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thesis entitled

THE RELATIONSHIP BETWEEN AGE
APPROPRIATE EDUCATIONAL LEVEL AND BARRIERS
TO PRENATAL CARE OF RURAL LOW INCOME

PREGNANT WOMEN

presented by
CHRISTA L . HOLLAND

has been accepted towards fulfillment
of the requirements for

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1198 chlRCDdoOm.pfi5-p.14

 

THE RELATIONSHIP BETWEEN
AGE APPROPRIATE EDUCATIONAL LEVEL
AND BARRIERS TO PRENATAL CARE OF
RURAL LOW INCOME PREGNANT WOMEN
By
Christa L. Holland

ATHESIS

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

MASTER OF SCIENCE OF NURSING

College of Nursing
1998

ABSTRACT

THE RELATIONSHIP BETWEEN
AGE APPROPRIATE EDUCATIONAL LEVEL
AND BARRIERS TO PRENATAL CARE OF
RURAL LOW INCOME PREGNANT WOMEN

By

Christa L. Holland

The purpose of this study was to identify the most frequently reported
barriers by age appropriate educational level and to determine if there were
differences in the number of reported barriers to age appropriate educational
level of rural low income pregnant women. Pender's Health Promotion
Model (1995) provided the conceptual framework. Secondary data collected by
Omar, Schiffman, and Bauer (1995) were used. Age appropriate educational
level was categorized as: (a) less than high school diploma 18 years of age or
younger, (b) less than high school diploma 19 years of age and older, (c) high
school diploma, and (d) post secondary education. Data analysis found that
pregnant women with less than a high school diploma and at least 19 years of
age found transportation to be the most frequently identified barrier, while
pregnant women with a high school diploma or more education reported
inability to pay for prenatal care. The economic barrier was the type of barrier
most commonly reported for rural low income pregnant women. The study
found no association between the educational level of pregnant women and
the number of reported barriers to prenatal care. Information from this study
can assist the APN working with rural low income pregnant women in

efforts to decrease barriers to prenatal care for these women.

Dedicate to those who have
unconditionally given
their love over the past two years

iii

ACKNOWLEDGMENTS

I first need to thank Mildred A. Omar, PhD, RNC, my thesis chair, for
her patience and wisdom. I would also like to thank my committee,
Jacqueline Wright, MSN, RN, and Rachel F. Schiffman, PhD, RN.

I must admit, it is rather exciting knowing how close to being done I
am and looking back over two and a half years of my life thinking who
helped me reach this point. First, Amy Montgomery who made me realize
how short life is. Secondly, my guardian angel Joan Predko, PhD, RN.
Finally, I need to thank my parents and my best friend, without whom none
of my dreams would ever come true. Mom and Dad, you are so incredibly
special, thank-you for your love and support over the years. I love you.
Tamara, you have been my rock, always there when I need you. Thank-you.

With the conclusion of this paper, comes to an end a special period of
my life, it has been one heck of a learning experience and I would like to
thank everyone at the Michigan State University College of Nursing. GO
GREEN!!

iv

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................ vii
LIST OF FIGURES ....................................................................................................... viii
Introduction. ..................................................................................................................... 1
Background of the Problem ............................................................................... 1
Statement of the Problem .................................................................................. 4
Research Questions ............................................................................................. 5
Significance of Study ........................................................................................... 5
Conceptual Framework .................................................................................................. 6
Conceptual Definition of Variables ................................................................. 6

Age Appropriate Educational Level .................................................... 6

Types of Barriers to Prenatal Care ........................................................ 7

Economic Barrier ..................................................................................... 8
Organizational Barrier ............................................................................ 9

Attitudinal Barrier ................................................................................... 9

Theoretical Model .............................................................................................. 10
Individual Characteristics .................................................................... 11
Behavior-Specific Cognitions and Affect .......................................... 13

Behavioral Outcomes ........................................................................... 14

Application of the Health Promotion Model .............................................. 14
Individual Characteristics .................................................................... 14
Behavior-Specific Cognitions and Affect .......................................... 15

Review of the Literature .............................................................................................. 17
Age Appropriate Educational Level and Barriers ....................................... 17

Low Income and Barriers to Prenatal Care ................................................... 18
Critique of Literature ......................................................................................... 21
Methods ........................................................................................................................... 24
Design. .................................................................................................................. 24
Sample .................................................................................................................. 24
Operational Definitions ................................................................................... 25

Instruments ........................................................................................................ 26

Human Subjects Protection ............................................................................ 26
Data Analysis ..................................................................................................... 27
Research Assumptions .................................................................................... 28
Research Limitations ....................................................................................... 28
Results ............................................................................................................................. 29
Demographics .................................................................................................... 29
Results Related to Research Questions ........................................................ 30

What is the most frequently identified barrier by

age appropriate educational level for rural low income

pregnant women? .................................................................................. 30
What type of barrier is most frequently reported by age
appropriate educational level by rural lwo income pregnant
women? ................................................................................................... 32
Is there any association between the number of reported

barriers identified and the age appropriate

educational level of rural low income pregnant

women? ................................................................................................... 32
Discussion. ....................................................................................................................... 34
Most Frequently Identified Barrier and
Most Frequently Reported Type of Barrier ................................................... 35
Association Between Educational
Level and Number of Barriers ........................................................................ 38
Conceptual Framework .................................................................................... 39
Implications for Advanced Practice Nurses ................................................. 4O
Implications for Research ............................................................................... 43
Summary ............................................................................................................. 45
References ....................................................................................................................... 47
Appendices
A: Ten-Item Checklist ...................................................................................... 52
B: Patient Satisfaction with Prenatal Care Instrument ............................. 63
C: UCRIHS Orginal Study ............................................................................... 65
D: UCRIHS Approval ...................................................................................... 66
E: Field Procedures ........................................................................................... 67

vi

LIST OF TABLES

Table 1 - Frequency of Identified Barrier by Age Appropriate
Educational Level for Rural Low Income Pregnant
Women. ........................................................................................................... 31

Table 2 - Type of Barrier Most Frequently Reported by Age
Appropriate Educational Level by Rural Low Income
Pregnant Women .......................................................................................... 33

Table 3 - Means and Standard Deviations of Number

of Reported Barriers by Age Appropriate Educational
Level ................................................................................................................ 33

vii

LIST OF FIGURES

Figure 1 - Health Promotion Model (Pender, 1996) .............................................. 12

Figure 2 - Age Appropriate Educational Level
and Barriers of Prenatal Care:
Application to the
Health Promotion Model ........................................................................ 16

