awn «WE 3.? "a“. . 7' ‘l 1... \ a. .uu. .t handrhsurwyf Alf. ll .J. ' I’lxth PHI-l1 Lu 1... .. ...l .. Laugh 1 if“! ‘fiuul...»-.......u.l?§sis.fl‘ #1.: h :bnmil... guumumtwvg E :0..- . . . I L)r.:3 . 3‘55: .fi...‘ . ‘ I. . s 3.... 1... y... .4. MT :x. 19114 as» q i .an........i. "w {IVERSITV LIBRARIES 1 lllfllllljflljllll Hill lllll m 156100 I". LIBRARY Michigan State University This is to certify that the thesis entitled THE RELATIONSHIP BETWEEN FUNCTIONAL SOCIAL SUPPORT, SOCIAL NETWORK AND THE ADEQUACY 0F PRENATAL CARE presented by Betty W. DaWSon has been accepted towards fulfillment of the requirements for Master We: degree in ming— W Major professor m - n ' 1 Inn-’mn'nn MSUI'JM if,” "" ‘ ‘ . vrr PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES mum on or before on. due. DATE DUE DATE DUE DATE DUE MSUIoAn.“" -' '1 ”n “5.43:“. THE RELATIONSHIP BETWEEN FUNCTIONAL SOCIAL SUPPORT, SOCIAL NETWORK AND THE ADEQUACY OF PRENATAL CARE BY Betty W. Dawson A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1996 111 L1 ' .0“ _,' o w . u: 3'! '5 E'- 3- fl 3 o - A J .1. D *L ~14 a ‘ J.“ 1" 1| l"v V‘v - _ -‘.u“‘ ABSTRACT THE RELATIONSHIP BETWEEN FUNCTIONAL SOCIAL SUPPORT, SOCIAL NETWORK AND THE ADEQUACY OF PRENATAL CARE oi By Betty W. Dawson The purpose of this study was to determine if there was an association between functional social support and the adequacy of prenatal care for low income women, and whether the size and composition of the social network were associated with the adequacy of prenatal care. The interactional systems of Imogene King provided the conceptual framework. Secondary data collected by Schiffman and Omar (1994) were used. The Norbeck Social Support Questionnaire was the tool utilized to measure social support and adequacy of prenatal care was defined by the adapted Kessner Index. Functional social support was not associated with the adequacy of prenatal care. The size of the social network of the pregnant woman did impact the amount of perceived social support the pregnant woman reported, however, the composition of the network was not associated with increased social support. The results of this study could help the clinical nurse specialist working with low income women in assessing existing support systems, directly affirming support and helping the woman expand support systems when necessary. ACKNOWLEDGMENTS First I would like to thank the chairperson of my thesis committee, Rachel Schiffman for her continuous assistance, patience and encouragement. I would also like to thank the other members of my committee, Millie Omar and Jackie Wright for their support, time and assistance. Also thanks to Rachel Schiffman and Millie Omar for providing the data from their research entitled, "Factors Influencing Pregnancy Outcome in the Center for Healthy Beginnings". Finally, I would like to thank my husband and children for their patience and support. iii TABLE OF CONTENTS iv Page LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . vi LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . vii Introduction . . . . . . . . . . . . . . . . . . . . 1 Statement of the Problem . . . . . . . . . . . . . . . . 3 Research Questions . . . . . . . . . . . . . . . . . 3 Importance of the Study . . . . . . . . . . . . . . 4 Theoretical Framework . . . . . . . . . . . . . . . . . . 5 Conceptual Definitions . . . . . . . . . . . . . . . 5 Functional Social Support . . . . . . . . . . . . 5 Social Network . . . . . . . . . . . . . . . . . 7 Adequacy of Prenatal Care . . . . . . . . . . . . 10 Conceptual Model . . . . . . . . . . . . . . . . . . . . 15 Review of the Literature . . . . . . . . . . . . . . . . 19 Social Support and Pregnancy . . . . . . . . . . . . 20 Social Network and Pregnancy Outcome . . . . . . . 22 Male Influence in Lack of Prenatal Care/Non-Economic Barrier . . . . . . . . . . . . . . . . . . . . . 23 Relationship of the Literature to the Study . . . . 24 Methods . . . . . . . . . . . . . . . . . . . . . . . . . 26 Design . . . . . . . . . . . . . . . . . . . . . . . 26 Sample . . . . . . . . . . . . . . . . . . . . . . . 26 Operational Definitions . . . . . . . . . . . . . . 26 Functional Social Support . . . . . . . . . . . 26 Social Network . . . . . . . . . . . . . . . . 28 Adequacy of Prenatal Care . . . . . . . . . . . 29 Instrument . . . . . . . . . . . . . . . . . 29 Reliability and Validity of the NSSQ . . . . . . 30 Data Analysis . . . . . . . . . . . . . . . . . . . 32 Assumptions . . . . . . . . . . . . . . . . . . . . 34 Limitations . . . . . . . . . . . . . . . . . . . . 34 Protection of Human Subjects . . . . . . . . . . . . 35 TABLE OF CONTENTS (continued) Results 0 O O C O O O O I O O O O O O O O O O O 0 Demographic Characteristics . . . . . Description of the Social Network and Adequacy Prenatal Care . . . . . . . . . . . . . . . . Analysis of Research Questions . . . . . . . . Research Question #1 . . . . . . . . . . Research Question #2 . . . . . . . . . . Research Question #3 . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . Implications for Future Research . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . LIST OF REFERENCES . . . . . . . . . . . . . . . . APPENDICES APPENDIX A: Data Collection Procedures . . . . 00.00000 N APPENDIX B: Norbeck Social Support Questionnaire APPENDIX C: UCRIHS Approval . . . . . . . . . 35 35 36 37 37 38 4O 42 53 S7 59 67 68 72 Table Table Table Table Table LIST OF TABLES Page Kessner Index Definition of Adequacy of Prenatal Care . . . . . . . . . . . . . . . . 14 Demographic Characteristics . . . . . . . . . . 36 Crosstabulation of Size and Composition of Network by Adequacy of PNC . . . . . . . . . . 37 Analysis of Variance of Social Network by Total Functional Support, Affect, Affirmation And Aid 0 O O O O O O O O O O O O O O O O O I 3 9 Means and Standard Deviations of Social Support by Social Network . . . . . . . . . . . . . . 40 vi Figure 1: GINDEX LIST OF FIGURES Figure 2: King's Conceptual Model . Figure Figure 3: Conceptual Model, Social Support, Network & Adequacy of PNC 4: Conceptual Model, Revised. interaction between pregnant woman and social network vii Outcome of Page . 50 311 Su an mm net Introduction The infant mortality rate in the United States is high compared to other developed nations (Boone, 1985; Long, Marques, & Harrison, 1994; Sable, Stockbauer, Schramm, & Land, 1990). Low birthweight caused by prematurity or delivery of small for gestational age infants has been implicated as the primary reason for the high neonatal morbidity and mortality rate (Poland, Ager, Olson, & Sokol, 1990; Raine, Powell, & Krohn, 1994). The literature provides substantial evidence linking adequate prenatal care with a decreased incidence of low birthweight infants (Alexander & Cornely 1987; McDonald & Coburn, 1988; Pascoe, Milburn, & Haynes, 1990; Raine et al., 1994; Sable et al. 1990). Identifying factors which promote enrollment in and utilization of prenatal care could favorably impact the current infant morbidity and mortality rate. The concept of social support has been recognized in the behavioral and social sciences for some time. Social support is defined by Cobb (1976) as "information that leads subjects to believe they are cared for and loved, esteemed and valued and belong to a network of communication and mutual obligation" (p. 300). Social support and social networks have been linked with helping families cope with 1 stressors (Bruhn & Phillips, 1983; Mitchell & Trickett, 1980). Social support and social networks also play important roles in the health care and behaviors of individuals. Aaronson (1989) suggests that the positive effect of social support on health is its ability to mitigate stress. Nuckolls, Cassel and Kaplan (1972) found social assets to be associated with a decrease in pregnancy complications. Giblin, Poland, and Ager (1990) found an association between intimacy and the start of prenatal care while McCormick, Brooks-Gunn, Shorter, Holmes, Wallace, and Heagarty (1989) state that social support, particularly the presence of a male relationship was linked with the start of prenatal care. Lia-Hoagberg et a1. (1990) reported that 69% of their study subjects stated someone encouraged them to seek prenatal care. The purpose of this investigation was to determine if there was a relationship between social support, social networks, and the adequacy of prenatal care received by a group of low income pregnant women. Secondary data collected by Schiffman and Omar (1994) were used. Consenting women, in the original study, were asked to complete the Norbeck Social Support Questionnaire. The completed questionnaire supplies information about the composition of the social network of the pregnant women and the amount and type of social support she receives from the individuals named. Of special interest in this study, was whether or not the network contained a boyfriend or husband, Slip] dffe SOci Comp netw 338° 3 the support received, and if these factors were associated with the adequacy of prenatal care of the pregnant women. Statement of the Problem Since inadequate prenatal care has been associated with the high neonatal morbidity and mortality rate in the United States, identifying factors that promote adequacy of prenatal care is an important component in decreasing the current high infant mortality rate. The current literature focuses on many factors identified as barriers to obtaining prenatal care. These factors have been identified as both economic and non-economic. It has been suggested that lack of social support may be one non-economic factor contributing to the inadequacy of prenatal care (Boone, 1985; McCormick et al., 1989; Young, McMahon, Bowman, & Thompson, 1989). However, this concept has not been well studied and social support has been defined and measured in a variety of ways. This study examined functional social support as perceived by the pregnant women, that is, social support that leads to supportive transactions in the form of affect, affirmation and aid (Norbeck, 1981). Thus, the social network of the pregnant women was an important component of this study. The size and composition of the network were examined to see if these factors were associated with adequacy of prenatal care. W 1. Is there a relationship between the size and composition of the social network of the pregnant women and the adequacy of prenatal care? 4 2. Is there an association between the total amount of functional social support perceived by the pregnant women and the size and composition of the social network and the adequacy of prenatal care? 3. Is there an association between the type of functional social support (affect, affirmation, and aid) perceived by the pregnant women and the size and composition of the social network and adequacy of prenatal care? WW Multiple factors, both economic and non-economic, influence enrollment and attendance in prenatal care. The literature involving barriers to prenatal care suggests that lack of social support may be one non-economic factor that contributes to inadequacy of prenatal care. The purpose of this study was to add to the body of knowledge by examining if there is a relationship between perceived functional social support and adequacy of prenatal care, from whom the pregnant women receive the support and if the amount of support was influenced by the size or composition of the subjects' social network. If social support is identified as a factor which promotes adequacy of prenatal care,- particularly the presence of a boyfriend or husband, the Advanced Practice Nurse working with prenatal clients may use this information to help promote attendance in prenatal care. This could be achieved by assisting pregnant women in identifying existing social support systems and establishing new social support systems if needed. 