepare the
young for future responsibilities and success in life through experience
and knowledge acquisition (1938). For the teens in this research who
are in APPs, they are being prepared for the responsibilities and

stresses of parenthood focusing on parenting skills, infant growth and

128
development and problem solving and decision making exercises about
their present and future situations. The arrows to and from the
adolescent, in Figure 3, decrease in number as the pregnancy progresses
representing the increasing physical discomforts impacting the teens
ability to attend school.

Teachers play an important role in a child’s education. The
teachers, in this research, were not singled out as to the amount of
supportiveness they provide. From statistical analysis of the data from
this research, the pregnant teens reported the counselors as providing a
different type of support as compared to the other school personnel.
Because of the small sample size it is difficult to determine how the
support differs. However, schematically, counselors are identified in
Figure 3 as providing different support to encourage more research on
this phenomenon.

Social support is likely to be effective only to the extent to which
it is perceived (House, 1981). Measuring social support objectively via
levels of amount and satisfaction with support activities was the goal
of this research. The tools used in this research contained questions
about emotional, instrumental (practical aid), information and appraisal
(feedback) support which House (1981) describes as integral concepts of
social support. It was not the intent of this research to look at the
individual concepts of social support. However, additional research
describing specific types of support (i.e., emotional, practical,
information and appraisal) perceived by pregnant
adolescent from school personnel would be advantageous in identifying

strengths and weaknesses in the APPs.

129

House (1981) bases his philosophy of social support on stress
producing situations at work/school which may impact the health of the
individual. The results of this research show that support was
perceived, at best, only at an average level. Group three, teens in
regular school, reported school to be less supportive when general
support was factored out. This raises the question as to whether school
is supportive at all or is it more of a stressor to this group of
pregnant adolescents.

In Figure 3, perceived social support from the school programs is
shown as wavy lines external to the adolescent. A scale is provided
indicating the level of support and the ranking of the school programs.
Support provided by APP has not been measured objectively and,
therefore, the results of this study are tenuous pending more research.

Research done with pregnant women shows social support to be
beneficial to buffering stress of pregnancy resulting in improved
maternal and newborn outcomes. (Nuckolls, Cassel, & Kaplan, 1972,
Tilden, 1983, Brown, 1986). School programs, because of the significant
contact with the pregnant teen can play a supportive role. Measuring
the support already provided by these programs, identifying weaknesses
and developing interventions to counter stress and enhance support
should be goals for school based APP.

In summary, it appears that there are programs and services
that have been created for pregnant teens to promote and improve health
and educational outcomes. Weaknesses lie in ongoing evaluation of of
the services related to social impact on the student, coordination and

linkage between the school and community resources and support for

130
continuing education for teachers and school staff about health needs of
pregnant students. Implications of the study findings for nursing

practice will be presented in the next section of the chapter.

Implications for Nursing Practice

 

Rogers’ theory of nursing is schematically presented in Figure 1
(Chapter II) and modified in Figures 2 (Chapter II) and 3 (Chapter IV).
In all the figures, nursing is represented as part of the pregnant
adolescents’ environment. Normally, nursing contact would be on a
routine, health promotion or health maintenance basis. However,
pregnancy changes the frequency and intensity of the contacts, i.e.,
monthly visits for six months and then biweekly and weekly as the
adolescent nears delivery. Utilizing the nursing process format,
implications from this research related to the nursing practice include:
a) determining the role of nursing in the care and treatment of the
pregnant adolescent, and, b) development and planning of supportive
interventions which will maintain the health of the pregnant adolescent
and her fetus while she remains in school.

Research about and evaluation of programs providing primary care to
pregnant adolescents supports the use of nurses in advanced practice
(i.e., clinical nurse specialists, CNS) to improve health and pregnancy
outcomes (Neeson, et al., 1983, Institute of Medicine, 1985, Skinner, et
al., 1986). There has been increasing support for school based clinics
to care for adolescents. Meeker, et al., (1968) in their research of
school based clinics supervised by nurse practitioners revealed that
nurse practitioners (NP) "can and do provide care without extensive

physical involvement for most of the child’s health problems and also

131
identify and manage critical and complex health problems" (p. 89).
Likewise, clinic based teenage pregnancy programs staffed by nurses in
advanced practice can effectively manage these teens. Nurses in
advanced practice (practitioners and midwives) tend to relate to their
patients in a non-authoritarian way and focus on education and support
for the pregnant teen (Institute of Medicine, 1985).

A nurse practitioner/clinical nurse specialist (NP/CNS) should be
available to inclusive and supplemental school based adolescent
pregnancy programs. If a school does not have a supplemental APP
curriculum on site and has a high incidence of adolescent pregnancy for
which those students choose not to transfer out to an inclusive program,
contracting with a NP/CNS might be an option to monitor the health of
these students. Availability of the NP/CNS may not mean daily visits to
school, however, estabilishing routine office hours at the schools
including involvement in teaching courses about pregnancy are ways to
increase the adolescents access to a health care professional.
Maintaining the continuous contact using the same NP/CNS is important to
maintain continuity, build rapport and plan and implement interventions
to help the teen. Visability at the school setting also increases the
school personnel’s access to the NP/CNS for collaboration and
coordination of services.