Figure 3 - Modification of the Health Promotion
Model Based on Study Findings:
Application to the
Health Promotion Model ....................................................................... 41

viii

Introduction
WW

Rural low income women often have limited access to prenatal care
and receive less than adequate prenatal care (Curry, 1989; Harvey 8: Faber,
1993; McClanahan, 1992). Adequate prenatal care has been associated with
increased birth weight, decreased incidence of pre-term deliveries, and
decreased infant and maternal mortality (Johnson, Primas, 8: Coe, 1994). The
inability of rural low income women to obtain prenatal care has been
associated with barriers (Scupholme, Robertson, 8: Kamons, 1991). Three
general types of barriers to prenatal care have been identified in the literature:
attitudinal, organizational, and economic (Burks, 1992; Curry, 1989; Joyce,
Diffenbacher, Greene, 8: Sorokin, 1983; Maloni, Cheng, Liebl, 8: Maier, 1996;
St. Clair, Smeriglio, Alexander, Connell, 8: Niebyl, 1990; Zambrana, Dunkel-
Schetter, 8: Scrimshaw, 1991); these barriers have been reported to decrease
the utilization of prenatal care for low income pregnant women (Harvey 8:
Faber, 1993). Barriers to receiving prenatal care have been related to
educational level (Aved, Irwin, Cummings, 8: Findeisen, 1993; Harvey 8:
Faber, 1993; Kotelchuck, 1994; Sable, Stockbauer, Schramm, 8: Land, 1990;
Zambrana et al., 1991 ). There is limited literature, however, about barriers to
prenatal care utilization for rural low income pregnant women. The purpose
of this study was to describe barriers to prenatal care by age appropriate
educational level of rural low income pregnant women and to explore
differences in the number of barriers among age appropriate educational
levels of these women.

Some studies have shown that less educated pregnant women

perceive more barriers and are less likely to receive prenatal care, these are

studies primarily of urban women (Lia-Hoagberg, Rode, Skovholt, Oberg,

Berg, Mullett, 8: Choi, 1990; Sable et al., 1990; Young, McMahon, Bowman, 8:
Thompson, 1989); however, the literature does not directly explain how
pregnant women's educational level affects their perceived barriers to
prenatal care. Perhaps with higher levels of education, pregnant women
report fewer barriers because education increases problem solving skills and
critical thinking. Increased problem solving skills may allow both rural and
urban low income pregnant women to overcome financial and
organizational barriers to prenatal care. Critical thinking skills are a
composite of attitudes, knowledge, and skills that are an indispensable
component in decision making for rural low income pregnant women when
faced with barriers to prenatal care (Miller, 1992).

Many rural low income pregnant women are without health insurance
or may not have the financial resources which can produce a financial barrier
to prenatal care (Curry, 1989; Goldenberg, Patterson, 8: Frees, 1992; Harvey 8:
Faber, 1993; Maloni et al., 1996; McClanahan, 1992; McDonald 8: Coburn, 1988;
Young et al., 1989). Living in a rural community often presents other barriers
to prenatal care, such as having a limited number of prenatal care providers
(McClanahan, 1992). Limited numbers of prenatal care providers have been
identified as an organizational barrier to prenatal care for rural low income
pregnant women (Harvey 8: Faber, 1993; Joyce et al., 1984; McClanahan, 1992).
As a consequence of few prenatal care providers, women often must travel
great distances for their prenatal care, and this can produce an additional
financial barrier for rural low income women with limited funds for gasoline
or car maintenance (Harvey 8: Faber, 1993; Maloni et al., 1996; McClanahan,
1992). Attitudinal barriers include fear of doctors or lack of knowledge of the

importance of prenatal care for rural low income pregnant women (Curry,

1989; Johnson et al., 1994; Lapierre, Perreault, 8: Goulet, 1995; Lia-Hoagberg et
al., 1990; Maloni et al., 1996; Sable et al., 1990; Young et al., 1989).

The literature suggests education plays a significant role in
determining if pregnant women will receive prenatal care (Aved et al., 1993;
Curry, 1989; Harvey 8: Faber, 1993; Joyce et al., 1984; McDonald et al., 1988;
Zambrana et al., 1991). The educational level of rural low income pregnant
women may influence the means in which barriers to prenatal care are
comprehended and managed (Burks, 1992; Harvey 8: Faber, 1993). If the
ability to overcome barriers is based on education, then pregnant teens or
women who have less education may lack the skills to overcome barriers to
prenatal care. In a study investigating barriers to prenatal care for low income
women, Aved et al. (1993) reported that pregnant women with a high school
diploma were more likely to be successful in acquiring prenatal care than
pregnant women with less education. The literature did not report the types
of barriers to prenatal care based on the educational levels. Most of the
studies noted that pregnant women with more education reported fewer
barriers to prenatal care (Aved et al., 1993; Lia-Hoagberg et al., 1990; Joyce et al.,
1984; Passannante, Espenshade, 8: Weiss, 1994).

A Michigan Department of Public Health survey (1989) reported that
pregnant women who had trouble finding a prenatal care physician were
younger and less educated. Of the studies which described barriers to prenatal
care, higher levels of education were related to the pregnant women's ability
to overcome barriers (Harvey 8: Faber, 1993; McClanahan, 1992; McDonald 8:
Coburn, 1988; Sable et al, 1990; Scupholme et al., 1991; Zambrana et al., 1991);
however, some authors made no link between educational level and prenatal
care utilization (Johnson et al., 1994). Cooney (1985) associated a higher
educational level with greater knowledge about good health practices and

receiving prenatal care. McDonald and Coburn (1988) and Aved et al. (1993)
reported that pregnant women's knowledge, beliefs, and attitudes, which are
related to educational level, play an important part in acquiring prenatal care
services.

The advanced practice nurse (APN) has become an important provider
in the delivery of health care. The APN is able to collaborate with other
health professionals with the potential for decreasing barriers to prenatal care
for rural low income pregnant women. State and federal initiatives have
supported the use of advanced practice nurses in rural areas. Advanced
practice nurses have the ability to provide prenatal care services to rural low
income pregnant women. Information regarding the educational level of
rural low income pregnant women and the association it may have with
barriers to prenatal care for this population can assist APNs in developing
interventions to decrease barriers to prenatal care for rural low income
pregnant women.

StatemenLthheEmhlem

International concern has focused on decreasing infant and maternal
mortality by providing prenatal care to all women beginning in the first
trimester. While the United States has stated the goal of adequate prenatal
care utilization for all pregnant women, the statistics reflect that there has
been a lack of improvement in pregnant women obtaining adequate prenatal
care (USDHHS, 1990). Inadequate prenatal care has been associated with
barriers to prenatal care (McClanahan, 1992). Studies report rural
communities have increased barriers to prenatal care and have limited access
to health care (Curry, 1989; McClanahan, 1992; Sable et al., 1990). Rural
pregnant women have been reported to have later entry into prenatal care as
compared to urban women (McManus 8: Newacheck, 1989). The educational

level of rural low income pregnant women may be one factor related to
identified barriers to prenatal care. Harvey and Faber (1993) reported that
pregnant women with less education were more likely to cite barriers to
prenatal care, while Aved et al. (1993) reported that pregnant women with a
high school diploma were more successful in overcoming barriers and
obtaining prenatal care. However, little is known about the association
between barriers to prenatal care and educational level for rural low income
pregnant women.