5 Theoretical Framework This section includes the conceptual definitions of the study variables. Secondly, the conceptual model utilizing the interactive model of King is described. : l 1 E E' ‘I' The concepts functional social support, social network, and adequacy of prenatal care are defined conceptually. These concepts are paramount to the study and they will first be defined independently. Linkages are analyzed in the literature review. Enngtignal_figgial_finppgrt. Social support is a concept developed by the social and behavioral sciences. It has been defined by Cobb (1976) as information that leads persons to believe they are loved, esteemed and a member of a network of mutual obligations. Lin, Ensel, Simeone, and Kuo (1979) stated that social support "may be defined as support accessible to an individual through social ties to other individuals, groups, and the larger community" (p. 109). Social support is described as something of benefit to an individual in itself if he/she perceives it is I available to him/her (Gore, 1978; Schaefer, Coyne, &. Lazarus, 1981). It is also viewed as valuable in its ability to mitigate stressful events and provide individuals with tangible assistance (Lin & Ensel, 1984; Nuckolls et . al., 1971). Bruhn and Philips (1984) state social support has both qualitative and quantitative properties, depending on its de¢ (ls 6 use. As a qualitative concept it describes the helpfulness of social relationships. Quantitatively, it can be measured in regard to psychosocial assets and networks. .Here the implication is that the more close friends, memberships in organizations and family ties a person has, the more likely he/she is to be happy and healthy. Bruhn and Philips (1984) refer to positive and negative effects of social support. Positive support is described by its function, to fulfill the need to belong, modify the effect of negative stress, strengthen or restore hope and morale, and enhance a person's ability to learn to use these skills in new situations. Negatively, social support may be a source of stress to the individual by stifling creativity and spontaneity (Bruhn & Phillips, 1984), creating demands, constraints and conflicts (Schaefer et al., 1981), or by setting a limited set of normative expectations, information and social contacts (Mitchell & Trickett, 1980). Social support is stated as a concept that acts as a buffer against stressful life events (Lin & Ensel, 1984; Nuckolls et al., 1971; Schaefer et al., 1981). Schaefer et al. (1981) describe three types of perceived social support, tangible, emotional and informational. Tangible refers to direct aid, emotional to intimacy and attachment, and informational to helpful advise and information. Social support and its relationship to health are also described in the literature. Kaplan, Cassel, and Core (1977) reviewing relevant studies of social support in both 7 tunmans and animals, concluded that social support could be as simple as the presence of a litter mate or as complex as a formal social network. Both were demonstrated to be protective of health. Thus, social support is defined and described in various ways, with different terms and measurements. Norbeck states there is a lack of conceptual agreement on what social support is and how it functions (Norbeck, Lindsey, & Carrieri, 1981). For the purpose of this study the functional definition of Norbeck et al. (1981) was used. These authors state the concept of social support is multidimensional with both functional and network properties. Function refers to the actual interactions which lead individuals to perceive they have social support. Network refers to the specific people from whom the individual receives the support. Norbeck et al. (1981) used the definition of social support developed by Robert Kahn, to describe its function "interpersonal transactions that include one or more of the following: the expression of positive affect of one person toward another; the affirmation or endorsement of another persons behaviors, perception, or expressed views; the giving of symbolic or material aid to another" (Kahn, 1975, p. 85). Norbeck (1981) stated that affect, affirmation and aid are components of supportive transactions. sgg131_Ngtwgzk. Literature describing social networks is often integrated with social support. Measures of social the Cam rs. I 8 Support characteristically refer to individuals described as 'the social network, Gore's Index of Social Support, Berkman and Syme's Social Network Index, Lin's Social Support Scale, Schaefer's Social Support Questionnaire, Wilcox Social Support Index, and Norbeck's Social Support Questionnaire (Bruhn & Philips, 1984). Like social support, the term social network has multiple definitions and components described in the literature. Mitchell and Trickett (1990) state that social networks go beyond formally recognized systems and are comprised of the salient reference group of the individual. The network has two components, size and density. Size refers to the number of individuals in the network. Density refers to the extent to which individuals in the network interface without the presence of the focal individual. Schaefer et al. (1981) describe social networks as a set of relationships of a particular individual, and describe the network in terms of its composition and structure. Composition refers to the type of individuals within the network, kinship or friendship. Structure refers to the number (size) of individuals in the network, and the number of individuals who know each other in the network. Cronewett (1985) in studying network structure, social support, and psychological outcomes of pregnancy, developed the Social Network Inventory. This tool used size and composition as important components of the index. 9 Kaplan et al. (1977) refer to social networks as the People with whom one communicates and the links within these relationships. Size or composition are not described as components of the network. Density, availability and types of support are among the components. The present study was concerned with the functional social support provided by the social network of the pregnant woman. Size and composition of the network are the important components with emphasis on composition, especially whether the presence of a boyfriend or husband in the social network is associated with adequacy of prenatal care. Single status is one factor that has been linked to inadequate prenatal care (Cooney, 1985; McCormick et al., 1989; Young et al., 1989). For the purpose of this study, composition referred to the specific people who made up the social network of the pregnant woman. These people are categorized by Norbeck in the NSSQ (1981) as spouse or partner, family or relative, friends, work or school associates, neighbors, health care providers, counselor or therapist, minister, priest, or rabbi, or other. Size refers to the total number of individuals who compose the social network. A number of 5 or greater refers to a large network, 4 or less is a small network. The network could possibly be large including a boyfriend or husband such as, boyfriend, mother, sister, two friends and a neighbor, or small consisting of boyfriend and mother. Likewise it could consist of other combinations, large or small, and exclude a 10 boyfriend or husband. Thus, the social network is defined as the total number (size) of individuals, family, friends, boyfriend or husband, and neighbors (composition) who provide functional social support to the pregnant women in the form of affect, affirmation, and aid. Adegnagy_gf_2:gnatal_gaze. Prenatal care refers to the total amount of medical care a pregnant woman receives during the entire length of her pregnancy. It has both qualitative and quantitative aspects. Adequate prenatal care has been linked favorably to pregnancy outcome (Cooney, 1985; Greenberg, 1983; McDonald & Coburn, 1988; Pascoe et al., 1990; Sable et al. 1990; Showstack, Budetti, & Minkler, 1984). According to Hobel (1986) it is not known what component of the total process of prenatal care is responsible for this improved outcome. Inadequate prenatal care has been associated with increased incidence of low birth weight infants (Leatherman, Blackburn, & Davidhizar, 1990; Pascoe et al., 1990; Sable et al. 1990; Showstack et al., 1984). Low birthweight is a major factor contributing to infant morbidity and mortality. A recent review of the literature linking prenatal care to improved outcomes has been challenged by Fiscella (1995). The author concluded that the link has been overestimated due to selection bias in most studies, yet the author concluded that even a small impact on improved outcomes will make prenatal care cost effective. 11 Currently, the structure of prenatal care is based on the pre-eclampsia model, with a few visits early in the ‘pregnancy and frequent weekly visits nearer term in order to diagnosis pre-eclampsia which occurs in the third trimester (Iams, 1988). Adequate prenatal care is generally defined quantitatively, based on the time prenatal care began and the total number of prenatal visits. The quality of prenatal care can be influenced by the skills and expertise of the person(s) providing the prenatal care. The standard of care is based on guidelines established by the American College of Obstetrics and Gynecology (ACOG, 1982). These include a complete history including risk assessment and identifying preexisting health conditions. A complete physical exam is necessary as well as screening for sexually transmitted diseases, anemia, gestational diabetes, and monitoring pregnant women at each visit for fundal height, proteinuria, weight gain, and blood pressure (ACOG, 1982). Qualitative aspects of adequacy of prenatal care are difficult to measure. Research involving adequate prenatal care generally use quantitative measures. The time prenatal care begins is often an important variable in describing its adequacy. Prenatal care must begin in the first trimester to be considered adequate (Cooney, 1985; McCormick et al., 1989; Pascoe et al., 1990; Petitti, Coleman, Bensacca, & Allen, 1990) and/or have a determined number of visits (Alexander & Cornely, 1987; Sable et al., 1990; St. Clair & Anderson, 1989). Poland et al. (1990) in describing the mfli‘ F 12 quality of prenatal care, used variables that could be measured, e.g. type of insurance, delay in telling others of the pregnancy, attitudes toward health professionals, month of gestation in which pregnancy was suspected, perception of the importance of prenatal care, and initial attitude toward the pregnancy. These variables were measured as to how they influenced the number of prenatal visits. Two qualitative studies were examined. The first by Kogan, Alexander, Kotelchuck, and Nagey (1994) examined the content of prenatal care in relationship to birthweight. Subjects were asked which standard procedures were done on the first or second prenatal visits, and health behavior advice received from their health care provider. Findings indicated that there was no relationship between standard procedures and birthweight but women who did not receive all the recommended health behavior advice had a significantly greater risk of delivering a low-birth-weight infant. Haas, Orav, and Goldman (1995) examined the relationship between the qualifications of the physician, the amount of deliveries and years of experience and the adequacy of prenatal care. Results were that board certification, number of deliveries per year and years of experience were associated with rates of recommended prenatal visits and increased birthweight of infants. Quantitatively, adequacy of prenatal care has been measured by the Kessner/Institute of Medicine Adequacy of Prenatal Care Index. This index is based on two factors, 13 when prenatal care begins and the total number of visits a pregnant woman receives during her pregnancy. While this index does not address the quality of care received, there is substantial evidence to indicate it is associated with favorable fetal outcome. According to McDonald and Coburn (1988) the quantitative model does address the conditions for quality of care to occur. That is, the content of prenatal care cannot occur without regular contact with a health care provider. The Kessner Index (Table 1) describes three categories of prenatal care, adequate, intermediate, and inadequate. This index has been the standard measure of adequacy of prenatal care in numerous studies (Alexander et al., 1987; Cartoof, Klerman, & Zazueta, 1991; Kogan et al., 1994; Lia-Hoagberg et al., 1990; McDonald & Colburn, 1988; Showstack et al., 1989; St. Clair et al., 1989). In this index prenatal care must begin in the first trimester to be considered adequate, even when there was frequent contact with the health care provider in the other two trimesters. Alexander and Cornely (1987) modified the Kessner Index to better define the categories, this measure is called the GINDEX. The GINDEX describes six prenatal care utilization groups: intensive, adequate, intermediate, inadequate, no- care, and missing/unknown. Like the Kessner Index, time prenatal care began, number of prenatal visits, and gestational age at the time of delivery are important components. Care must begin in the first trimester and have 7-15 visits to gain the adequate rating. Intermediate care 14 Table: 1. If Gestation is: Then Number of Definition (Weeks) Prenatal Visits ‘ Must Be: Adequate =/< 13 >/=1 (Care initiated in the 14 to 17 first trimester and) 18 to 21 >/=3 22 to 25 >/=4 26 to 29 >/=5 30 to 31 >/=6 32 to 33 >/=7 34 to 35 >/=8 >/=36 >/=9 Inadequate 14 to 21 0 (Care initiated in the 22 to 29 =/<1 third trimester or) 30 to 31 =/<2 32 to 33 =/<3 >/=34 =/<4 Intermediate All combinations other than above. Based on the Institute of Medicine definition: However, cases with missing data or gestational length, number of prenatal visits, or