Having office hours at the school may or may not include the
facilities to provide physical care. Linkage to a convenient, community
based health care facility where the NP/CNS can provide the clinical
care is a must. This aspect can be attractive to a health care system

as this represents community outreach and increased Visability.

132

The role of the clinician involves assessment of client needs
related to physical care, education and support as she adjusts to the
pregnancy. The current project utilized two assessment tools to provide
subjective information on perception of support which could be
administered in the clinic setting. The Adolescent Pregnancy Program
Social Support Source Scale (APPS4) provided a rating of the student’s
perception of support from her school program, specifically school
teachers, counselors, social workers and nurses. The Inventory of
Socially Supportive Behaviors (ISSB) provided a rating the pregnant
teens perception of general support from persons other than school
personnel.

Rogers’ theory supports the continued assessment of 'Unitary man"
over time to identify patterns of growth and organization. The
adolescent and her world are considered energy fields which interact.

It is the pattern and organization of man’s interaction with the
environment that develops his unique identity (Rogers, 1970).
Interaction patterns are altered by the crisis of pregnancy making the
adolescent vulnerable to difficulties in communicating needs. Utilizing
comprehensive lists of health or personal needs with pregnant
adolescents has produced well defined interests (Giblin, Poland & Sachs,
1986). The instruments used in this research could be used at the
initial visit to identify the need for specific types of support and
assess the teens relationship with her school program.

As a clinician, measuring social support objectively, other than by
written questionnaire, can be problematic. Encouraging the teen to

bring her mother, the father of the baby or a significant other who she

133
feels is supportive during prenatal visits can provide additional social
support information. Observing interactions of the teen helps to
evaluate how she is coping with the pregnancy. The ability to provide
continuous care can promote the role of nurse assessor related to
personal support systems of the pregnant teen.

The information obtained by the APPS4 assesses another aspect of the
environment surrounding the adolescent. The importance of and
satisfaction with school are identified as predictors of risk taking
behaviors and the adolescents’ ability to cope with normal stresses and
strains of adolescence (Held, 1981, Pletch, 1988). Through continued
contact with school personnel, the NP/CNS can confirm the academic
status, verify support, identify referrals the school system provides
and allow for collaboration in the care of the pregnant adolescent.

A distressing finding in this study is the number of students not in
school. Dissatisfaction with school and limited occupational goals have
been identified as precursors to pregnancy risk behavior (Ralph, Lockman
& Thomas, 1984). Pregnant students who remain in school attain more
health care during pregnancy and have better pregnancy outcomes
(Leppert, Namerow & Horowitz, 1985, Epstein, 1986). Continued
assessment of school attendance and supportive counseling to assist the
adolescent with problem solving and decision making in the primary care
site can identify pregnancy risk behaviors and prevent interruption of
academic and health care services.

Assessment of needs allows for the development of objectives and
goals to plan interventions (Giblin, Poland and Sachs, 1986). Goals for

care of the pregnant adolescent include:

134
a) Health promotion and health maintenance for the teen and her

fetus,
b) Detection and treatment of potential health complications during

pregnancy.

0) Continuing academic study before and after delivery,

d) Psychological maturation to deal with present stresses and in

preparation for delivery, and finally,

e) Identification of support services within the school system for

pregnant and parenting teens.

In this study, the need to attain and strengthen support systems
surrounding the pregnant adolescent was emphasized. Interventions
focusing on building support within the teen’s family and peer network
are important (Becerra & deAnde, 1984, McCubbin, Needle & Wilson, 1985).
Developmentally, the pregnant teen is experiencing identity diffusion as
she becomes more dependent on her parents versus the developmental task
of gaining independence and increase incteractions with peers
(Havighurst, 1972, Cochran & Brassard, 1979). Instead, the pregnant
teen becomes isolated from peers and identify their mother as the most
important person at this time (Becarra & deAnde, 1984, Panzarine, 1986).
The teen’s mother should be included in the care of the adolescent.

Isolation from peers and increased dependence on her mother can
interfer with development of her identity and self-confidence. The
NP/CNS should stimulate discussion with the adolescent about
relationships with her peers prior to the pregnancy, including the
relationship with the father of the baby, and how those relationships
have changed. Through active listening and discussion, the NP/CNS can
assist the adolescent to develop ways of handling these situations
including acting them out through role playing. Encouraging the teen to

invite a special friend to come with her to appointments with the nurse

may strengthen the relationship and support the teen.