In a rural community in Michigan, maternal reasons for not seeking
prenatal care were examined by Omar, Schiffman, and Bauer (1995); however,
the association between barriers and age appropriate educational level was
not reported. Factors that inhibit access to prenatal care for rural low income
women need to be better understood to design interventions that will
decrease barriers to prenatal care. If the educational level of rural low income
pregnant women is associated with barriers to receiving prenatal care, it is
important to understand this association in order to enhance success in
reducing the barriers to prenatal care for this population.

Researrhfluestions

The research questions were: (1) What is the most frequently identified
barrier by age appropriate educational level for rural low income pregnant
women? (2) What type of barrier is most frequently reported by age
appropriate educational level of rural low income pregnant women? (3) Is
there an association between the number of reported barriers identified and
the age appropriate educational level of rural low income pregnant women?
5' 'E' E I] S l

Discovering the type of barrier to prenatal care in each educational

level provides information regarding the impact educational level has on

barriers to prenatal care for rural low income pregnant women. By
identifying an association between the number of reported barriers to prenatal
care and educational levels, the impact pregnant women's educational levels
have on their barriers to prenatal care can be recognized. By studying
educational levels and barriers to prenatal care for rural low income pregnant
women in one rural community, information is provided which enables
health care providers to further understand barriers to prenatal care for
women in their community and can assist in the development of
interventions to decrease barriers to prenatal care.
Conceptual Framework

C llDET [11']!

This section includes the conceptual definition for each of the study
variables. Secondly, the conceptual framework using the Health Promotion
Model of Pender is - described. Conceptual definitions of the variables of age
appropriate educational level and barriers to prenatal care are based on a
synthesis of existing literature and the conceptual framework of the Health
Promotion Model (HPM) (Pender, 1996). First, the conceptual definitions are
presented for age appropriate educational level and barriers to prenatal care.
Second, these definitions are applied to the theoretical model of the Health
Promotion Model (Pender, 1996).

E l . | E l I' l I 1

Education and educational level are not commonly defined concepts in
research or the literature. Education is the process of learning, acquiring
reasoning, and knowledge (Webster's, 1989). Educational level has been
defined according to the grade of education attained, given in years. Higher
levels of education increase a person's problem solving abilities, inductive

reasoning, and critical skills (Miller, 1992). Research has continually

categorized the level of education by documenting how many years of school
a person has received. Cooney ( 1985) defines education by the years of school
completed, and refers to it as "not only formal instruction but also the extent
of exposure to middle class American values" (p. 988).

A high school diploma is a standard that indicates a marker reached in
the learning process of a woman's life. Women who are 18 years or less
without a high school diploma need to be considered differently than
pregnant women 19 years and older that do not have a high school diploma.
The younger women have not yet had the opportunity to accomplish the set
standards to achieve a high school diploma, they may still be in high school,
and may not have attained those skills that are provided through formal
education. In addition, women younger than 19 years of age, may not have
the informal skills of gaining education through life's experience, which
women 19 years and older without a high school diploma may have attained.
Therefore, educational level must be assessed by not only the level of formal
education that pregnant women have attained but also by their age and if it is
appropriate for that educational level.

For this study, age appropriate educational level was defined as the
appropriate level of education based on a pregnant woman's age. Age
appropriate educational level refers to a person being a certain age at a
particular level of education. It is assumed that with higher levels of
education the more knowledge, problem solving skills, and critical thinking
skills a pregnant woman will have.

W

Barriers are considered to be obstacles or impediments for pregnant
women in receiving prenatal care (Harvey 8: Faber, 1993; Reis, Robinson,
Anderson, Mills-Thomas, 1992; Scupholme et al., 1991). The literature

extensively defined barriers to prenatal care for pregnant women (Aved et al.,
1993; Cooney, 1985; Goldenberg et al., 1992; Higgins, Murray, 8: Williams,
1994; Poland, Ager, Olson, 8: Sokol, 1987; Zambrana et al., 1991). The
literature used a multitude of different words to define barriers such as:
factors, deterrents, variables, and problems (Cooney, 1985; Hansell, 1991;
Poland, Ager, Olson 8: Sokol, 1990; Sable et al., 1990; St. Clair et al., 1990).
Barriers can be classified by type, which include: financial, organizational,
medical, sociocultural, personal attitudes, situational, sociodemographic,
psychosocial, economic, emotional, behavioral, internal or external (Hansell,
1991; Harvey 8: Faber, 1993; Higgins et al., 1994; Maloni et al., 1996; Melnikow
8: Alemagno, 1993; Omar et al., 1995; Passannante et al., 1994; Poland et al.,
1987; Sable et al., 1990; Scupholme et al., 1991; St. Clair et al., 1990). The
various authors did not offer a consistent list of types of barriers. In this
study, types of barriers were defined as economic, organizational, and
attitudinal.

W; Economic barriers have been defined by researchers
as obstacles leading to the inability to pay for health care services (Harvey 8:
Faber, 1993; Sable et al., 1990). Meikle, Orleans, Leff, Shain, and Gibbs (1995)
found the economic barriers to prenatal care such as lack of finances and little
or no health insurance were the main barriers for not receiving prenatal care.
Joyce et al. (1983), Johnson et al. (1994), and Higgins et al. (1994) used the term
external barriers to define economic factors which included lack of financial
resources or insurance coverage, and inadequate access to transportation and
child care. Transportation is considered an economic barrier for rural low
income pregnant women because it takes money to own and maintain and
run a car (Omar et al., 1995). Lack of child care is also an economic barrier
‘ (Johnson et al., 1995) based on lack of funds to pay for child care and

office / clinic restrictions which do not allow children to come to prenatal
visits. In this study, the economic barrier to prenatal care for rural low
income pregnant women was defined as the lack of financial resources
making it difficult to pay for prenatal care, obtain child care and/ or
transportation that the pregnant woman perceived as an obstacle(s) to
receiving prenatal care.

WW Organization barriers include the woman's
inability to access prenatal care based on the characteristics of the prenatal care
system (Curry, 1989; Maloni et al., 1994; McClanahan, 1992; Passannante et al.,
1994; Scupholme et al., 1991). Availability of prenatal care, limited clinical
hours, difficulty with appointment scheduling, staff attitudes, and ineffective
communication are all factors included in organizational barriers to prenatal
care (Harvey 8: Faber, 1993; Higgins et al., 1994; Kieffer, Alexander, 8: Mor,
1992; Lee 8: Grubbs, 1995; Lia-Hoagberg et al., 1990; Maloni, et al., 1996;
Scupholme et al., 1991). Harvey and Faber (1993) describe difficulty getting off
from work or school as an organizational barrier due to inconvenient and
limited office hours. The organizational barrier was defined in this study as
characteristics of the prenatal care delivery system which may result in fear of
being reported to the police, difficulty scheduling prenatal appointment, not
knowing where to go for prenatal care, and difficulty getting time off from
work or school.