trimester of initiation of prenatal care are excluded. From Alexander & Cornely (1987) p. 244. must have 4-6 visits for first trimester care and 4-12 visits for second trimester care. Intensive refers to a category of women who receive more than the recommended number of visits. This may be related to risk factors or complications of the pregnancy. The number of visits in this category is greater than 16 for first trimester care, greater than 13 prenatal visits for second trimester care, and greater than 11 prenatal visits for third trimester care. The other categories are no prenatal care prior to delivery and those with missing or incomplete data. The index is then adjusted for gestational age thus women 15 delivering prematurely would be expected to have had fewer visits than women who delivered at 40 weeks gestation (See Figure 1). Kotelchuck (1994) criticizes the Kessner Index stating in reality it is only a measure of the initiation of prenatal care, does not distinguish inadequate care based on number of visits from inadequate based on later care, and an inability to distinguish prenatal care for normal gestation from post-date pregnancies. Other criticisms are the total number of visits needed to deem prenatal care as adequate is less than the total number of visits recommended by ACOG standards, and non standardized definitions lead to differences in calculations. For this study adequacy of prenatal care was defined quantitatively utilizing the adaptation of the Kessner Index by Alexander and Cornely (1987). The GINDEX categories used in the study were adequate, intermediate, inadequate, and intensive. W The interactional systems presented by King (1981) provided direction for this study. King describes three systems: personal, interpersonal, and social systems(see Figure 2). Individuals comprise one type of system in the environment called personal systems. Individuals interact to form dyads, triads, and small and large groups, which comprise another type of system called interpersonal systems. Groups with special interests and needs form 16 iflunhpunufl . «when: 9 W W“. 111°} . W 31W” 131: 1 6 W s WINNEHI. I ‘ i 2 “SUN“. 1 Figure 1. GINDEX. Na. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18+ on: Ehmhudflmmuusuzmnu From Alexander and Cornely, p. 244. PCVIPrenatal Care Visits; TPCB- Term Prenatal Care Began ’ SOCIAL SYSTEMS (Society) - INTERFERSONN. SYSTEMS . -Lmepél _ - - 1 ,FBQSONAL SYSTBVS : I ‘J\> (Individuals) .- > 1 A . ‘ ’ Figure 2: King's Conceptual Framework for Nursing From King (1981) p. 11. -—-— -— —- —— a... —- - —- -.— -- —— —.- -— ——- 17 Organizations, which make up communities and societies and are called social systems (King, 1981, p. 141). Interactions among the different systems lead to transactions. King defines transactions as interactions which lead to goal attainment. Goal attainment has been derived from an open systems framework. In King's goal attainment for health care the major elements occur between the interpersonal systems when two peOple come together to help and be helped to maintain a state of health. For the purpose of this study, interactions of note are those that occur between the pregnant woman and her social support system (interpersonal system) especially between the woman and boyfriend/husband, which promote interactions with the health care system providing prenatal care (social system) which lead to the goal of adequacy of prenatal care (see Figure 3). This could be accomplished by a person (perhaps the boyfriend or husband) in the pregnant woman's social network by expressing positive affect, affirming or endorsing the pregnancy or assisting the woman in obtaining prenatal care. Perception of social support refers to amount and type of social support the pregnant woman perceives she has available from her social network. 'This concept is not directly measured. However, as the pregnant woman is completing the Norbeck Social Support Questionnaire, her perception influences whom she names and how much support she identifies that she receives from them. 18 anuydfiumHCue f m: Meet i Social Network NfirmAag'on I I @1221. / <9 / Figure 3. Cmoeptual model - Functional social support, social network, adeqracy of pruratel care The circle on the right in Figure 3 is the individual, in this case, the pregnant woman. The dotted lines indicate that this system is moving and interacting with the others. The circle on the left refers to the social network, this also is a fluid system moving and interacting with the individual. The vertical lines indicate that this system can expand or contract. This circle includes all individuals the pregnant woman stated as being significant in her life, including family, friends, neighbors, 19 professionals, and others. The size of the network may influence the amount of functional social support, the pregnant woman receives from her social network. The pregnant woman may receive a small amount of social support from a large number of individuals or a great deal of support from just a few members of the network. The small circle within the social network circle is reserved for the boyfriend or husband. This support system gets special attention, as indicated by the study question, if there is a relationship between social support received from the boyfriend or husband and adequacy of prenatal care. The arrow upward from the center where the social network, boyfriend or husband, and pregnant women interact to create social support and aims towards adequacy of prenatal care. indicates there may be an association between functional social support and adequacy of prenatal care. Review of the Literature The purpose of this section is to examine the empirical literature relevant to the variables under study. There is little direct literature relating social support to adequacy of prenatal care, thus this section examines related literature. First, literature describing social support and pregnancy is presented. This is followed by social network and pregnancy, and finally, literature describing lack of social support as a noneconomic barrier interfering with adequacy of prenatal care. 20 Social support is a concept that is believed to be protective of health, especially during a time of crisis (Kaplan et al., 1977; Lin et al., 1979; Schaefer et al., 1981). Norbeck (1981) states pregnancy is a maturational crisis, a time when social support is needed. Tilden (1983) examined the relationship of life stress and social support to emotional disequilibrium. Findings were that high life stress and low social support were related to emotional disequilibrium during pregnancy. Norbeck and Tilden (1983) found high stress to be modified by high social support in relationship to pregnancy complications in low-risk women. Nuckolls et al. (1972) in a classic study involving 170 pregnant women measured life change events and psycho-social assets (i.e., social support). Findings of this study were that almost all of the women with high life change events and low psycho-social assets had pregnancy complications compared to 33% of women with high life change events and high psycho-social assets. Current literature continues to examine a relationship between social support and pregnancy. Giblin et al. (1990) in a study of 300 women post partum, examined social support and its effect on attitudes, health behaviors and obtaining prenatal care. Social support was defined as intimacy, comfort, and security. The measure of intimacy included the woman's personal relationship with the infant's father. Findings of this study were that women who received adequate 21 Prenatal care had a significantly higher score on intimacy than those who received inadequate prenatal care. Collins, DuflkeleSchetter, Label, and Scrimshaw (1993) in a prospective study of 129 mostly Hispanic women examined birthweight, Apgar score, labor progress and post-partum depression and their relationship to social support. Results indicated that greater network resources (of the pregnant women) were linked with deliveries of higher birthweight infants. The more satisfied the women was with the support she received and the more actual support she received the higher the Apgar scores were and the fewer problems she had in labor. A decrease in the quality of the support and smaller network resources were linked to more depression after childbirth. Women who were dissatisfied with the prenatal support they received especially from the infant's father were at greater risk for depressed mood during pregnancy and reported more depressive symptoms 6-8 weeks post-partum. Women who reported high prenatal life events but had received social support during pregnancy reported less depression after childbirth. However, Pascoe et al. (1990) in study of 107 indigent women found no correlation between social support and the decision to seek prenatal care by the pregnant women. Likewise, St. John and Winston (1989) found little association between social support and obtaining prenatal care, which could not be explained by other variables; however, women whose family members were happy about the pregnancy did receive more 1---:s-. . r “.1". 22 prenatal care than those whose family members were not supportive . This section focuses on the social network of the pregnant woman. St. Clair and Anderson (1989) stated that pregnant women get much of their health advice pertaining to the pregnancy from their social network. The majority of the advice was sound and health-promoting even when it lacked a scientific base. Findings related to seeking health care were that only 23% of the women (N=185) were encouraged to seek routine prenatal care by members of their network. However, 33% were encouraged to seek care for specific problems. No reference to boyfriend or husband involvement in this question is mentioned. However, the authors found that 62% of women received pressure from brothers, boyfriends, and partners to take action that would prevent them from getting out of shape and gaining too much weight. St. Clair, Smeriglio, Alexander, and Cenentano, (1989) in a study of social network structure and its relationship to prenatal care found that utilizers of prenatal care visited and telephoned friends more often than relatives and underutilizers had more contact with relatives than with friends. There were no significant differences in prenatal visits between married or cohabiting and non- married or not cohabiting individuals. Both studies relied on convenience samples of low-income post-partum women who gave birth in a university teaching hospital. 23 Ramsey, Abell, and Baker (1986) used the Family Adaptability and Cohesion Evaluation Scales (FACES) and the Family'APGAR to determine whether there was a relationship between family functioning, life events, family structure, and the outcome of pregnancy. Birthweight was the dependent variable. Of interest to this study is number of prenatal visits was not associated with an increase in birthweight. Family structure was categorized as women living with husbands, women living with extended family and women living alone. Women living with their husbands gave birth to infants weighing 8.6 ounces more than women living with extended families. Women living alone had infants who weighed 6.6 oz. less than women living in extended families, and 15.2 oz. less than women living with their husbands. In contrast, Belizan, Barros, Langer, Farnot, Victora, and Villar (1995) in a randomized trial of 1115 Latin American woman who were at risk for delivering a low birthweight infant found no improvement in fetal outcome by reinforcing the pregnant woman's social network. Improved prenatal education and reinforcement of health services also failed to make an impact on birth outcome. .; . . -. - . . , . - -.. . . . (.. .... :. . This section addresses lack of social support as one non-economical barrier to adequate prenatal care. Young et al. (1989) found conflict with the infant's father as a reason for delayed prenatal care by 3.1% of women less than 20 years of age, and by 12.5% of women older than age 20. 