135

There are many dimensions to caring for the pregnant adolescent
which could overwhelm the nurse. Recognition of the need for
multidisciplinary support for the client and including them in the plan
of care is important (Giblin, Poland & Sachs, 1987). Comprehensive care
for this population includes input from dieticians, social workers,
counselors, teachers and physicians who play different roles and can
also provide support to the adolescent. Rogers eloquently describes the
coordinator role of nursing, "Professional nursing seeks to promote
symphonic interaction between man and environment . . . and to direct
and redirect patterning of human and environmental fields" to achieve
maximal health outcomes (p. 122).

Many people, including teachers, have difficulty addressing or
dealing with issues related to sexuality. Furthermore, the teachers
have ambivalent feelings about pregnant teens remaining in regular
school classes. Educational and counseling opportunities should be
offered to teachers to strengthen their ability to communicate, interact
with and help pregnant students. The NP/CNS involved with the school
could provide information about the impact of pregnancy on the teens
growth and development and health care issues the teen has to deal with.
The counselor could clarify the school referral system and other
community resources for the teachers.

Programs to educate and inform teachers need money for program
development and time to get school staff involved. Manpower and
commitment is a must to promote involvement which the teachers can share
with other students to promote a supportive and understanding

environment for pregnant adolescents.

136

Implementation of the plan of care involves consistent care givers
who are accessible to the adolescent. Joint visits and mutual goal
setting with the adolescent and the physician who will be delivering her
will promote continuity and help to decrease her fears once in the labor
and delivery area. Working with adolescent can be trying under normal
circumstances because of their unpredictable behavior and emotional
lability. Development of rapport and trust is the building block to
the nurse-client relationship (DeSantis, 1986). Repeated visits to the
same care giver with input from the primary physician promotes
individualized prenatal care to implement and evaluate health activities
(Neelson, et al., 1983).

A report prepared for the U. S. Department of Health and Human

Services on planning adolescent pregnancy programs supports the use of

case managers .

". to expand the availability of and access to comprehensive

services, (adolescent pregnancy) programs must both assess their
client’s individual needs and provide or arrange for services to
meet those needs. Some one must assume responsibility for
monitoring individual cases to make sure that clients get available
services according to their needs (Burt & Sonenstein,

1984, p. 16)

Case management is not a new concept to health care. Currently,
however, it is being brought back as a health management intervention
for clients with complex health needs. Acting as change agents in the
care of pregnant adolescents, nurses in advanced practice can and should
be case managers providing services in health education and counseling
coordinating services and providing hands on care assuming the

responsibility for services. Assisting the adolescent in working with

137
the social/medical systems and coordinating efficient care provides
support to maintain a productive relationship.

The NP[CNS as case manager would need to develop a strong working
relationship with the counselors, school nurse and teachers. In this
study, it appears that counselors provide support to the pregnant
adolescent which was different than the support provided by teachers,
social workers or nurses. Further research on the role of the counselor
in working with pregnant adolescents is indicated.

The role of the school nurse in the care of the pregnant adolescent
is questionable. Many districts do not have school nurses. Those who
employ nurses, utilize these professionals to coordinate school wide
health promotion activities such as immunizations, provide episodic care
and health education. Because of these broad responsibilities, the
NP/CNS could assist the school nurse in monitoring the teens through
consultation and team meetings including the school faculty involved
with the student. Supporting the role of the burdened school nurse in
the care of the pregnant adolescent promotes the comprehensive focus of
APPs related to provision of health monitoring and education.

Evaluation of services provided to pregnant adolescents is based on
the pregnancy outcomes of maternal and fetal complications, infant
outcomes, completion of high school and reduction of repeat pregnancy
(Smith, et al., 1978, Epstein, 1986, Heins, Nance and Ferguson, 1987).
This research focused on identifying supportive factors provided which
then could be used in attaining healthy outcomes and develop productive
individuals. As the primary care giver, the CNS/NP is in the position

to identify system weaknesses, coordinate and evaluate services and

138
implement referrals. The CNS/NP promotes her role as clinician
and educator via continuity of care and monitoring the adolescents
progress.

In summary, the research findings were related to the steps in the
nursing process with a focus on the nurse in advanced practice providing
care in a primary care setting. Using instruments such as the APPS4 and
ISSB in the assessment of the pregnant adolescent’s perceived social
support assists in the development of a comprehensive data base. Study
findings raise questions about potential gaps in the health and
educational needs of adolescent which have implications for nursing.
Promotion of primary care services through case management has been
discussed as a vehicle to improve and promote comprehensive services to
pregnant adolescents.

In the next section of the chapter, implications for nursing

education will be presented.

Implications for Nursing Education

Implications of nursing education based on the research findings
will emphasize the conceptual framework upon which this study was based.
Selected concepts of the framework will be presented followed by
pertinent study findings and the implications which they infer.

Use of Rogers’ five assumption, described in Chapter II, have
importance for nursing education. These assumptions describe the growth
and development of Unitary man over time who develops a unique
personality and mind in response to environmental experiences and

interactions. Use of Rogers theory by nurse educators in the

139
conceptualization of adolescent growth and development allow theory to
illuminate reality and promote understanding theoretical concepts.