AWL Attitudinal barriers are personal factors that
influence whether a pregnant woman will seek prenatal care (Maloni et al.,
1996; McClanahan, 1992). Inability to accept the pregnancy, lack of knowledge
concerning pregnancy, inadequate social supports, failure to notice the signs
of pregnancy are attitudinal factors that hinder access to prenatal care services
(Augustyn 8: Maiman, 1994; Maloni et al., 1996; McClanahan, 1992; Young et

al., 1989). Poland et al.'s (1987) study revealed that negative personal attitudes
about being pregnant, the importance of prenatal care, and health
professionals were attitudinal barriers for poor women accessing prenatal
care. Johnson et al. (1994) refer to a woman's attitudes, beliefs, and values as
internal factors that influence her decision to utilize prenatal care. _
Attitudinal barriers also include denial of the pregnancy, depression, fear
about the pregnancy, and feeling that prenatal care is unimportant (Curry,
1989; Harvey 8: Faber, 1993; Lia-Hoagberg et al., 1990; Meikle et al, 1995; Sable
et al., 1990). Goldenberg et al. (1992) found that women's attitudes toward past
experiences with health care and efficacy of prenatal care may influence the
timing of initiation into prenatal care. Rural low income pregnant women
may not obtain prenatal care due to the fact that they dislike physicians or the
health care system (Aved et al., 1993; Curry, 1989; Poland et al., 1987).
Attitudinal barriers that rural low income pregnant women are faced with in
obtaining prenatal care were defined in this study as personal factors
including perception that prenatal care was not necessary earlier in
pregnancy, personal problems that the pregnant woman may report, and
diser of the physician or health care staff.
IheereticaLMmiel

In this study, the Health Promotion Model (HPM) (Pender, 1996) was
used to describe the association between the variables of age appropriate
educational level and frequency and type of barriers to prenatal care. The
Health Promotion Model was developed by Pender in 1982 and revised in
1996. Health promotion focuses on efforts by an individual to approach or
move toward a positive state of health and well-being (Pender, 1996).

"The HPM is an attempt to depict the multidimensional nature of

persons interacting with their environment as they pursue health" (Pender,

1O

1996, p.53). The framework integrates a number of theories within a nursing
perspective of holistic human functioning. The framework is used in
research to predict the overall health promoting lifestyles and specific
behaviors of individuals.

In the model (Figure 1) there are three major concepts: (a) Individual
Characteristics and Experiences; (b) Behavior-Specific Cognitions and Affect,
and (c) Behavioral Outcome. Each concept contains variables that directly
impact the concept and influence the outcome. The variables in the HPM are
described below.

Individual characteristics and experiences, behavior-specific cognitions
and affect, and behavioral outcomes are factors that affect or are relevant
influences on a population's particular health promoting behaviors. The
ability to recognize the interrelationships between the factors and their
influence on the outcome of the health behavior allows researchers to
explain, predict, and alter health promoting behaviors.

11.11:] |.|. IE .

Prior related behaviors have both direct/ automatic and
indirect/ influences that affect the likelihood of engaging in health promotion
(Pender, 1996). Prior experience with prenatal care has a direct effect on if
rural low income pregnant women will achieve prenatal care. If prior
experiences with prenatal care were positive than it is likely that the pregnant
women will obtain prenatal care; however, if it was a negative experience
than they may not be willing to engage in prenatal care.

Personal factors include biological, psychological, and sociocultural
aspects of the person (Pender, 1996). In this study, personal factors include the

rural low income pregnant women's age appropriate educational level.

11

Behavior-Specific Behavioral

 

 

 

 

 

 

 

 

Individual Characterletlce Cognitions and Affect Outcome
and Experiences
‘_ Perceived
7’ benefits of .__.
action
p _ Immediate
nor .
related __> Perceived Icompeltmg
behavior barriers and
__ to action ._ preferences

 

 

 

 

 

 

 

 

 

i

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_+ Perceived
Personal self-efficacy
factors; f
biological ‘ . .
mama” . Activity-related Commitment Health
affect to a " promoting
plan of action behavior
Interpersonal #
influences; norms, -
F support. models
Situational
Influences; options —
" demand
characteristics
E39111: Health Promotion Model (Pender, 1996)

12

B] '-S 1.: °|' lEEfI

Perceived benefits of action are intrinsic and extrinsic beliefs about the
effectiveness of recommended preventive actions and affect the individual's
perceived value of early detection (Pender, 1996). This is the belief by rural
low income pregnant women that reaching prenatal care is a benefit for
themselves and their babies.

Perceived barriers to action are parallel to perceived benefits, exercising
a direct influence on the inclination to engage in health-promoting behavior
(Pender, 1996). The barriers to receiving prenatal care for rural low income
pregnant women are in this study referred to as economic, organizational,
and attitudinal barriers. The barriers are influenced by the age appropriate
educational level of the rural low income pregnant women.

Perceived self-efficacy is an individual's accountability for his or her
own health (Pender, 1996). The women's self efficacy is their belief that they
can overcome the barriers and obtain prenatal care.

Activity-related affect refers to the subjective states that occur before,
during, and after a behavior (Pender, 1996). Activity-related affect is
interpreted as the feelings that the rural low income women experience prior
to prenatal care and during the pregnancy.

Interpersonal influences are defined as norms, or expectations of
significant others, social support, or instrumental and emotional
encouragement, and modeling learned through observations (Pender, 1996).
Interpersonal influences are the expectations or thoughts of others toward the
rural low income pregnant women which influence if these women will
engage in prenatal care.

Situational influences are perceptions of available options, demand

characteristics, and aesthetic features of the environment (Pender, 1996).

13

Situational influences include living in a rural area and also being low
income for the women of this study.
BehaxieraLQntcemes

Immediate competing demands and preferences are behaviors that
consciously intrude on the course of action and may affect the health-
promotion activity (Pender, 1996). Immediate competing demands and
preferences refers to environmental contingencies that rural low income
pregnant women have little control over such as clinic hours, family care
responsibilities, or work.

Commitment to a plan of action refers to a decision to carry out specific
actions and identification of specific strategies to succeed with the plan
(Pender, 1996). Rural low income pregnant women make a decision to
engage in prenatal care and identify certain behaviors that will help them
reach their health promoting behavior of prenatal care.

Health-promoting behavior is the outcome or result of health
promotion activities. The health-promoting behavior in this study is the
rural low income pregnant women obtaining prenatal care.

:. or- an . 1‘ 1‘2- - ,' 0910901 um.‘ o 3.. 1‘!» o. ' 'l.'.?3.

In the application of the study variables the major concepts of the
model have not been altered. However, the variables within each concept
have been replaced with the variables under investigation in this study,
which include barriers to prenatal care and age appropriate educational level
(Figure 2).