24 McCormick et al. (1989) also cited social support by a boyfriend or husband to be lacking in women receiving inadequate prenatal care. A large portion (71%) of 599 low- income pregnant women, did not have a stable relationship with a man as indicated by living with a boyfriend or husband. The presence of a male relationship was positively associated with the start of prenatal care (McCormick et al., 1989). Sable et al. (1990) studied 1,484 primarily low income women in Missouri to determine barriers to prenatal care. Women in the inadequate group were more likely to experience stressful life events, less social support and were less likely to marry the father of the baby during the pregnancy. Bedics (1994) in a qualitative study of the non use of prenatal care found that seekers of prenatal care (Ns18) reported emotional support from the father of the baby as compared to non-users (N=6). Lia-Hoagberg et al. (1990) also found relationship problems with boyfriend or husband to interfere with adequate prenatal care, however' 80% of subjects reported that someone in their social network encouraged them to seek prenatal care. In contrast, St. Clair, Smeriglio, Connell and Niebyl (1990) found no difference in prenatal care utilization between married or cohabiting women and non-married or cohabiting women. WW2 If adequacy of prenatal care leads to better pregnancy outcomes and women continue to have inadequate prenatal care, it is necessary to identify factors which promote 25 adequate prenatal care. Functional social support may be one factor associated with adequate prenatal care. Current literature is not consistent in its definitions of social support or its measurements. Few studies have examined directly how social support influences adequacy of prenatal care, what type of support is most needed, or if the person who provides the support influences the outcome. At best previous research merely identified lack of social support as a barrier to obtain prenatal care, rather than if its presence lead to increased utilization of prenatal care. The definition of adequacy of prenatal care is described broadly in the literature. The Kessner Index has been the most widely used definition of adequacy of prenatal care and indeed, was the standard used in most of the previous research. The Kessner Index is somewhat difficult to interpret. The trimester prenatal care began is an important component of the Kessner Index, however, when critiquing the model it is difficult to distinguish this concept. Kotelchuck (1994) in a critique of the Kessner Index states that the lack of documentation for the index has lead to nonstandardized definitions and discrepancies in calculations, which leads to overstating the adequacy category and an inability to distinguish a difference between initiation and continuity of care. Lack of social support is only one non-economic barrier, certainly other factors influence a pregnant woman's decision such as health beliefs, availability of prenatal care providers, Vht Dr: of Va! (30111 Que: 26 transportation and relationship with health care providers. This study hoped to add to the body of knowledge by looking at one possible barrier, social support, and determine if it was associated with adequacy of prenatal care. Methods The methods section describes the sample, the research design, instrumentation, the operational definitions, the limitations of the study, and the procedures for the protection of human subjects. Design This study was a descriptive correlational study using secondary data from the study "Factors Influencing Pregnancy Outcome at the Center for Healthy Beginnings," with Schiffman and Omar (1994) as co-principal investigators. This was an evaluative study with both a survey component and a chart review component. See Appendix A for data collection procedures. Sample The original sample consisted of 137 low income women who received prenatal care at a private not for profit prenatal center. The final sample for this study consisted of 86 subjects for whom there was complete data on all the variables. : l' J n E' i!’ Euncticnal_Sccial_Sunnert. Functional support and its components were measured by the Norbeck Social Support Questionnaire (Appendix B). The three components were: $1 #1 27 affect, the expression of positive affect of one person toward another; affirmation, or endorsement of another person's behaviors, perceptions, or expressed views; and aid, the giving of symbolic or material aid to another. Total functional support was the total score of the three components. In total functional support, as well as the individual components, the mean score was used. The concepts were measured as follows: Affect was measured by questions #1 and #2 on the Norbeck Social Support Questionnaire: #1 How much does this person make you feel liked or loved? #2 How much does this person make you feel respected or admired? Affirmation was measured by questions #3 and #4 on the Norbeck Social Support Questionnaire: #3 How much can you confide in this person? #4 How much does this person agree with or support your actions or thoughts? Aid was measured by Questions #5 and #6 on the Norbeck Social Support Questionnaire: #5 If you needed to borrow $10, a ride to the doctor, or some other immediate help, how much could this person usually help? #6 If you were confined to bed for several weeks, how much could this person help you? nil Pei 28 (Norbeck, 1981) . Total Functional Support was obtained by adding the scores in all components and then obtaining the mean. Scoring was done using a Lickert scale of 1 to 5, which indicated the degree of support received for each question from 1 (ngt_at_a11) to 5 (a_great_deal). Only questions 1 through 6 were used for this study. A higher score indicated that the subject perceived she had more support than a lower score. The researcher was aware that the total support number was somewhat inflated as a score of 1 indicated no support. Sggial_Ngtwgrk. The two important components of the social network used for this study were size and composition. Size was measured as the total number of persons identified on the Norbeck Social Support Questionnaire by the pregnant women. Composition refers to the relationship of the individual named in the social network to the pregnant woman, for example, friend, parent, boyfriend/husband. In the Norbeck Social Support Questionnaire after the subject lists the person in her network there is a space to describe the relationship from a choice of nine such as spouse or partner, friend, neighbor or family member. Of special interest to this study was the inclusion of a boyfriend or husband in the social network. A large network was defined as one with 5 or greater persons named. A small network was defined as one with 4 or fewer persons named. Composition referred to whether or not the QL' 29 network included a boyfriend or husband. Thus, the four network categories were identified as: 1) size 5 or greater including a boyfriend or husband, 2) size 4 or less and including a boyfriend or husband, 3) size 5 or greater without a boyfriend or husband, and 4) size 4 or less without a boyfriend or husband. - Adggnagy_gfi_2zgnatal_gazg. Adequacy of prenatal care for the purpose of this study is defined quantitatively, that is, using the adapted Kessner index, the GINDEX (Alexander & Cornely, 1987) (see Figure 1). The GINDEX categorizes adequacy based on trimester prenatal care began, and the total number of prenatal visits adjusted for gestational age at time of delivery. Adequate Care begins in the first trimester and would include 9-15 visits for full term deliveries. Intermediate care‘would begin in the first or second trimester and includes 5-13 visits. Inadequate care could begin at any time and vary from 1 -12 visits. Intensive care usually begins in the first trimester and consists of individuals whose number of prenatal visits were one standard deviation above the mean. Two other categories of the GINDEX are no prenatal care, and missing/unknown data. This study used the original four categories of the GINDEX: adequate, intermediate, inadequate, and intensive. Instrument The Instrument used was the Norbeck Social Support Questionnaire (NSSQ) (Norbeck, 1981). This instrument is f; 111 st Soc dim Car tes def dep att Sta 1 on Hun lea 30 designed to measure total functional support, total network and total loss. The functional components are affect, affirmation, and aid previously described in the conceptual and operational definitions. Total network refers to the individuals listed by the subject. This questionnaire allows individuals to list significant persons in their life and state the relationship they have with them. The questionnaire has 24 lines for person and relationship. Examples of relationships are given as: spouse or partner, family or relative, friend, work or school associates,- neighbors, health care providers, counselor or therapist, minister priest or rabbi, other. Next the pregnant woman is asked to rate how much social support she receives from each person she has listed. Total loss was not addressed in this study. W. The Norbeck Social Support Scale was developed to measure multiple dimensions of social support. Norbeck, Lindsey, and Carrieri (1981, 1983) present the instrument as well as tests of its reliability and validity. Reliability is defined in Brink (1988) as the degree of consistency] dependability with which an instrument measures the attribute it is designed to measure. An instrument's stability, the extent to which the same results are obtained on repeated administration of the instrument (Polit & Hungler, 1987). Norbeck (1981) demonstrated stability by means of test/retest reliability. The NSSQ was 31 readministered to 67 subjects one week later with the correlation reported as .83. Further testing (Norbeck et al., 1983) of stability was done by readministering the NSSQ to 75 graduate students 7 months after the initial testing with correlations of .58 to .78. Correlation between the individual items measuring each construct, affect, affirmation and aid was tested using Pearsons correlation coefficients. The mean correlation between the items were .92 for affect, .96 for affirmation and .89 for aid (Norbeck et al., 1981). Validity (Brink, 1988) is the degree to which an instrument measures what it is intended to measure. Predictive validity refers to the adequacy of an instrument in differentiating between the performance or behaviors of individual on some future criterion. Concurrent validity refers to the ability of an instrument to distinguish individuals who differ on some criterion (Polit & Hungler, 1987). Predictive and concurrent validity were first tested by Norbeck et al. (1981) by comparing the subscales affect, affirmation, and aid with the of Cohen and Lazarus Social Support subscales tangible, informational, and emotional. Results demonstrated a low relationship between tangible support and aid, and informational support and affirmation. A moderate relationship was demonstrated between emotional support and affect. Further testing (Norbeck et al., 1983) demonstrated moderate concurrent validity when comparing the NSSQ with the Personal Resource Questionnaire of Brandt and 32 Weinert. Norbeck et al. (1983) also state predictive validity was found in interaction between life stress and duration or relationships and life stress and aid. Construct validity is concerned with the question what is the measuring device measuring (Polit & Hungler, 1987). Two concepts are convergence and discriminability. Convergence refers to the fact that different method of measuring a construct will yield the same results. Discriminability refers to the ability to distinguish the construct from similar constructs (Polit & Hungler, 1987). When comparing social support with psychiatric symptoms, The NSSQ and the Profile of Mood States were administered to 75 subjects demonstrated no correlation. Also, when correlating social support (NSSQ) to life stress (Sarason Life Experiences Survey, and Profile of Mood States) no relationship was found, thus, demonstrating some degree of discriminability. Comparison of the NSSQ with the PRQ demonstrated medium level of association (.35 to .41) between their functional components. Further testing in this area is needed. mm Data analysis was done utilizing SPSS/PC+ computer program. Descriptive statistics were used to present demographic characteristics, such as, age, race, income, marital status, number of pregnancies and number of deliveries. Ftp-H 01 33 Research question #1: Is there a relationship between the size and composition of the social network of the pregnant woman and the adequacy of prenatal care? 'This question refers to the social network, specifically the number of individuals in the network, and whether or not there is was boyfriend or husband in the network. A cross tabulation using a chi-square statistic was used for data analysisn ”The chi square statistic is used when we have categories of data concerning the proportions of cases that fall into the various categories” (Polit 8 Hungler, 1987, p. 412). It is computed by comparing two sets of frequencies, those observed in the data and those that would be expected if there were no relationship between the two variables. In this case the relationship was social network and adequacy of prenatal care. The social network was grouped in 4 categories determined by size and composition and into four categories of adequacy of prenatal care based on the GINDEX. Research question #2: Is there an association between the total amount of functional social support perceived by the pregnant woman and the size and composition of the social network and the adequacy of prenatal care? This question refers to the relationship between amount of support received from the social network and the adequacy of prenatal care. Type of support is not differentiated in this question. Six questions on the Norbeck Social Support Questionnaire pertain to the amount of support received from each member of the social network. A 4x4 factorial ANOVA 11.