The impact of pregnancy on adolescent growth and development
identifies chronological age versus gynecological age as a dimension of
risk. Although controversies exist about the "high risk" status of the
pregnant adolescent, it promotes critical analysis of literature and
application in practice (Bucholtz & G01, 1986). Naeye (1981) supports
the notion that pregnant adolescents are not at risk for pregnancy
complications because of physical immaturity. Rather it is the
psychosocial dimension surrounding the adolescent that increase risk
factors.

Social support as a dimension of the adolescent environment includes
the school program. Community health nursing must be involved in the
care of the pregnant adolescent and interface with the educational
system. Dewey’s educational theory stresses the learning that occurs
because of experiences the student encounters. This client is under
age, but soon to be a single parent. Her resources are limited because
of her inability to negotiate a complex health and social services
system. Nursing education and experience dealing with community
networks, including schools, social services, mental health and health
care, is essential in order to provide comprehensive care and
appropriate referral of adolescent clients for services. The nurse, as
a role model for the adolescent, can promote understanding of
negotiating systems which will be useful in future situations.

Social support from the family needs to be a primary focus of

nursing education. Change in one part of the family system impacts

140
other parts of the system. Education about exercises to use with
adolescent related to values clarification and decision making are a
must (Mercer, 1985). In this study, 90% of the teens were at home with
their mothers. Family interaction and counseling, especially the
inclusion of the teen’s mother is essential as a source of support
(Mercer, 1985, Panzarine, 1986).

In this study, two tools which assess the perception of support by
the adolescent were utilized. The NP/CNS can use these tools, which are
short and easy to understand, to assess the pregnant adolescent’s
perception of social support from school and in general. Although the
APPS4 needs further testing, it provides specific information about the
school environment. Use of well developed and tested tools like the
ISSB should be promoted by nurse educators in the gathering of objective
data about client perceptions and feelings.

Negotiating complex education, social and health care systems in the
midst of the crisis of pregnancy is overwhelming for the adolescent.

The impact of these complexities and the identification of adolescents
who may drop out of school needs to be included in nursing education
about the care of adolescents for the prevention of being lost in the
system and isolated from peers and potential support systems.

While the findings from this study are inconclusive, implications
about the primary care role of nurses including provision of support and
collaboration with the educational system provides new perspectives for
nursing education related to the care of pregnant and non-pregnant
adolescents. In the next section of this chapter, implications for

future research will be presented.

141

Implications for Nursing Research

 

A number of implications for further research may be derived from
this study. Suggestions for improvement of design of this study
include:

1. An increase in sample size in order to both increase the
generalizability of findings and enhance the possibilities of obtaining
statistically significant correlations

a. Increase the age range to include adolescents less than 18
years of age to attain a larger sample size.

b. Increase the number of data collection sites, especially
the school programs and additional clinics who have teen
pregnancy programs.

2. Provide incentives for the adolescent to participate in the
study.

a. Develop a "buddy system" using teens who already
participated to recruit other eligible participants.

3. Enhancing the parental consent process to include phone consent
and mail consent.

4. Ideal data collection times at school sites should be November
and December and March through May.

Additional recommendations for further study include:

1. With a larger sample size, statistical analysis of the types of
perceived support each category of school personnel may provide,
especially focusing on the role of the counselor.

2. Development of objective measures to evaluate the peer to peer

support.

142

3. Development of measures to assess the impact of having to change
schools on the pregnant adolescent.

4. Description of the teens who stay in their regular school
program while pregnant.

5. Identification of those teens who drop out of school,
assessment of their support systems, values and plans for the
future, including longitudinal follow up.

6. Specific focus on teens age 14 and younger related to the role
of school, including the junior high and/or the transition to an
inclusive, in providing a supportive environment.

Summary
In Chapter VI a summary and interpretation of study findings was
presented. Findings were related to the conceptual framework and the
nursing theory of this study. Recommendations for nursing practice,

education and research were presented.

APPEND ICES

APPENDIX A

BACKGROUND DATA QUESTIONNAIRE

APPENDIX A

BACKGROUND DATA QUESTIONNAIRE

Section One

Below are general questions about your background and school
program. Please place an (X) in the appropriate blank or fill in the
blank as you answer each question. Answer all the questions to the best
of your ability. Remember all your answers are confidential. Thank you
for volunteering to participate in this research.

1. Date of birth (fill in) /
Month Year

 

2. What is your ethnic background? (Check one)
Black

White (caucasian)
Mexican American

Native American (Indian)
Asian American
Other (specify)

 

3. With whom are you now living? (check one)

mother only ____ father only ____ both parents
____ boyfriend ____ husband ____ relatives
friends other live alone

4. When is your estimated date of delivery? (fill in)

/ /
Month Day Year

5. At what age did you have your first menstrual period? (fill in)
Age _______

6. Do you anticipate the father of your baby to be involved
with the care of the infant after the birth? (check one)
a lot somewhat a little _not at all

7. Was this pregnancy planned? yes no

8. What month did you first go to the doctor or clinic to
find out if you were pregnant? (check one)

____ First Month ____ Fifth Month
____ Second Month ____ Sixth Month
____ Third Month ____ Seventh Month
____ Fourth Month ____ Eighth Month

Ninth Month

143

10.

ll.