W The concept of Individual
Characteristics and Experiences includes the variable of age appropriate

educational level of the pregnant woman. In the model, age appropriate

educational level is directly associated with perceived barriers to prenatal care

14

for rural low income pregnant women. In this study, the age appropriate
educational level is being studied to determine if it is a predictor of barriers
for rural low income pregnant women.

WW. Within Behavior-Specific
Cognitions and Affect include the perceived benefits, barriers, and beliefs
regarding obtaining prenatal care. Perceived benefits of prenatal care (having
a healthy baby), self-efficacy (perceived skills and competence to engage in
prenatal care), and situational influences are not variables under study;
however, as displayed in the model they do directly affect perceived barriers
to prenatal care for rural low income pregnant women.

Barriers are considered impediments to achieving the health
promoting behavior. Rural low income pregnant women's perceived
barriers to prenatal care include economic, organizational, and attitudinal.

In the implementation of the HPM, the direct association between age
appropriate educational level with economic, organizational, and attitudinal
barriers to prenatal care for rural low income pregnant women is identified.
By utilizing the HPM the APN can determine the potential for rural low
income pregnant women with different educational levels to experience
barriers to prenatal care. The HPM allows the APN to assess the influence of
education on barriers to prenatal care and develop interventions that will
modify behavior and assist rural low income pregnant women overcome

barriers to prenatal care.

15

Individual
CharacterletIce
and Experiences

 

 

Personal Factors

A90
Appropriate
Educational

Level

Behavior-Specific
Cognitions
and Affect

 

Perceived Benefits of
Prenatal Care

F Having a Healthy

 

Baby

Behavioral
Outcome

 

 

 

i

 

 

Perceived BarrIera
to Prenatal Care

-Economlc
Organizational
-Attitudinal

—

 

Obtains
Prenatal Care

 

 

 

]

 

 

 

 

 

Eeroeived Sell-Efficacy

-Perception of
Skills and
Competence
to engage in
Prenatal Care

 

 

 

Situational Influences

-Low income
-Rural Community

 

A A

 

 

 

 

 

 

Figure}. Educational Level and Barriers to Prenatal Care: Application to the
Health Promotion Model (Pender, 1996)

16

 

Review of Literature

The research was reviewed on age appropriate educational level and
barriers to prenatal care for pregnant women which included rural, urban,
and low income pregnant women. Research was limited in describing
barriers to prenatal care based on the age appropriate educational level of the
pregnant women, especially for rural low income women. Barriers to
prenatal care on the other hand have been extensively documented in the
literature; however, most of the literature described barriers of urban low
income pregnant women in receiving prenatal care (Aved et al., 1993; Curry,
1989; Johnson et al., 1994; Joyce et al., 1983; Maloni et al., 1996; Poland et al.,
1987); only a few studies investigated barriers rural women face (Harvey 8:
Faber, 1993; Nesbitt, Connell, Hart, 8: Rosenblatt, 1990; Omar, et al., 1995).

An exhaustive literature review was done on age appropriate
educational level and its effects on barriers to prenatal care for rural low
income pregnant women in obtaining prenatal care. No specific research
studies were found which took into account pregnant women's age
appropriate educational level. Studies consistently grouped pregnant women
into different educational levels; however, they did not indicate if the age of
the pregnant women was appropriate for educational levels.

The literature did report that less educated pregnant women were
found to indicate more financial barriers to prenatal care (Sable et al., 1990).
Pregnant women with less education were three times more likely to report
barriers to receiving prenatal care (Harvey 8: Faber, 1993; Sable et al., 1990).
Meikle et al. (1995) found a significant association between pregnant women
who had less than a high school education and financial barriers. The more

education a pregnant woman had, fewer barriers to prenatal care were

17

reported (Harvey 8: Faber, 1993; Sable et al., 1990). Donabedian and Rosenfield
(1961) in their study with urban mothers concluded that higher education
could offset the barriers of low income. Research found that low income
pregnant women whether urban or rural with inadequate prenatal care were
less likely to be high school graduates and those who received inadequate
prenatal care reported facing more barriers than women who received
adequate prenatal care (Braveman, Bennett, Lewis, Egerter, 8: Showstack,
1993; Harvey 8: Faber, 1993; Lia-Hoagberg et al., 1990; McDonald 8: Coburn,
1988; Sable et al., 1990; Zambrana et al., 1991). In these studies the age
appropriate educational level was not reported. Research studies have left a
gap in differentiating between the age appropriate educational levels and
barriers to prenatal care (Harvey 8: Faber, 1993; Lia-Hoagberg et al., 1990; Sable
et al., 1990).

It is unclear in the literature if pregnant women with less than a high
school diploma are 18 years or younger and have achieved the appropriate
level of education for their age, or if they are 19 or older and have not
received a ~ high school diploma. Without considering the age appropriate
educational level a deficit exists in the literature since it is unclear whether
pregnant women with the same educational level but different ages identify
the same barriers to prenatal care or handle the barriers in the same manner.
Therefore, interventions to assist rural low income pregnant women to
overcome barriers to prenatal care need to be specific for age appropriate
educational levels .

W
The literature has described various economic, organizational, and
attitudinal barriers experienced by low income women in rural and urban

communities (Aved et al., 1993; Burks, 1992; Cooney, 1985; Harvey 8: Faber,

18

1993; McClanahan, 1992; McDonald 8: Coburn, 1988; Poland et al., 1987; Sable
et al., 1990). The majority of the studies were performed in urban areas (Aved
et al., 1993; Lia-Hoagberg et al., 1990; McCormick, Brooks-Gunn, Shorter,
Holmes, Wallace, 8: Heagarty, 1989; Meikle et al., 1995; Scupholme et al.,
1991); only three studies clearly stated that they sampled rural low income
pregnant women in their research (Harvey 8: Faber, 1993; Omar et al., 1995;
Sable et al., 1990).

Harvey and Faber (1993) found that three-fourths of the rural low
income pregnant women in their study (n = 236) who received inadequate
prenatal care experienced barriers to care in more than one category. Sable et
al. (1990) found that women who received inadequate prenatal care were
three times more likely to report financial, organizational, and attitudinal
barriers to acquiring prenatal care. Passannante et al. (1994) indicated that
attitudinal barriers were cited by more than half of the respondents (n = 93)
and the remaining participants (1; =74) identified financial or organization
barriers as the reason prenatal care was not obtained.

Economic barriers that were identified by rural low income pregnant
women included lack of finances to pay for prenatal care, inability to miss
work for prenatal appointments due to financial restraints, lack of money for
child care to attend prenatal care appointments, and lack of finances for
transportation to obtain prenatal care (Harvey 8: Faber, 1993; Sable et al., 1990).
Rural low income pregnant women indicated that difficulty paying for care
was the major obstacle to prenatal care and transportation difficulties due to
limited financial resources (Harvey 8: Faber, 1993, Maloni et al., 1995).

In the literature, organizational barriers can play a significant role in
detouring low income pregnant women from obtaining prenatal care.