-r 34 was used with four social network cells and four adequacy of prenatal care cells. The dependent variable was the total mean score of functional social support. Research question #3: Is there an association between the type of functional social support (affect, affirmation and aid) perceived by the pregnant woman and the size and composition of the social network and the adequacy of prenatal care? This question asks if there is an association between E the type of support (affect, affirmation and aid) and adequacy of prenatal care. Again the mean score was used. The four categories of adequacy of prenatal care remain the same, as well as the four categories of the social network. A 4x4 factorial ANOVA was used for data analysis for each separate type of functional social support: affect, affirmation and aid. Assumptions There were two assumptions to this study. First, it was assumed that the subjects understood the questionnaire and answered the questions honestly. The second assumption was that all data were entered accurately. Limitations The Center provides services to primarily low income women, results may differ with different population. Participation in the study was voluntary. Subjects who chose to participate may differ from those subjects who declined participation. The Norbeck Social Support Questionnaire may not have been the ideal instrument for this study. Participating subjects may have been influenced Cc at th 35 by how they felt at the time they completed the questionnaire, thus, a recent argument or disappointment could result in less perceived support at that time. W The original study by Schiffman and Omar was approved by the University Committee on Research Involving Human Subjects (UCRIHS) (Appendix C). Data were provided by code number only. The present study utilized secondary data from the original study and the researcher did not have access to the identities of the subjects. The present study was approved by UCRIHS on February 21, 1995 (Appendix C). Results This section describes the results of the investigation. First the demographic information is described, followed by analysis of the three research questions. The research subjects were between the ages of 15 and 37 with a mean age of 22.72 years. The majority of women were white (75%), followed by African/American (22.1%), and Hispanic (2.3%). More than half the subjects were single, (59.3%). Of the total sample, 23 were married or cohabiting. Slightly more than half of the women had completed high school or had a GED. Only 13 subjects had attended college. Many of the women (43%) were expecting their first baby (See Table 2). Tabdezz. Characteristic N 3 Age Range 15-37 Race Caucasian 65 75.6 African/American 19 22.1 Hispanic 2 2.3 Marital Status Single 51 59.3 Married/Cohab. 23 26.7 Separated/Divorced 12 14.0 Educational Level Less than High School 1 1.2 Some High School 26 30.2 High School Diploma/GED 45 52.3 Some College 11 12.8 Associates Degree 2 2.3 Gravid l 37 43.0 2 15 17.4 3 17 19.8 4 14 16.3 5 3 3.5 Parity O 41 47.7 1 15 17.4 2 21 24.4 3 9 10.5 I : e e. e e e .0 0| 0‘ £323 The research components were the size and composition of the social network, and the adequacy of prenatal care. The majority of subjects (77%, n=66) had a large network. Cl 111 37 Likewise, the majority of subjects, (74%, Ira-=64) reported a boyfriend or husband in their social network. For adequacy of care, 31% (ns27) had adequate care, 30% (ns26) had intensive care, and 28% (ns24) had intermediate care. Only 11% (ns9) had inadequate care. WW Reseazgh_Qnestign_£1. The first research question asked if there was a relationship between the size and composition of the social network of the pregnant women and the adequacy of prenatal care. Analysis of the data failed to demonstrate a relationship between these variables, X (9, N=86)=10.22, p < .05. Therefore, there was no significantly different proportion of subjects in the various adequacy categories based on the size and composition of the social network (see Table 3). Table 3. r- ltiono Si ea . am" No . ocia etw- . Adeogsua Qf’k Large with Small with Large wlo Small wlo Category hush/boy hush/boy hush/boy hush/boy N 96 N 96 .N %1 N '% INTENSIVE 16 30.2 6 54.5 2 15.4 2 22.2 ADEQUATE 20 37.7 2 18.2 3 23.1 2 22.2 INTERMEDIATE 12 22.6 3 27.3 5 38.5 4 44.4 INADEQ UATE 5 9.4 — -— 3 23.1 1 1 1.1 as] 38 . The second research question oaks whether there is an association between the total amount of functional social support perceived by the pregnant woman and the size and composition of the social network and adequacy of prenatal care. This question used factorial analysis of variance of total functional support by the variables adequacy of prenatal care and social [b network. Results revealed there was no significant interaction between the variables social network and adequacy of prenatal care (see Table 4). However, the main effect of social network was significant for total ; functional social support perceived by the pregnant woman. Further analysis using a oneway ANOVA (see Table 5) revealed that large networks regardless of composition had similar mean scores. Likewise, small networks had similar mean scores, and small networks differed significantly from large networks. Subjects with large social networks had significantly more social support than subjects with small social networks regardless of composition (F (3, 77)=11.50, p < .000)(see Table 5). Thus, the analysis of variance indicated that size of the social network was significant for the amount of total functional support received perceived by the pregnant woman. While the size of the social network was significant for the amount of support perceived it was not significant for the adequacy of prenatal care. However, some conclusions can be drawn concerning network characteristics and the amount of .‘ 39 Table 4. Source of Variation DE E US Total Functional Support 2-way Interaction 8 0.30 1923.5 Main Effects Adequacy 3 0.13 865.6 Network 3 8.97*** 57998.0 Affect 2-way Interaction 8 0.24 243.5 Main Effects Adequacy 3 0.21 208.4 Network 3 7.78*** 7845.4 Affirmation 2-way Interaction 8 0.36 269.3 Main Effects Adequacy 3 0.07 49.9 Network 3 7.83*** 5839.4 Aid 2-way Interaction 8 0.17 105.0 Main Effects Adequacy 3 0.11 69.9 Network 3 8.20*** 5223.3 ***p<.001 1.11111 40 Table 5 . Banana; Social Network N M SD 251.91 Total Functional Support Large with bf/hueb 49 197.9 90.3 172.02 to 223.90 Small with bf/hueb 11 91.5 19.7 78.30 to 104.80 Large w/o bf/hueb 12 191.3 70.0 146.76 to 235.74 r" Small w/o bf/husb 9 68.8 23.7 50.60 to 86.96 Affect Large with bf/hueb 51 71.3 36.1 61.21 to 81.50 Small with bf/hueb 11 32.1 6.4 27.87 to 36.50 Large w/o bf/hueb 12 69.3 24.8 53.54 to 85.12 Small w/o bf/husb 9 23.4 8.5 17.37 to 30.41 . IL' Affirmation Large with bf/hueb 50 64.0 29.7 55.58 to 72.46 Small with bf/husb 11 32.5 7.8 27.33 to 37.76 a Large w/o bf/husb 12 65.8 27.6 48.24 to 83.26 Small w/o bf/husb 9 22.6 8.4 16.11 to 29.00 Aid Large with bf/husb 51 60.7 28.0 52.87 to 68.62 Small with bf/husb 11 26.8 7.9 21.53 to 32.11 Large w/o bf/husb 12 56.2 19.5 43.78 to 68.55 Small w/o bf/husb 9 22.3 8.1 16.07 to 28.60 Note: bf/husb = boyfriend/husband w/o - without functional social support perceived by the subject. This study demonstrated that for this sample of low income women large networks provided more functional social support than small networks regardless of composition. Egagazgh_Qng§tign_ta. The third research questions asks if there is an association between the type of functional social support (affect, affirmation, and aid) perceived by the pregnant woman and the size and composition of the social network and the adequacy of prenatal care. 41 This question was analyzed by factorial variance, this time examining the specific type of support perceived by the pregnant woman. Again the data demonstrated no significant interaction between each type of functional support and adequacy of prenatal care (see Table 4). However, the main effect of social network was significant for the amount of each type of functional social support perceived by the pregnant woman (see Table 4). Further analysis of each component was done utilizing a oneway ANOVA (see Table 5). The Affect component revealed the same pattern as previously described for Total Functional Support, large networks had similar mean scores and overlapping confidence intervals, small networks had similar mean scores and overlapping confidence intervals and differed significantly from large networks E (3, 79)=10.06, p < .000. Pregnant women with large social networks perceived they had more functional support in terms of affect than pregnant women with small social networks. Again the composition of the network did not make a difference for women with large social networks. Small social networks with a boyfriend or husband provide slightly more, though insignificant, functional social support in terms of affect than small social networks without a boyfriend or husband (see Table 5). The results from the Affirmation component of social support show that large networks again have similar mean scores and overlapping confidence intervals regardless of composition. Small social networks while not significantly 42 different from each other do vary more for this component than the other components of social support. There is little overlap in the confidence intervals and the mean score for the small network with a boyfriend or husband is higher than the mean score for the category without a boyfriend or husband. Again more affirmational social support is perceived by pregnant woman with large social networks E (3, 78)=10.08, p < .000. Although the data are not statistically significant pregnant women with small social networks who have a boyfriend or husband receive more social support in terms of affirmation than pregnant women without this relationship, indicated by higher mean support scores (see Table 5). The Aid component shows a similar pattern to that of Total Functional Support and Affect. Large social networks have similar mean scores and overlapping Confidence intervals as do small social networks. Pregnant women with large networks perceive they have more functional social support in terms of Aid than woman with small social networks E (3, 79)=11.21 p < .000. Composition is not a factor. Small social networks provide less functional support in terms of Aid then large social networks, and small social networks without a boyfriend or husband provided the least amount of support (see Table 5). Discussion Overall, the subjects who participated were a fairly homogeneous group. The majority of subjects were single 11 61 43 (59.3%) yet most listed a boyfriend or husband in their social network (74%). It can be assumed, therefore, that many of the subjects had a boyfriend. The relationship married/cohabiting were combined into one category, therefore, the researcher is unable to determine if support is received from a boyfriend who resides separately from the subject. The subjects as a whole had large social networks and the majority had adequate care. Only 10.5% of the sample had inadequate prenatal care. The small sample size and particularly the small sample that received inadequate care impeded finding any association between functional social support and adequacy of prenatal care. To adequately assess this association the sample would need to have a larger percent of women with inadequate prenatal care. An association could then be made if these women differed in the amount of functional social support they received from women with adequate care. The small number of women receiving inadequate prenatal care was somewhat surprising. The literature describes many barriers for low income women receiving adequate prenatal care (St. Clair et al., 1990; Young et al., 1989) perhaps the Jackson Center has been successful in eliminating many of these barriers. Another possible explanation for the small number of women receiving inadequate prenatal care in this study could be the use of the GINDEX rather then the Kessner Index to assess adequacy of prenatal care. The GINDEX has the additional category of intensive care. Data analysis revealed that 30% of the 44 women received intensive prenatal care. It is not known at what.gestational age these woman began prenatal care. Perhaps if the Kessner Index had been used, many of these woman would have been in the inadequate category. Further studies of low-income woman receiving prenatal care from other clinics or providers would be helpful. If adequate care is specific to this center further assessment of their model of care could be beneficial to others providing prenatal care to low income women. Question #1 asked about a relationship between the size and composition of the social network of the pregnant woman and the adequacy of prenatal care. No relationship was found. The majority of subjects (n=53 or 61.6%) had large networks with a boyfriend or husband. Only nine subjects reported small networks without a boyfriend or husband and only one subject from this category had inadequate prenatal care. Most of the women with a boyfriend or husband and a large network did have adequate care. However, many of the subjects without these relationships also had adequate care. The total number of subjects with inadequate care was only nine; five of these woman had a boyfriend or husband in their social network and four did not. Of the 86 subjects, 66 reported large networks and 20 reported small networks. In the category small network with a boyfriend or husband no one had inadequate care. The total number of subjects in this category was only 11, perhaps with a larger sample the presence of a boyfriend or husband in the small network . 