12.

144

How many prenatal visits have you attended to date? (check one)

How old was your mother

 

What is the highest
(check one)

What is the highest
(check one)

Age

when she had her first baby?

5 or less visits
6 to 11 visits
12 or more visits

(fill in)

grade of education your mother completed?

grade

 

9th grade or less

10th grade

11th grade

High school diploma

Some college

Two (2) years of college
Four (4) years of college
Graduate level or above

of education your father completed?

 

9th grade or less

10th grade

11th grade

High school diploma

Some college

Two (2) years of college
Four (4) years of college
Graduate level or above

The following questions are

Section Two

about your school and classes. Please

place an (X) in the appropriate blank as you answer each question.

13.

14.

15.

What grade are you in now? (Check one)

__ 8th _ 9th _ 10th _ 11th _ 12th

On the average, how many days per week have you attended
school during the last two (2) months? (Check one)
___ l-2 days _ 3-4 days _ 5 days

On the average, how may hours per day do you spend at school?
(Check one)
1 to 2 hours
5 to 6 hours

3 to 4 hours

7 or more hours

145

How many months have you attended the classes provided by this
program? (check one)

____ one month ____ five months

____ two months ____ six months

____ three months ____ seven months
four months eight months

____ nine months
How did the school system find out about your pregnancy?
(Check one)
You confided in or approached a school teacher
You confided in or approached a school counselor
You confided in or approached a school nurse
You confided in or approached a school social worker
Friends told
A school teacher approached you
A school counselor approached you
A school nurse approached you
A school social worker approached you
Other
I don’t know

-..-_—

APPENDIX B

ADOLESCENT PREGNANCY PROGRAM SOCIAL SUPPORT SOURCE SCALE

APPENDIX B

ADOLESCENT PREGNANCY PROGRAM SOCIAL SUPPORT SOURCE SCALEt

This is a questionnaire about the school personnel involved with
the adolescent pregnancy program you attend. I would like to learn more
about the support you receive from : 1) school teachers, in general
(both the program teachers and any teachers you have contact with during
the school day), 2) school counselors, 3) social workers, both in your
school or if they come to your school to talk with you, and 4) school
nurses or community nurses who come to your school.

As you can see in section one, the answers are ranked on a scale
from "Almost None" to "A Great Deal" for section one. In section two,
the answers are ranked on a scale from "very dissatisfied" to ”greatly
satisfied". Please circle the number that best describes your feelings
or perceptions.

Section One IE
-H O ‘E
5 5 8 7:
o O o
s s e. 5 a
z .-. 8 a: :3
If you wanted to talk to someone at school about .3 r; g h 8
things that are very personal and private, in o a < 3 c
general, how much comfort, concern or caring a < 5 < v:
do you feel you receive from:
1. School teachers? 1 2 3 4 5
2. School counselors? l 2 3 4 5
3. School social workers? 1 2 3 4 5
4. School nurses? 1 2 3 4 5
If you needed to borrow something or needed help
with something (clothes, food, money, help with
finding housing or services), in general, how
much help or assistance do you feel you
receive from:
5. School teachers? 1 2 3 4 5
6. School counselors? l 2 3 4 5
7. School social workers? 1 2 3 4 5
8. School nurses? 1 2 3 4 5

*Adapted from Caldwell & Reinhart (1987)

146

147

How much positive feedback, (meaning when they
like your ideas or the things that you do),
do you feel you receive from:

9. School teachers?

10. School counselors?

11. School social workers?

12. School nurses?

In general, how much advice or information
do you feel you receive from:

13. School teachers?
14. School counselors?
15. School social workers?

16. School nurses?

Section Two

In general, how satisfied have you been with the
concern or caring (for example, the opportunities
to talk about things that are personal and
private) you have received from:

17. School teachers?

18. School counselors?

19. School social workers?

20. School nurses?

Almost None

H

H
C
:3
O
5
H
H
(U
E
U)
<
2
2
2
2
2
2
2
2
'U
G)
«4
@-
M
0H
4.)
O
n
n
or!
9
Z’
O
>
1
l
l
l

to Dissatisfied

N

An Average Amount

00

Satisfied

00

r 4’ 4‘ 4* A Large Amount

bob-859

Largely Satisfied

fink-k9

A Great Deal

CIVIC!