Organizational barriers for low income rural women included fragmented,

19

uncoordinated care, inconvenient location, not knowing where to go for
prenatal care, long waiting times, negative staff attitudes, limited
appointment times, difficulty scheduling appointments, and inflexible rules
regarding bringing children to appointments (Harvey 8: Faber, 1993; Maloni et
al., 1995; Sable et al., 1990). Clinic hours are routinely scheduled during the
day which can hinder working mothers or students in attending prenatal
visits (Maloni et al., 1995). Rural low income pregnant women reported that
previous experience in clinics, long waits, staff attitudes, fear of being reported
to the police, and inconvenient hours were barriers to prenatal care (Harvey
8: Faber, 1993; Maloni et al., 1995; Omar et al., 1995; Sable et al., 1990). Women
stated that being unable to find a prenatal care provider was a major
organizational barrier to prenatal care (Sable et al., 1990).

Attitudinal barriers, which Curry (1989) defined as experiences,
attitudes, and beliefs, were found in the literature to be significant barriers to
receiving prenatal care for rural pregnant women (Harvey 8: Faber, 1993;
McDonald 8: Coburn, 1988; Sable et al., 1990). Johnson et al. (1994) refer to
attitudinal barriers to seeking prenatal care as a lack of motivation,
knowledge deficit, fear, and fatigue. Depression, denial of pregnancy, and
unplanned pregnancy were attitudinal barriers to prenatal care for rural low
income pregnant women (Harvey 8: Faber, 1993; Maloni et al., 1995; Sable et
al., 1990). Pregnant women's attitudes towards health professionals and
previous experiences with the health care system were perceived as barriers to
prenatal care (Harvey 8: Faber, 1993; Maloni et al., 1995; Omar et al., 1995;
Sable et al., 1990; Young et al., 1989).

Research has been thorough in examining economic, organizational,
and attitudinal barriers to prenatal care for urban low income pregnant

women (Aved et al., 1993; McCormick et al., 1989; Scupholme et al., 1991).

20

The literature has identified that both urban and rural low income pregnant
women experience some of the same barriers to prenatal care. However,
because research studies of rural low income pregnant women and barriers to
prenatal care are limited (Harvey 8: Faber, 1993; Omar et al., 1995; Sable et al.,
1990), it is impossible to draw conclusions regarding barriers to prenatal care
and possible solutions to these barriers for rural low income pregnant women
without further investigation.

C 'I' E I] I 'l |

Very limited literature was found which reported the association
between barriers to prenatal care and age appr0priate educational level for
rural low income pregnant women. Most of the current research focused on
adequacy of prenatal care related to educational level. Also, the majority of
research had urban low income pregnant women as their study population
(Aved et al., 1993; Johnson et-aL, 1994; Poland et al., 1990). It was also noted
that the research which did consider the variables, barriers to prenatal care
and age appropriate education level, did not thoroughly explain the
association between age appropriate educational level and barriers to prenatal
care for pregnant women (Cooney, 1985; Harvey 8: Faber, 1993; Maloni et al.,
1995; McDonald 8: Coburn, 1988; Poland et al., 1987).

The literature lacked clarification regarding educational level and if the
appropriate age for the pregnant women was taken into consideration for the
outcomes of the studies. (Burks, 1992; Harvey 8: Faber, 1993; McDonald 8:
Coburn, 1988). Most of the research acknowledged that education did have an
effect on the utilization of prenatal care by pregnant women.(Maloni et
al.,1995; McDonald 8: Coburn, 1988; Scupholme et al., 1991;Young et al., 1989);
however, the research did not interpret how the various educational levels

affected utilization of prenatal care. Some studies reported that pregnant

21

women with lower educational levels reported more barriers to prenatal care,
but again, age appropriate educational level was not taken into consideration,
nor was the association between educational level and barriers to prenatal
care explained (Aved et al., 1993; Harvey 8: Faber, 1993; Meikle et al., 1995;
Joyce et al., 1983).

The majority of the research studies included demographic characteristics
about the sample which included age, parity, level of education, race, married,
and insurance information (Aved et al., 1993; Meikle et al., 1995; Melnikow 8:
Alemagno, 1993; Scupholme et al., 1991); however, a few studies did not
provide demographic information (Poland et al., 1990; Sable et al., 1990).

The literature was extensive in identifying barriers to prenatal care for
pregnant women. Each author, however, categorized the barriers to prenatal
care in different ways; therefore, barriers that were classified as organizational
in one study were called structural barriers in another. This can be seen in
Harvey and Faber's (1993) study defining transportation problems as an
organizational barrier, while Lia-Hoagberg et al. (1990) identified
transportation as a structural barrier. The inconsistency between studies on
the names of barriers was confusing. Terms to classify barriers were multiple,
for example: financial, economical, attitudinal, sociodemographic,
psychological, structural, internal, external, organizational, system, and
situational barriers (Aved et al., 1993; Curry, 1989; Goldenberg et al., 1992;
Harvey 8: Faber, 1993; Lia-Hoagberg et al., 1990).

Most of the research studies used urban low income women for their
populations (Aved et al., 1993; Cooney, 1985; Lia-Hoagberg et al., 1990; Meikle
et al., 1995; Petitti, Coleman, Binsacca, 8: Allen, 1990; Poland et al., 1987;
Poland et al., 1990). Some studies did not indicate if they used rural or urban
populations or did not report the income for the pregnant women (Johnson

22

et al., 1994; Melnikow 8: Alemagno, 1993; Scupholme et al., 1991) and some
studies used urban and a rural populations combined (Burks, 1992; Sable et
al., 1990). The literature lacks in specific investigations of barriers for rural
low income pregnant women.

Sample size was adequate for most studies; however, there was a wide
variation in sample size ranging from 15 (Johnson et al., 1994) to 600
(McCormick et al., 1989). Some studies used hospital or vital statistical
records, providing a larger sample and more data; however, the researchers
had to assume that the hospital data was accurate (Braveman et al., 1993;
Cooney, 1985; Hansell, 1991; McDonald 8: Coburn, 1988; Nesbitt et al., 1990).
limited information was provided regarding sample selection making it
difficult to determine how participants were included in the studies (Meikle
et al., 1995; Poland et al., 1990; Poland et al., 1987; Sable et al., 1990). In most of
the studies, questionnaires were used to ascertain barriers and educational
level, however, frequently no sample of the questionnaire was provided
which limited one's ability to specifically determine barriers (Aved et al., 1993;
Harvey 8: Faber, 1993; Scupholme et al., 1991). Lack of reliability and validity
of instruments used was a common deficiency in some studies (Aved et al.,
1993; McCormick et al., 1989; Sable et al., 1990).