45 category would have yielded a significant amount of increased functional social support. It is not known what prompted the women to seek prenatal care. According to Lia- Hoagberg et al. (1990), 80% of subjects studied stated someone in their social network prompted them to receive prenatal care. Perhaps it is important that the pregnant woman has a significant supportive person in her social network but this person may not need to be the boyfriend or husband. McCormick et al. (1989) reported the presence of a male relationship was linked to the start of prenatal care. While the majority of subjects had both adequate care and large networks with a boyfriend or husband the results were not significant. The chi-square value would need to be 16.92 at .05 level of significance. Research questions #2 and #3 refer to an association between functional social support (total, affect, affirmation, 8 aid) perceived by the subject and the size and composition of the social network and the adequacy of prenatal care. An association between social support and adequacy of prenatal care was not demonstrated in this study. This contrasts with previous research of Giblin et al. (1990) who stated that higher degree of intimacy (a measure of social support) was related to adequate prenatal care (N=300) and McCormick et al. (1989) who found an association between social support and the start of prenatal care. Giblin et al.(1990) used the Kesner index to define adequacy of prenatal care and found adequacy of care to be 51 t1 1 l I V I II J '. i f ‘U 1 1 . 1 . A .D; 1. 1‘ " Il‘ . '3 .i . T ' . . I 1' . 46 positively correlated with intimacy (p <.001) and comfort (p <.05). Intimacy represented a close relationship with the infant's father and a willingness to share news of the pregnancy with others. Failure of the present study to find an association between these components may have been impeded by the small sample size. Others (Beolizan et al., 1995; Pascoe et al., 1990; St. John 8 Winston, 1989) also found no relationship between prenatal care and social support. Different results in these studies are difficult to explain. McCormick asked specific questions pertaining to asking for assistance and advice and emotional support. Interestingly both McCormick et al. and Pascoe et al. found an association between a high amount of stress and the start of prenatal care. Giblin et al. (1990) found that women who did not use drugs had more social support than women who did. Likewise St. John and Winston (1989) stated that when the pregnant woman's family was happy about the pregnancy the woman received more social support. In conclusion, based on these studies it is difficult to determine if lack of social support leads to inadequate prenatal care or if women who have inadequate care are less likely to have social support due to other factors. Some association between network characteristics and the amount and type of social support perceived by the pregnant women can be stated based on this study. Women with large social networks perceived they had more support than women with small social networks. Thus size of the 47 social network was a significant factor in the amount of perceived functional social support. Composition, that is, the presence of a boyfriend or husband within the social network was not a factor in the amount of perceived support for either woman with a large or small social network. However, within small social networks women who had a relationship with a boyfriend or husband had a small but insignificant increase in perceived functional social support. Perhaps, with fewer people to rely on for support, the support received from the boyfriend or husband becomes more important. The social network literature often uses size of the network as an important component of the network (Cronenwett, 1985; Mitchell 8 Trickett, 1990; Schaefer et al., 1981). Yet the research on social support during pregnancy often did not refer to the size of the social network of the pregnant woman. Collins et al. (1993) did report on the size of the social network of pregnant women and concluded that women with larger networks had babies of higher birthweight. Several studies linking social support with prenatal care report that having a person, family member or friend within their social network who was happy about the pregnancy was a motivator for receiving prenatal care (Lia-Hoagberg et al., 1990; St. John 8 Winston, 1989; Young et al. 1990). Perhaps women with a large social network are more likely to have contact with someone who is excited and supportive about the pregnancy. Indeed, Turner, 48 Grindstaff and Phillips (1990) found that for teenage mothers, subjects who lived with their parents had lower depression score than subjects in other living situations. Family support was a predictor of more favorable outcomes for both the infant and the teenage mother. The literature focuses on lack of support by the boyfriend or husband as a barrier to obtaining prenatal care (Lia-Hoagberg et al., 1990; McCormick et al., 1989; Sable et al., 1990; Young et al., 1989). This study did not find a relationship between the presence of a boyfriend or husband and the adequacy of prenatal care or between the presence of a boyfriend or husband and the amount of total functional social support. This could possibly be due to the large size of the social network of most subjects which made it difficult for one person to statistically stand out as providing more support. Another possibility is that the boyfriend or husband did not want the pregnancy or his ability to provide functional social support was negated by fear of responsibility, lack of resources to assist with the pregnancy or an inability to understand the support required. Analysis of type of support produced similar results. Again, the presence of a boyfriend or husband made no difference in perceived social support for subjects with large social networks. Subjects with small social networks had lower mean scores for all types of social support, affect, affirmation and aid. The presence of a boyfriend or 49 husband for subjects with small networks had a slightly higher mean score than those without this relationship. The variable, affirmation, produced the greatest difference in overall mean support, as subjects with a boyfriend or husband had higher mean support scores than those without this relationship. Perhaps this type of social support was most easy to provide for the boyfriend or husband. That is he may be able to endorse the pregnant woman's behaviors and views on the pregnancy without actually providing financial or material aid. The result was still insignificant but little overlap in the confidence intervals demonstrated that this relationship did provide the pregnant woman with more of this type of functional social support. The original conceptual model demonstrates that the pregnant woman is part of an open fluid interacting system. The social network is capable of expanding and contracting. The boyfriend or husband was given a special place within the network. This study did not find that this relationship lead to adequacy of prenatal care or even to increased functional social support. Pregnant women with large social networks had more functional social support than pregnant women with small social networks. The model has been revised in the following way (see Figure 4). This revised model reflects the findings of this study. The pregnant woman is paramount to the model, and interacts with her social network. The social network remains an open fluid system, capable of expanding and 50 Functional Social Support Meet, Mermstion. Aid *1 Afi/ \\ 4.3.6 \ / I CNS Figure 4. Conceptial Model Reu‘sed. Outcome of interaction between pregnant woman and social network contracting. The arrows extending outward indicate the social network is increasing in size. The boyfriend or husband has been deleted from the figure, this does not mean he is not a part of the social network but that his presence alone does not equate increased social support. Due to the study design, this study may not have been able to identify all supportive relationships. Perhaps there is a key person in the social network of the pregnant woman who was excited about the pregnancy and provided unconditional acceptance. Adequacy of prenatal care has also been deleted from the model as the outcome goal. This is not because adequacy of 51 prenatal care is not the goal, but rather based on this study no association was found between these concepts. Perhaps if the pregnant woman has enough functional social support it will be easier for her to obtain adequate prenatal care. Finally the CNS impacts this system by assessing the social network of the pregnant woman and assisting her to expand it as necessary to obtain the needed functional social support. Nursing Implications for Nursing Practice This study demonstrated that pregnant women with large social networks had more functional social support than women with small social networks and that the composition of the network is not a factor in the amount of perceived functional social support. This information has several implications for the primary care provider or CNS working with low income women in primary care. Other studies (Cooney, 1985; Giblin et al., 1990; Lia-Hoagberg et al., 1990; McCormick et al., 1989; McDonald 8 Coburn, 1988; 8 Sable et al., 1990) have linked adequate social support with adequacy of prenatal care. Thus the CNS may impact adequacy of prenatal care by assuring adequate social support. The CNS may impact adequacy of prenatal care by conscious interactions that lead to transactions in this case, obtaining prenatal care in all three systems, personal, interpersonal, and social systems. In the personal system the CNS in the role of counselor must consider the individual pregnant woman and know that 52 she is a social being able to perceive, think, feel, set goals and make decisions (King, 1981). The CNS working directly with prenatal clients can begin by treating the pregnant woman with respect, taking time to answer her questions and treating her as a capable person able to deal well with pregnancy and caring for an infant. The CNS may reinforce positive behaviors concerning the pregnancy and listening to her views on pregnancy, birth, and impending motherhood. The CNS can express positive affirmation concerning the pregnancy, supporting her in her decision to have a baby. In the interpersonal system the CNS in the role of counselor can assess the social support system of the pregnant woman. When this assessment reveals that the amount of support is inadequate the CNS may assist the pregnant woman by identifying individuals she may count on for additional support. The CNS should consider the possible impact of her/his interactions with the pregnant woman in the delivery of prenatal care. Supportive interactions may influence the pregnant woman to continue keeping prenatal care appointments. As an advocate the CNS may speak to all clients about prenatal care. Knowing that someone in the pregnant woman's social network can be influential in her decision to seek prenatal care, the CNS may inform all patients of the availability and importance of prenatal care with the goal that this individual will encourage someone she/he knows to obtain prenatal care. 53 Finally, in the social system, in the role of advocate the CNS can be a voice in the community speaking for low- income pregnant women to assure the community has adequate