UIOIOIOI

Greatly Satisfied

OI

148

In general, how satisfied have you been with the
amount of help or assistance (opportunities to
borrow or receive money, food, clothes, etc.)
you have received from:

21. School teachers?

22. School counselors?

23. School social workers?

24. School nurses?
In general, how satisfied have you been with the
amount of positive feedback (letting you know they
liked your ideas or things that you did) you have
received from:

25. School teachers?

26. School counselors?

27. School social workers?

28. School nurses?
In general, how satisfied have you been with
the amount of advice or information you have
received from:

29. School teachers?

30. School counselors?

31. School social workers?

32. School nurses?

Very Dissatisfied

H

Dissatisfied

N

N

Satisfied

OD

Largely Satisfied

Q

has»

Greatly Satisfied

0|

APPENDIX C

INVENTORY OF SOCIALLY SUPPORTIVE BEHAVIORS

APPENDIX C

INVENTORY OF SOCIALLY SUPPORTIVE BEHAVIORS*

I am interested in learning about some of the ways that you
feel people, other than school personnel, for example, your family,
friends or neighbors, have helped you or tried to make life more
pleasant for you over the past four weeks. Below you will find a list
of activities that other people might have done for you, to you, or with
you in recent weeks. Please read each item carefully and indicate how
often these activities happened to you during the past four weeks.
Please circle the reply that best fits you. Use the following scale to

make your ratings:

Not at all

One (1) or two (2) times in the past four (4) weeks (2/30)
One time per week (4/30)

Several times a week (12/30)

Once a day (30/30)

fiWNr—‘O

Past Month

00 One Time per Week
per Week

4: Once a Day

During the past 4 weeks, how often did people do
these activities for you, to you or with you:

O Not At All
1 to 2 Times in
93 Several Times

...;

1. Was right there with you (physically)
in a stressful situation.

0
...;
N
w
A

2. Provided you with a place where
you could get away for awhile

3. Told you what she/he did in a situation that 0 l 2 3 4
was similar to yours.

4. Did some activity with you to help get your 0 l 2 3 4
mind off things.

5. Talked with you about some interests of yours. 0 1 2 3
6. Let you know that you did something well.

7. Went with you to someone who could take action. 0 1 2 3

O

...;

N

w
hbk-fi

8. Told you that you are OK just the way you are. 0 l 2 3
*Berrera, Sandler, & Ramsay (1981)

149

10.
ll.

12.

l3.

14.
15.

16.

17.

18.
19.

20.

21.

22.

23.

24.

150

Told you that she/he would keep the things that
you talked about private - just between the

two of you.

Assisted you in setting a goal for yourself.

Made it clear what was expected of you.

Verbalized admiration or respect for a skill
or personal quality of yours.

Gave you some information on how to do
something.

Suggested some action that you should take.
Gave you over $25.

Comforted you by showing you some physical
affection.

Gave you some information to help you
understand a situation you were in.

Provided you with some transportation.

Checked back with you to see if you
followed the advice you were given.

Gave you under $25.

Helped you understand why you didn’t do
something well.

Listened to you talk about your private
feelings.

Loaned or gave you something (a physical
object other than money).

Agreed that what you wanted was the right
thing to do.

0 Not At All

1 to 2 Times in

Past Month

...:

...:

N

'2 One Time per Week

00 Several Times

per Week

45 Once a Day

.b

uh

25.

26.

27.

28.

29.
30.

31.

32.
33.

34.

35.
36.

37.

38.
39.

40.

151

Said things that made your situation
clearer and easier to understand.

Told you how he/she felt in a situation
that was similar to yours.

Let you know that he/she will always be
around if you need assistance.

Expressed interest and concern in your
well-being.

Told you that she/he felt very close to you.

Told you who you should see for assistance.

Told you what to expect in a situation that
was about to happen.

Loaned you over $25.
Taught you how to do something.

Gave you feedback on how you were doing
without saying it was good or bad.

Joked and kidded to try to cheer you up.
Provided you with a place to stay.

Pitched in to help you do something that
needed to get done.

Loaned you under $25.

Looked after a family member while you
were away

Watched after your possessions when you
were away (pets, plants, books, home,
apartment,etc.)

0 Not At All

C)

1 to 2 Times in

l-‘

Past Month
“3 One Time per Week

N

(0

Several Times
per Week

00

Once a Day

APPENDIX D

PROPOSAL TO DATA COLLECTION SITES

APPENDIX D

PROPOSAL TO DATA COLLECTION SITES

Comparative Study of Perceived Social Support by
Pregnant Adolescents Attending Alternative
School-Based Pregnancy Programs

Sharon E. Long RN
Michigan State University

College of Nursing, Graduate Program
May 16, 1988

Address: 41709 Bedford
Canton, MI 48187
(313) 981—3430

Purpose: Completion of a Thesis for a Master of Science Degree in
Nursing

Proposed beginning and termination dates: May 3 to June 3, 1988

Thesis Committee Chairperson: Barbara Given, RN PhD

Research Proposal

Purpose

Pregnant adolescents, by law, have the right to receive education of
equal quality as other students as described in Title IX of the
Education Amendments. School districts have developed programs to
assist the pregnant teens to remain in school, to support her through
this stressful time and to promote the health of both the adolescent and
the fetus. The purpose of this study is to compare two groups of
pregnant adolescnets who attend different alternative school-based
pregnancy programs (APP) as to the perceived supportiveness provided by
the teachers, counselors, social workers and nurses to pregnant teens
enrolled in these programs.