The literature that exists lacks information about rural low income
pregnant women, their barriers to prenatal care, and the association of age
appropriate educational level with barriers. This study adds to the knowledge
about age appropriate educational level and its association on the number
and type of barriers to prenatal care of low income pregnant women who live
in rural areas. Exploration of the association between age appropriate
educational level and the types of barriers to prenatal care, APNs can

understand barriers to prenatal care that rural low income pregnant women

23

face. Understanding the association between age appropriate educational
level and types of barriers to prenatal care may assist APNs with developing
interventions for rural low income pregnant woman to assist them in
overcoming economical, organizational, and attitudinal barriers to prenatal
care.
Methods

The methods section describes the research design, sample, operational

definitions, instruments, and procedures for the protection of human

subjects.

Design

The research design was a descriptive study of rural low income
pregnant women's age appropriate educational level and barriers to prenatal
care through a secondary analysis ofdata previously collected by Omar et al.
(1995). The original study done by Omar et al. (1995) examined barriers,
expectations, and patient satisfaction as predictors of prenatal care utilization
and maternal and infant outcomes in a rural community. Questionnaires
were distributed between June 1994 through July 1995. This was a prospective
study with both a survey component and a chart review component. Field
procedures for the original study are in Appendix D. " ‘-
Sample

The secondary study utilized the same sample as the original study by
Omar et al. (1995). The original study sample included 61 low income women
who met the following criteria: (a) third trimester of pregnancy attending at
least three prenatal visits, (b) eligible for the Women, Infants, and Children
(WIC) program, (c) able to read, write, and understand English, and (d)
residents of the rural county under study. Of the 62 pregnant women initially

24

approached to participate in the original study, 61 of the women agreed,
resulting in a 98% participation rate which was the final sample for this study.

Q |° l D f 'I'
W Age appropriate educational level

was identified by the pregnant women on the Patient Satisfaction with
Prenatal Care (PSPC) instrument (Omar 8: Schiffman, 1992). Respondents
indicated less than high school, some high school, high school graduate,
some college, college graduate, or beyond. Respondents indicated their age in
years. For the secondary analysis, the educational level was operationalized
into four categories: (1) less than high school diploma and 18 years of age or
less, (2) less than high school diploma and 19 years of age and older, (3) a high
school diploma and 19 years of age and older, and (4) any post secondary
education and 19 years of age and older. Age appropriate educational level
was operationally defined by the number of years of schooling completed
within a specific age category. Eighteen years and younger was considered an
age appropriate educational level if the pregnant women had either some
high school or a high school diploma due to the fact this is the average age of
completion or near completion of high school in society. Pregnant women 19
years and older were considered an age appropriate educational level if they
had at least a high school diploma or post secondary education.
W Barriers to care were operationalized in the
primary study by the Ten-Item Checklist (Richwald, Rhodes, 8: Kersey, 1987)
(Appendix A). The types of barriers were organized into three categories
based on related characteristics. The descriptive questions on the Ten-Item
Checklist (Appendix A) were categorized into the three types of barriers as
follows: (a) economic- item 3, item 5, and item 6, (b) organizational- item 2,

item 4, item 7, and item 9, and (c) attitudinal- item 1, item 8, and item 10.

25

Due to the fact that each type of barrier had a different number of
corresponding questions the types of barriers were weighed. For example, for
a woman to be identified as having an economic barrier, she needed to
respond either to item 3 or item 6 on the Ten-Item Checklist. Organizational
barriers were assigned if item 4, item 7, or both item 2 and 9 were selected. To
be considered as having an attitudinal barrier, item 1 or both items 8 and 10
needed to be identified. The pregnant women were asked to identify all the
barriers that applied.

Instruments

The Ten-Item Checklist (Richwald et al., 1987) (Appendix A), and the
Patient Satisfaction with Prenatal Care (PSPC) instrument (Omar 8:
Schiffman, 1992) (Appendix B) were distributed to the pregnant women. For
the secondary analysis, the data from the Ten-Item Checklist, the educational
level, and age were gathered from the PSPC instrument for this study. The
Ten-Item Checklist (Richwald et al., 1987) was formulated to assess barriers to
prenatal care. The instrument does not have a reported reliability or validity
(Omar et al., 1995).

The Patient Satisfaction with Prenatal Care (PSPC) Instrument (Omar 8:
Schiffman, 1992) is an 108 item, five scale instrument designed to assess a
client's motivation to seek prenatal care, satisfaction with prenatal care, and
expectations of prenatal care. The instrument includes a section containing
demographic items. The investigator used only the educational information
and age of the women obtained from the demographic section of the PSPC in
this secondary study.

' tor-m _, - 0, To who: 0 1.11.2! .0: s 11...; n o -. o '_g,_

The original study was approved by the Michigan State University

Committee on Research Involving Human Subjects (UCHRIS) (Appendix C).

26

There were no identified psychological, social, physical, economical, or legal
risks for the subjects in the secondary study due to the fact that no further data
were collected. The participants remained completely anonymous in the
secondary study. Data were coded in the original study and the researcher did
not have access to data that could potentially identify any of the participants
in the original study. Data were provided by code number only. Approval by
the University Committee on Research Involving Human Subjects was
obtained for this study prior to data analysis (Appendix D).
W

The research questions and the variables involved in this study were
analyzed using the statistical SPSS program. Descriptive statistics were used
to describe the sample as a whole and also in each of the four age appropriate
educational levels by race, age, number of children, and marital status.

Research question #1: What are‘the most frequently identified barriers
by age appropriate educational level? Frequencies were calculated to identify
the barriers that were most frequently reported by pregnant women according
to the categories of age appropriate educational level.

Research question #2: What type of barrier is most frequently reported
by age appropriate educational level by rural low income pregnant women?
The educational levels were coded into four categories; the barriers were
categorized into three types. To answer this research question, criteria were
established for each type of barrier as mentioned previously. The original
data analysis plan was for a cross tabulation with Chi square analysis of the
four age appropriate educational levels by the three categories of types of
barriers. Due to the fact that there were only two participants who had less
than a high school diploma and were 18 years of age or less, the final analysis
was with three age appropriate educational levels by three barrier types. The

27

number of women reporting types of barriers in each of the three age
appropriate educational levels was identified and in each type of barrier the
number of women that reported the barrier was calculated. To arrive at the
percentage the total number of rural low income pregnant women in each
type of barrier was divided by the total number of women that reported any of
the three types of barriers this was done separately in each educational level.
The barrier with the highest percentage over 50% was accepted as the most
frequently reported type of barrier.

Research question #3: Is there any association between the number of
reported barriers identified and the age appropriate educational level of rural
low income pregnant women? Educational level was categorized and the
statistical procedure one way analysis of variance (ANOVA) was used to
identify if there was an association between the number of reported barriers
and the three age appropriate educational levels of rural low income
pregnant women. The 0.05 level of significance was accepted.