resources to meet their needs. This could be accomplished by becoming politically involved with county and state governments, and involvement with community and professional organizations. As an advocate, counselor and perhaps educator the CNS is able to assist the pregnant woman utilize existing services provided by the community (social system). This may be done by assuring the pregnant woman is aware of existing services and has the means and knowledge to access them. This can include programs such as medicaid, WIC, and AFDC. The CNS as part of the health care system may begin by assessing her/his own practice to determine what barriers exist for low income woman in obtaining services and work on eliminating these barriers. Assessing the individual clients is important as well as mutually determining what types of support are needed. Assisting the client obtain services such as parenting classes, prenatal classes, public health nurse and support groups can be done by the CNS who has established a relationship with the pregnant woman. Implications for Future Research This study failed to demonstrate an association between functional social support and adequacy of prenatal care. Previous studies have linked lack of social support as one non-economic barrier in obtaining prenatal care. The 54 failure of the present study to find an association may be in part to the small sample size in general and the even smaller number of subjects who received inadequate care. Previous research has used different measures of social support (Bruhn 8 Phillips, 1984; Cronewett, 1985; Norbeck, et al., 1981; Schaefer, et al., 1981). Although most of the adequacy of prenatal research has used the Kessner Index (Alexander et al., 1987; Cartoof, et al., 1981; Kogan et al., 1994; Liea-Hoagbert et al., 1990; McDonald 8 Colburn 1988) as a measure of the adequacy of prenatal care, as critiqued by Kotelchuck (1994) this index has not been consistent in its interpretation. Thus, possibility that increased social support does not lead to adequacy of prenatal or that this study due to factors of sample size, few with inadequate care, and most women with abundant social support was not able to find the association. Since adequate prenatal care is important in decreasing the high infant morbidity and mortality rate future research linking these concepts could prove to be important. Samples with consistent interpretation of adequacy of prenatal care and a like tool assessing social support would be needed. The difficulties in obtaining this data is in finding pregnant woman who have been given a like instrument for the assessment of social support. Since this concept relies on the pregnant woman's perception of social support she receives, it would be necessary to administer a social support instrument to a large sample at some time during the 55 ‘womanfis pregnancy or shortly thereafter. The Kessner Index or the GINDEX as measures of adequacy of prenatal care can be obtained by chart review of the pregnant woman's prenatal record. As previously stated the GINDEX, used to determine adequacy of prenatal care, may not have been the ideal tool. Perhaps with the additional category of intensive care, may women who received inadequate care were now classified as receiving intensive care. Another possibility is that the GINDEX is more accurate in determining adequacy of prenatal care and previous studies which utilized the Kessner Index actually overestimated the percent of women who received inadequate prenatal care. Both measurements rely on the gestational age at the initial visit as an important factor in determining the adequacy of prenatal care. There may be different motivators for a pregnant woman in beginning prenatal care versus continuing prenatal care. Perhaps functional social support is more important in one component than the other. Additional research is need to determine what factors lead a woman to seek prenatal care initially and what factors determine whether or not she continues to keep her prenatal care appointments. This study did find an association between the size of the social network and the amount of social support perceived by the pregnant woman. If social support would prove to be a factor in adequacy of prenatal care this could be important information. Composition of the social network 56 had no influence on the amount of perceived support. This study may have failed to find an association between composition of the social network and social support based on the definition. Composition was defined only as it pertained to the presence or absence of a boyfriend or husband. Other relationships were not specifically addressed other than their relationship to the size of the network. Perhaps more important than then the relationship, i.e., boyfriend/husband, friend, mother, is the importance of one significant person in the social network who is supportive and excited about the pregnancy. Also living arrangements were not addressed in this study. The majority of the subjects were single yet they had a boyfriend or husband in their social network. Perhaps there may be a difference in perceived support from boyfriends or husbands who lived with the subject in comparison to those boyfriends or husbands who live independently from the subject. Future research addressing the issue of whether or not there was a person in the pregnant woman's social network who was supportive of the pregnancy needs to be addressed. Indeed, there are also other factor briefly mentioned that influence a woman in her decision to obtain prenatal care. These include perception of the importance of care, accessibility to health care providers, comfort with the health care provider, acknowledgment of the pregnancy, transportation, insurance, daycare and multiple other factors. It is possible that these factors impact adequacy .ww— __.__.. —' 57 of prenatal care more than functional social support. Thus, while functional social support is a concept worthy of additional research other factors which may help explain the large proportion of women who receive inadequate care need further study. In conclusion, based on this study it would be helpful if future research linking these concepts would distinguish whether or not a focal member of the woman's social network who provides unconditional acceptance of the pregnancy is important, or if indeed, the size of the social network is more important than the composition. Another key analysis would be to examine if an association between the concepts is different for the initiation or the continuation of prenatal care. Summary This investigation of perceived functional social support and adequacy of prenatal care for a sample population of low income women failed to demonstrate an association between the two components. This may be in part due to the small sample size and the homogeneity of the sample. Social support is not always an easy concept to measure: it is subjective and may be influenced by the subject's mood, feelings and perceptions. Thus, failure to demonstrate an association by this study does not mean an association between these components does not exist. This study did find an association between the size of the social network and the perception of functional social support. 58 Since social support overall is deemed to be beneficial, this information could be important to the CNS working with low income pregnant women. Assessing and aiding the pregnant woman in expanding her social network could lead to more functional social support for that woman. LIST OF REFERENCES Aaronson, L. (1989). Perceived and received support: Effects on health behavior during pregnancy. Nursing Research—18(1). 4'9- Alexander, G., 8 Cornely, D. (1987). Prenatal care utilization: Its measurement and relationship to pregnancy outcome. WW5). 243-252. Bedics, B. (1994). Nonuse of prenatal care: Implications for social work involvement. Health_8_£gcial w(2),84-92. Belizan, J., Barros, F., Langer, A., Farnot, U., Victora, C., 8 Villar, J. (1995). Impact of health education during pregnancy on behavior and utilization of health resources WWW 111(3), 894-899. Boone, M. (1985). Social and cultural factors in the etiology of low birthweight among disadvantaged blacks. SociaLSciencLMedicianmm), 1001-1011. Brandt, P., 8 Weinert, C. (1981). The PRQ - A social support measure. Nursing_3gseargh*_fig(5), 277-280. Brink, P. J., 8 Wood, M. J. (1988). Bafiig_fitgp§_in planning_nnrsing_zgseazch. Boston: Jones and Bartlett. Bruhn, J., 8 Philips V. (1984). Measuring social support: A synthesis of current approaches. lgnrnal_gf BehaxioralJedicine.J(2) . 151-169- 59 6O Cartoof, V., Klerman, L., 8 Zazueta, V. (1991). The effect of source of prenatal care on care-seeking behavior and pregnancy outcomes among adolescents. Journal_gf Adolescent_nealth1_12. 124-129- Cobb, S., (1976). Social support as a moderator of life stress. Esychgsgmatic_fledicine‘_38(5), 300-313. Collins, N., Dunkel-Schetter, C., Lobel, M., 8 Scrimshaw S. (1993). Social support in pregnancy: Psychosocial correlates of birth outcomes and postpartum depression. WW 65(6), 1243-1258. Cooney, J. (1985). What determines the start of prenatal care? Medical_gare+_zz(8), 986-997. Cronewett, L. (1985). Network structure, social support, and psychological outcomes of pregnancy. Nursing Research1_34(2), 93-99. Curry, M.A. (1989). Nonfinancial barriers to prenatal care. H9m3n_dnd_fisalth1_1§(3)1 35-99- Fiscella, K. (1995). Does prenatal care improve birth outcomes? A critical review. obstetrics_8_fixnecclcsxi §5(3), 468-479. Giblin, P., Poland, M., 8 Ager J. (1990). Effects of social supports on attitudes, health behaviors and obtaining Prenatal care. Jonrnal_cf_conmunit¥_fiealth1_15(6). 357-368. Gore, 8. (1978). The effect of social support in moderating the health consequences of unemployment. lgnrnal cf_Hea1th_and_Socia1_Behaxior1_12. 157-165. 61 Greenberg, R. (1983). The impact of prenatal care in different social groups. Amsrisan_Jgnrnal_gf_9hstetrics_i Grnecslns¥1_145, 797- Haas, J., Orav, J., 8 Goldman, L. (1995). The relationship between physician' qualifications and experience and the adequacy of prenatal care and low birthweight. WWW”). 1087- 1091. Hobel, C. (1986). Prenatal care. In N. Hacker 8 J. Moore. EssentialufJbstetricLanLgynecclm (pp-54-63l- Philadelphia: W. B. Saunders Company. Iams, J. (1988). Obstetric inertia: An obstacle to the prevention of prematurity. Amsrisan_Jgnrnsi_s£_thrsrriss_§ firnecnles¥1_152(4). 796‘798- Kahn R.L. (1979). Aging and social support. In M.W. Riley. Aging from birth to death: Interdisciplinary psrsnsgrixss, (pp. 77-91). Boulder, Co: Westview Press. Kaplan, B., Cassel, J., 8 Gore, S. (1977). Social support and health. Msdisai_£arsi_15(5), 47-57. King, I. (1981). A_rnsgry_£gr_nnrsing. New York: Wiley Medical Publications. Kogan, M., Alexander, G., Kotelchuck, M., 8 Nagey D. (1994). Relationship of the content of prenatal care to the risk of low birth weight. Jgnrna1_gf_ths_Amsrigan_Msdisni Association1_211(17), 1340-1345. '_~ I.‘ ‘I. ' ‘ 1' - i ' a. . . . I“ e - , 62 Kotelchuck, M. (1994). An evaluation of the kessner adequacy of prenatal care index and a proposed adequacy of prenatal utilization index. Ansrissn_1gnrnsi_gf_2nbiis W”) , 1414-1419. Leatherman, J., Blackburn, D., 8 Davidhizar R. (1990). How postpartum women explain their lack of obtaining adequate prenatal care. Jgnrnn1_nf_Adxnnssd_Nnrsing+_ifi, 256-267. Lia-Hoagberg, 8., Rode, P., Skovholt, C., Oberg, C., Berg, C., Mullett, S., 8 Choi, T. (1990). Barriers and motivators to prenatal care among low-income women. Sgsini Science_MedicineI_19(4l. 437'495- Lin, N. 8 Ensel, W. (1984). Depression-mobility and its social etiology: The role of life events and social support. IQnrnal_QI_HsalIh_dnd_SO£ial_BshAYiQZ1_25. 176-188- Lin, N., Ensel, W., Simeone, R., 8 Kuo, W. (1979). Social support, stressful life events, and illness: A model and eupirical test. MW 29. 108-119. Long, S. Marquis, S. 8 Harrison E. (1994). The costs and financing of perinatal care in the United States. MW”). 1473-1478- McCormick, M., Brooks-Gunn, T., Holmes, J., Wallace, C., 8 Heagarty, M. (1989). Outreach as case finding: Its effect on enrollment in prenatal care. Msdisnl_£ars+_21(2), 103-111. 63 ‘McDonald, T., 8 Coburn, A. (1988). Predictors of prenatal care utilization. sggini_sgisnss_nsdisinsr_21(2), 167-172. Mercer, R., Ferketich, S., DeJoseph, J., May, K., 8 Sollid, D. (1988). Effect of stress on family functioning during pregnancy. Nursing_3sssarsnr_11(5), 268-275. Mitchell, R. 8 Trickett, E. (1980). Task force report: Social networks as mediators of social support: An analysis of the effects and determinants of social networks. .Communitx_Mental_Health_Jcnrna11_16, 27-44. Norbeck, J. (1981). Social support: A model for In clinical research and application. Adynnsss_in_Nnrsing Science. 