Hypothesis

 

Pregnant adolescents enrolled in inclusive adolescent pregnancy programs
will perceive more social support from selected school personnel as
compared to those pregnant adolescents enrolled in the supplemental
adolescent pregnancy programs.

152

153
Methods

The research consists of a cross-sectional survey design utilizing two
questionnaires to be administered to pregnant adolescents. Background
data on the subjects will, also, be collected (tools enclosed). The
sample population is 20 pregnant adolescents, ages 14 to 17, who are at
least 24 weeks gestation or greater. Rationale for selection of the age
group is related to the various developmental stages that occur during
the period of adolescence, defined as from age 12 to 19. This age range
is middle adolescence which the literature describes as having specific
developmental tasks to deal with. Selection of teens who are at least
24 weeks gestation is related to the decision to continue the pregnancy
and, furthermore, most teens have been identified by the school program
and are enrolled in courses related to the pregnancy.

Permission to access the students will be obtained from either the
school superintendent or program director by either written letter or by
school district criteria and application to perform research. Selection
of the sites was based on ease of access to student and the number of
students in each program to obtain an appropriate sample from each type
of school program. This represents a non-random convenience sample.
Participation by the students is voluntary. Time to complete
questionnaires is estimated to be 20 to 30 minutes.

RiskZbenefit ratio

A. There are no identified risks to the individual student or the
school program.

B. Confidentiality for the students will be maintained. No names
or identification numbers will be put on the forms. The background data
to be collected would be difficult to trace back to individual students.
Only this researcher and her research advisors in the College of Nursing
will have access to the data.

C. There are no direct benefits to be gained by the individual
students. The school programs will receive analyzed results of the
study which may be utilized as a form of evaluation and feedback from
the students about their program. If requested, results from their
specific program will be provided.

This research will add to the body of knowledge about an aspect of
educational and health care services provided to pregnant adolescents.
A main concept of this research is that the recipients of the services
are evaluating the respective programs which, to date, has not been done
in the literature.

Consent
After approval to do the research at each data collection site,

determination of the eligible participants will be made via discussion
with each site contact person. Parental/guardian consent will be

154

obtained. A letter and consent form will be sent home with the
participant (see attached). Both parent and student have to sign the
consent and return it the day of data collection.

Arrangements will be made to meet with the participants. Time and
room arrangements will be made with the help of each site contact
person. Need for repeat data collection times will be determined by the
number of participants, their stage of pregnancy, and their progression
to 24 weeks gestation. Administration of the questionnaire will be in a
"classroom” style setting depending on the number of participants and
space available at the facility.

This researcher will be the sole data collector. At each data
collection time, the researcher will read a brief overview of the
purpose of the research, the questionnaires and the procedures, which is
printed on the cover sheet of the tool (see enclosed tool with cover
sheet).

APPENDIX E

SCREENING QUESTIONNAIRE

APPENDIX E

SCREENING QUESTIONNAIRE

Please answer the following four questions as indicated.

1. During January, 1988 to June, 1988, did you attend school at least
three (3) days per week? (check one)

If yes, continue to question two. If no, thank you for your time; it
was very much appreciated.

2. Did you attend a special school program, because you were pregnant,
which was not located in your regular school building? (check one)

yes _____ no _____
3. Did you remain in your regular school and attend special classes at
your school during the day that taught you about pregnancy,
childbirth and how to stay healthy while you are pregnant? (check
one)
yes no

4. Did someone in the school system ( a teacher, a counselor, the nurse
or other school personnel) know about your pregnancy? (check one)

yes no

155

APPENDIX F

COVER LETTER AND CONSENT

APPENDIX F

COVER LETTER AND CONSENT

Dear Parent/Guardian:

The (data collection site) has graciously consented to allow me
to conduct a study about perceptions of social support by pregnant
adolescents on a group of students who are willing to participate. This
study is being conducted by myself as part of the requirements of Master
of Science in Nursing through Michigan State University.

 

I am a registered nurse and have worked with pregnant and parenting
teens for several years, presently in a hospital in Detroit. I am
interested in finding out more about how pregnant adolescents feel about
the support they receive from their school program and, in general, how
much support they are receiving now. I will be asking them to:

1. Fill out a questionnaire asking for general background
information, for example, their age, grade, delivery date, number of
prenatal visits, hours spent at school, etc.

2. Check how they feel about the support they receive from school
teachers, school counselors, school social workers and school nurses.

3. Check how they feel about the amount of support they are
receiving in general, for example, from family, friends or neighbors.

The questionnaires are confidential and the student anonymous.
Participants will not be known to school officials. Participation is
voluntary. You may choose not to participate or your daughter may
refuse to answer certain questions and may stop at any time. Estimated
time to complete the questionnaires is 20 to 30 minutes.