43-59- Norbeck, J., Lindsey, A., 8 Carrieri, V. (1981). The development of an instrument to measure social support. Nursin9_Research1_39(5). 264-269- Norbeck, J., Lindsey, A., 8 Carrieri, V. (1983). Further development of the Norbeck social support questionnaire: Normative data and validity testing. Nursing Research1_32(5), 4-9. Norbeck, J. 8 Tilden V. (1983). Life stress, social support, and emotional disequilibrium in complications of pregnancy: A prospective, multivariate study. 1snrnsi_gf HaalIh_and_SOCidl_Bshn¥iOri_24, 30-46. Nuckolls, K.B., Cassel, J., 8 Kaplan, B.H. (1972). Psychosocial assets, life crisis, and the prognosis of Pregnancy. American_Jcnrnal_of_Enidemioles¥1_25. 431-441. An. 64 Pascoe, J., Milburn, M., 8 Haynes, K. (1990). Correlates of first trimester care in a public health pre- natal clinic. Eam11¥_MedicineI_22(1). 25-28- Petitti, D., Coleman, C., Bensacca, D., 8 Allen, B. (1990). Early prenatal care in urban black and white women. 31%—11(1) I 1'50 Polit. D- 5 Hungler. 3- (1987l- Nursins_research1 Principles_and_metnods. Philadelphia: J. B. Lippincott. Poland, M., Ager, J., Olson, K. 8 Sokol, R. (1990). Quality of prenatal care: Selected social, behavioral, and biomedical factors; and birth weight. Qbsrsrriss_8 fixnecolns¥1_15(4). 507'511- Ramsey C., Abell, T., 8 Baker, L. (1986). The relationship between family functioning, live events, family structure, and the outcome of pregnancy. Ins_1snrnai_gfi Eam11¥_£racticei_22(6). 521-527- Raine, T., Powell, 8. 8 Krohn M. (1994). The risk of repeating low birth weight and the role of prenatal care. Qbstetrics_8_fixnecolnnxi_fii(4)u 485-489- Sable, M., Stockbauer, J., Schramm, W, 8 Land G. (1990). Differentiating the barriers to adequate prenatal care in Missouri, 1987-88. Enbiis_Hsalth_Rsngrtsr_iQ5(6), 549-555. St. Clair, P., 8 Anderson N. (1989). Social network advice during pregnancy: Myths, misinformation, and sound counsel. Birtn+_i§(3), 103-107. 65 St. Clair, P., Smeriglio V., Alexander, C., 8 Celentano D. (1989). Social network structure and prenatal care utilization. Medina1_£nzs1_21(3): 323-331- St. Clair, P., Smeriglio, V., Alexander C., Connell, F., 8 Niebyl, J. (1990). Situational and financial barriers to prenatal care in a sample of low-income, inner-city women. WU). 264-266- St. John, C., 8 Winston, T. (1989). The effect of social support on prenatal care. Tns_zgnrnsi_gr_Apniisd Wm), 79-98. Schaefer, C. Coyne, J., 8 Lazarus, R. (1981). The health-related functions of social support. Jgnrnsi_nf William—4(4) , 381-405. Schiffman, R. 8 Omar, M. (1994). £astgrs_1nfinsnging . -.... . .u- '. .- -. - . 1-. o 0‘9 00.10‘. Unpublished Manuscript. Showstack, J., Budetti, P. 8 Minkler, D. (1984). Factors associated with birthweight: An exploration cf the roles of prenatal care and length of gestation. Ansrissn W9) 1 1003-1003- Standards for Obstetrics/Gynecology Services, 5th ed. (1982). The American College of Obstetricians and Gynecologists, Washington D.C. Tilden, V. (1983). The relationship of life stress and social support to emotional disequilibrium during pregnancy. WWII“. 167-174- 66 Turner, R., Grindstaff, C., 8 Phillips, N. (1990).Social support and outcome in teenage pregnancy. Jnurna1_cf_Health_and_Sccial_Beha¥ior1_31, 43-57. Villar, J., Farnot, U., Barros, F., Victora, C., Langer, A., 8 Belizan J. (1992). A randomized trial of psychosocial support during high-risk pregnancies. Th£_NEH Ensland.lcurnal_of Medicine1_321(18), 1266-1271. Young, C., McMahon, J., Bowman, V., 8 Thompson, D. (1989). Maternal reasons for delayed prenatal care. Nursing Research1_38(4), 242-243. Appendix A Data Collection Procedures W Centgr {gr BEBISDX Beginnings. 'The following procedures were used for data collection at the Center for Healthy Beginnings: 1. Subjects were approached in the waiting room at their first prenatal visit by the data collector. The project was explained and informed consent obtained. At the first prenatal visit, after consent, the data collector: a. Assisted subjects to complete the Ten Item Check List. b. Recorded sociodemographic and physiologic data from the subjecte' records on the data collection form. c. Marked the subjects' records and the data collection form for the next scheduled visit. . At the one of the next two scheduled visits, the data collector: a. Administered the instruments (CBS-D, Family APGAR, IFSAP, LEQ, NSSQ, and F55) in a room separate from the examination and waiting rooms. b. Answered subjects‘ questions for clarification of instructions and meaning of words only. c. Marked the record and data collection form for the post-partum visit. The data collector identified when subjects had delivered and placed the post-partum instrument packet in the subjests‘ records. At the post-partum visit, subjects: a. Completed the instruments (CES-D, Family APGAR, IFSAC, LEQ, NSSQ, and child health survey) and placed them in a special folder for the data collector. A chart review was conducted to collect variables from the subjects' records. [We 68 Appendix B Norbeck Social Su ort uestionnaire SOCIAL SUPPORT QUESTIONNAIRE (A) PATID9 __ PLEASE READ ALL DIRECTIONS ON THIS PAGE BEFORE STARTING. :93 as Please list each significant person in your life on the right. Consider all the persons who provide personal support for you or who are important to you. Use only first names or initials, and then indicate the relationship, as in the following example: Example: First Name or Initials Relationship 1_ M ARY T. ' - -F-£1€RPU--‘ 2. BOB 3R5?” ER 3, M .‘l'. Me THER’ 4. 5A M FR \E Nb 5. MR$ , '2 . N EAG‘AEO‘R etc. Use the following list to help you think of the pe0ple important to you, and list as many peOple as apply in your case. — spouse or partner — family members or relatives - friends — work or school associates - neighbors — health care providers — counselor or therapist — minister/prieSt/rabbi - other (You do not have to use all 24 spaces. Use as many spaces as you have Important persons in your life. WHEN YOU HA VE FINISHED YOUR LIST, PLEASE TURN T0 PA GE .7. ©1980 by Jane S. Norbeck, D.N.Sc. University of California, San Francisco Revised l982 69 For each person you listed, please answer the following questions by writing in the number that applies. "-._1 = not at all Q=afiuh 3 = moderately .‘4 = quite a bit .5 = a great deal QUCSlion 1': Question 2: How much does this person make How much does this person you feel liked or loved? make you feel respected ‘ or admired? l. 1. 2. 2. 3. . 3. 4. 4. 5. S. 6. 6. 7. 7. 8. 8. 9 9. 10 10 ll. 11. __ l2. - 12. 13. 13. « M 14. ' 15. ' 15. 16. ]5_ I- 17. i3 18. 19 19. 20. 20_ 31. 21. 33 22. 33 23. 24 24. 60 ON TO NEXTPA GE (8‘10) (ll-13) 70 l = not at all 2 = a little 3 = moderately 4 = quite a bit 5 = a great deal Question 3: Question 4: How much can you confide How much does this person in this person? agree with or support your actions or thoughts? 1. 1. 2. 2. 3. 3. 4. 4. S. S. 6. 6. 7. 7. 8. 8. 9. 9. 10. 10. 11. 11. 12. 12. i3. 13. 14. 14'. 15. 15. 16. 16. 17. 17_ 18. - 18. 19. 19. 20. 20. 21. 21. 22. 22. 23. 23. 24. 24_ (Ill-16) GOON TONEXTPACE (”-19 71 1 = not at all 2=afluh 3 = moderately 4 = quite a bit 5 = a great deal Quesrion 5: Question 6: If you needed to borrow $10, a ride If you were‘confined to bed for to the doctor, or some other ' several weeks, how much could immediate help, how much could this person help you? this person usually help? 1. 1. 2. 2. 3. 3. 4. 4, S. 5, 6. 5, 7. 7. 8. 3. 9. 9. 10. 10. ll. 1]. I‘J .a N ADJ .—s.—a Aw U: —a M O‘\ and 0" i .—a \l >000~ d.‘ sooo o M .9 N —I N M IQ ls.) fJ k) k) JAleQ-d' N La.) ._ i 24. GO ON TO NEXTPAGE -. 'wze’w 734' ‘yI-"ls ~31 M 72 Appendix C UCRIHS Approval ICHIGAN STATE UNIVERSITY OFFICE OF VICE PRESIDENT FOR RESEARCH EAST LANSING 0 MICHIGAN 0 «824-1046 AND DEAN OF THE GRADUATE SCHOOL March 2. 1993 TO: Rachel Schiffman. Ph.D. Mildred Omar. Ph.D. A230 Life Sciences RE: [RB 19': 92-115 TITLE: FACTORS INFLUENCING PREGNANCY OUTCOME CATEGORY: l-C REVISION REQUESTED: February 23. I993 APPROVAL DATE: March 1, 1993 The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complete. I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore. the UCRIHS approved this project including any revision listed above. UCRIHS approval is valid for one calendar year. beginning with the approval date shown above. Investigators planning to continue a project beyond one year must seek updated certification. Request for renewed approval must be accompanied by all four of the following mandatory assumces. l. 2. 3. 4. The human subjects protocol is the same as in previous studies. There have been no ill effects suffered by the subjects due to their participation in the study. There have been no complaints by the subjects or their representatives related to their participation in the study. There has not been a change in the research environment nor new information which would indicate greater risk to human subjects than that assumed when the protocol was initially reviewed and approved. There is a maximum of four such expedited renewals possible. Investigators'wishing to continue a project beyond that time need to submit it again for complete review. UCRIHS must review any changes in procedures involving human subjects. prior to initiation of the change. Investigators must notify UCRIHS promptly of any problems (unexpected side effects. complaints. etc.) involving human subjects during the course of the work. If we can be of any future help. plme do not hesitate to contact us at (517) 355-2180 or FAX (517) 336-1171. Sincerely, .‘t avid E. Wright. Ph.D. UCRIHS Chair DE\V:pjm 73 MICHIGAN STATE UNIVERSITY mum»; 0'; VICE "mom son "sung: EAST LANSING ' MICHIGAN 0 «datum AND ”FAN OF nut GRADUATE SCHOOL March 19. 1992 Mildred A. Omar. Ph.D. , Rachel F. Schiffman, Ph.D. A-230 Life Sciences Bldg. RE: FACTORS INFLUENCING PREGNANCY OUTCOHE, IRB #92-115 Dear Drs. Omar and Schiffman: The above project is exempt from full UCRIHS review. One of the Committee's members has reviewed the proposed research protocol and finds 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 plan to continue this project beyond one year. please make provisions for obtaining appropriate UCRIHS approval one month prior to March 16. 1993. Any changes in procedures involving human subjects must be reviewed by the UCRIHS prior to initiation of the change. UCRIHS must alsobe 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. S incere 1y , David E. Urigh , Ph D. Chair. UCRIHS DEV/pin WY. -9... -m1-'z"“‘- "- "1” "w- "'"' Oflfiflfl RESEARCH AND GRADUATE STUDIES University Committee on Research Involving Human Subjects (UCRIHS) Mkmwmsweumeuy 225 Minimum-m Building [:51 1mm. Michigan “824-1046 517/355-2180 FAX. 517/‘32-1i71 74 MICHIGAN STATE UNIVERSITY tebruary 23, 1995 TO: Betty N. Dawson 1434 Bisca ne Ha Basslett, I 48 40 RE: IRBI: 95-088 TITLE: IS TIER! A RELATIONSHIP BETWEEN FUNCTIONAL SOCIAL SUPPORT AND THE ADEQUACY OP PRENATAL CARE ascsrvrn av rarcnanr nouns asvrston aroussrsn: N/A carsconv: 1-2 arenovar pars: 02/21/95 The University Committee on Research Involving Human Sub ects'(UCRIHS) review of this project is complete. I am pleased to adv so that th rights and.welfare of the human subjects appear to.be adequately protected and methods to obtain informed consent are appropriate. 12.§:5°:36 the UCRIHS approved this project including any revision s ve. RENEWAL: the approval date shown above. continue a project be ond one year must use the pro ect is renewed) to seek u a certification. max of four such expedite renewals ssible. wishing to continue a roject beyond tha again or complete rev ew. RZVISIONS: UCRIHS must review an subjects, rior to in tiation of t e change. the time o renewal, please use the green renewal form. revise an ap roved protocol at an 0 send your wr tten request to the approval and referencin the project‘s I38 I and title. changes in in your request a descr ption of the change and any revised ins ruments, consent forms or advertisements that are applicable. eaosnsus/ CIANOES: Should either of the followin work, investi ators must noti y UCRIHS promptly: 11) p (unexpected s de effects comp aints, e c.) involv ng subjects or (2) changes in information indicating existed when the protocol was previously reviewed an If we can be of any future helpé lease do not hesitate to contact us at (512)355-2180 or sax (s12)3 avid B. Nrightr/Rh. . UCRIHS Chair \ 171. sincerely, new:pjm cc: Rachel F. Schiffman UCRIHS approval is valid for one calendar year, beginning with Investigators planning to green renewal form (enclosed with t e original approval letter or when a to There is a Investigators time need to submit it rocedures involving human If this is done at her time during the year CRIBS Chair, requesting rev arise during the course of the the research environment or new greater risk to the human sub ects than approved. .- 1w..—V.w— LV- V q"__,' k" u. "if"! T“ "Iinn1111117111“