It is very important to learn as much as we can about the amount of
support school programs are providing to the teenager. This evaluation
may be used to continue to develop stronger programs for this special
group. Your teenager’s input will help nurses, educators, and other
professionals deal with the special needs of pregnant adolescents.

If you are willing for your daughter to participate in this study,
will you please sign the attached consent form and send it back with her
on the day of the survey. I would be more than happy to discuss any
part of the research with you.

Home Phone: Sincerely,
(313) 981-3430 Sharon E. Long, RN,
Graduate Student
Michigan State University
Clinical Nurse Specialist Program

156

157

CONSENT FORM

 

PARENT/GUARDIAN:

I voluntarily consent to my daughter participation in this research
study about perceptions of social support in pregnant adolescents
conducted by Sharon E. Long, RN as part of the requirements of the
degree, Master of Science in Nursing, through Michigan State University.
I understand the purpose and the format of the study. I understand that
I or my daughter may decide not to participate at any time without any
penalty or may choose not to answer certain questions. I also
understand that all results of the survey will be kept strictly
confidential and all participants will be anonymous. However, the
results will be made available to the participants, within the
confidential restriction, upon request.

 

Signature of Parent/Guardian Date

STUDENT:

I am willing to participate in this research study about perceptions of
social support in pregnant adolescents conduction by Sharon E. Long, RN.
I understand that I may decide not to participate at any time without
any penalty or I can refuse to answer certain questions. I also
understand that all results will be kept confidential and I will be
anonymous. I may request the results, in the confidential format, after
the research is completed.

 

Signature of Student Date

APPENDIX G

QUESTIONNAIRE COVER SHEET

APPENDIX G
QUESTIONNAIRE COVER SHEET
INSTRUCTIONS

**THANK YOU FOR VOLUNTEERING TO PARTICIPATE IN THIS RESEARCH STUDY!!**

This research will be looking at how supportive your school program
has been to you while are pregnant. Answers to the questionnaire you
agreed to fill out will only be seen by myself and my advisors at
Michigan State University. No one from your school or the clinic will
be able to see these answers. You may request results of the findings of
this study after the research is completed. The questionnaire has three
parts:
— Part A asks for background information about yourself and your
school. Most questions require only a 'check mark’ or short answer, for
example, your age.
- Part B asks for your feelings about the amount and satisfaction of
support you feel you receive from specific school personnel you have
contact with. There is a scale provided with each question for which
you circle a number that corresponds to your feelings.
— Part C asks for your feelings about the amount of support you feel
you have received people other than school personnel, for example, your
family, your friends or your neighbors, during the past month, both at
school and at home. Again, a scale is provided with each question for

which you circle a number that corresponds to your feelings.

** PLEASE ANSWER EACH QUESTION AS HONESTLY AS POSSIBLE. THERE ARE NO
RIGHT OR WRONG ANSWERS, JUST WHAT YOU FEEL.

I expect you will be able to complete all parts within 20 to 30 minutes.
More time will be allowed if you need it. I will be here to answer any
questions while you complete the questionnaire. Thank you again for your
time.

Sharon E. Long, RN, Graduate Student

Michigan State University

Family Clinical Nurse Specialist

Home Phone: (313) 981-3430

158

APPENDIX H

APPROVAL FROM UNIVERSITY COMMITTEE ON

RESEARCH INVOLVING HUMAN SUBJECTS

MICHIGAN STATE UNIVERSITY

 

UNIVERSITY COMMITTEE ON RESEARCH INVOLVING EAST LANSING . MICHIGAN . 488244046
HUMAN SUBJECTS (UCRIHS)

258 ADMINISTRATION BUILDING

(517) 355-2186

May 26, 1988

Sharon Long, RN.

41709 Bedford

Canton, MI 48187

Dear Ms. Long:

Subject: "COMPARITIVE STUDY OF PERCEIVED SOCIAL SUPPORT BY

PREGNANT ADOLESCENTS ATTENDING ALTERNATIVE SCHOOL-
BASED PREGNANCY PROGRAMS IRB£ 53-162"

The above pro'ect is exempt from full UCRIHS review. I have reviewed the proposed research

protocol and d that the rights and welfare of human subjects appear to be protected. You have

approval to conduct the research.

You are reminded that UCRIHS approval is valid for one calendar year. If you lan to continue

this project beyond one year, lease make provisions for obtaining appropriate CRIHS approval
ono month prior to May go, 1382,

Any changes in procedures involving human subjects must be reviewed by the UCRIHS prior to
initiation of the change. UCRIHS must also be notified promptly of any problems (unexpected
side effects, complaints, etc.) involving human subjects during the course of the work.

Thank you for bringing this project to our attention. If we can be of any future help, please do not
hesitate to let us know.

Sincerely,

,’\ '1 ; My
Join 1c Hudzik, Ph.D.

Chair, UCRIHS
JKH/sar

cc: B. Given

159

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m!”

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