Assumptions

There were four assumptions to this study. First, it was assumed that
the participants were truthful about reporting their educational level. The
second assumption was that the data had been collected and entered
accurately.
Thirdly, it was assumed that all potential subjects were given the opportunity
to participate in the original study and lastly, that participants understood the
instructions and asked questions if they did not understand the questions or
instructions.
I . 'I I'

1. The sample used in the primary study was a convenience sample

which was limited to those participants that chose to take part in the

28

study. Women who chose to participate may differ from those
subjects who declined participation.

2. The lack of validity and reliability of the Ten-Item Checklist may
have an impact on the results of the secondary analysis such that
the Checklist may not capture the barriers to prenatal care of rural
low income women.

Results
12 l . Ci | . I'

The sample consisted of 61 subjects recruited for the primary study in
one rural community (Omar et al., 1995). The majority of the rural low
income pregnant women were white (87%, n = 52), married (75%, n = 45),
with a mean age of 24 years (SD = 5, range 15-41 years). Number of
pregnancies ranged from 0 to 5 with a mean of 2 (SD = 1.26), and most of the

women had at least one living child with a range from 1 to 4 children (512 =
1).

 

category there were two subjects whose average age was 15.5 years (SD = .7);
neither of the participants indicated having living children. One of the
participants was white and the other was Hispanic; one woman was single

and the other was separated.

 

women comprised this group with their ages ranging from 19 to 37 years,
with the mean being 24 years of age (SD = 6). Three of the women (30%) were
single, two divorced (20%), and five were married (50%). The number of
living children ranged from 0 to 4 with the average being 2 children (512 =
1.2). Number of pregnancies varied from 1 to 5 with the average being 3 (SD =

29

1.1). One woman in this group was Hispanic (10%), eight were white (80%),
and one indicated Other (10%).

MW Twenty-five participants in this group ranged in
ages from 18 to 34 with the mean being 22 years of age (SD = 3.6). Four were
single (16%), 20 were married (80%), and 1 was separated (4%). Number of
living children averaged 1 (SD = .57) with the number of pregnancies ranging
form 0 to 5 with the average being 2 (SD = 1.1). Two of the participants were
Hispanic (8%), one was Native American (4%), and 22 were white (88%).

W In this category there were 24 women whose ages
ranged from 18 to 41 with an average of 25.5 years (SD = 5.6). Two women
indicated they were single (8%), while 20 were married (92%). The range of
living children was 1 to 3, with a mean of 1.0 (SD =.82). The number of
pregnancies ranged from 0 to 5 with an average of 2 (SD = 1.1). In this group
22 participants were white (92%), one Native American (4%), and one
Hispanic (4%).

Want:

The research results are reported for each of the research questions
undertaken in this analysis and the results are discussed.

W What is the most frequently identified barrier
by age appropriate educational level for rural low income pregnant women?

Each of the participants was placed in one of the four age appropriate
educational levels (Table 1). In the first age appropriate educational level,
pregnant women 18 and younger with less than a high school diploma, there
were no reported barriers to prenatal care. Pregnant women with less than a
high school diploma and 19 years of age or older identified the transportation

barrier most often. Rural low income pregnant women with a high school

30

Table 1

Q
swamp”:-

 

Barriers

Educational Level

 

n 5’12

 

+11 didn't think prenatal care
was necessary (earlier in the pregnancy)

oZIdidn'tknow wheretogo

03 I didn't know how
I would pay for prenatal care

04 I couldn't take time of
from work or school

05 I couldn't find someone
to watch the children '

061 didn't have a way to
get to the doctor or clinic

9? I had trouble
sclwduling an appointment

181 don't like doctors, clinics, or hospitals
o91wasafraidlwouldbereported

mflwpolioeiflwentmgetprenatalcare

+101 had personal problems

21

13

 

Nate, Educational Levels were represented by 1-4. 1 = 18 years or younger without a high

school diploma; 2 = 19 years or older without a high school diploma; 3 = High school diploma;

4 = Post secondary; 0 = Economical barrier; a = Organizational barrier; + = Attitudinal barrier.

31

diploma or post secondary most often reported that paying for the prenatal

care was a barrier (Table 1).

WWhat type of barrier is most frequently reported

by age appropriate educational level by rural low income pregnant women?

Only rural low income pregnant women who reported barriers were
included in this analysis. Of the women that did report barriers to prenatal
care (n_= 21), the type of barrier most frequently identified by each age
appropriate educational level was the economic barrier. Some women who
had a high school diploma or any post secondary education also indicated the
organizational barrier to prenatal care. Only one woman with an educational
level of less than high school and 19 years or older identified the attitudinal
barrier to prenatal care. Since only women that reported barriers were used in
the analysis, the percentages in the columns do not add up to 100% due to the
fact that a rural low income pregnant woman may have reported not only an
economic barrier but that same woman may have reported an organizational
barrier (Table 2).

W Is there an association between the number of
reported barriers identified and the age appropriate educational level of rural
low income pregnant women?

This question was answered by using one way analysis of variance
(ANOVA). Results revealed there was no significant association between the
variables, age appropriate educational level and the number of barriers,

E (2, 59 ) = .62, p = .59; therefore, the number of reported barriers to prenatal
care by rural low income pregnant women was not associated with age

appropriate educational level.

32

Table 2

,l"',;:il.!’_u-°r~‘ ‘rgn I'M "so a,"‘-ot‘0-1-‘_t -!'

 

Barriers

 

Economic Organizational Attitudinal

 

AAEL f i f
Less than HS

Diplomaz 19 yrs of age (n_= 5) 5 0 1
High School Diploma (n_= 8) 5 4 0
Post Secondary (n_= 8) 7 4 0

 

Nata. AAEL = Age appropriate educational level; HS =‘ High school; n = Number of subjects

who reported a barrier to prenatal care.

 

 

Table 3

Dar-”1'. .:._l'.:_'...'-i-.!'_l--" \...!.l" 0 L‘Hs‘! i:-.r!'9:- .‘.°'
3 . I E1 I' H “11:52]

AAEL n M 512

Less than HS Diploma219 yrs of age 10 .90 1.10

High School Diploma 25 .52 0.87

Post Secondary 24 .75 1.26

 

Mme. AAEL = Age appropriate educational level; HS = High school.

33

Discussion

Overall, the subjects who participated in this study were fairly
homogeneous. The majority of the subjects were married with a mean age of
24 years. Interestingly, 80% of the women had at least a high school education
and half of these women had an educational level beyond a high school
diploma. This is a somewhat different picture of rural low income women as
compared to literature involving low income urban women (McCormick et
al., 1989; Melnikow 8: Alemagno, 1993; Petitti et al., 1990; Poland et al., 1987);
women who participated in this study were older, married, and more highly
educated. These may be women who have chosen to live in a rural area and
represent a different population of women than previous literature has
reported. The women in this study were basically low-risk multiparious
women who attended prenatal care. Previous research has shown women
with higher levels of education are more likely to receive prenatal care (Sable
et al., 1990).

One unexpected finding of this study was that few of the rural low
income pregnant women in any age appropriate educational level actually
reported any barriers to prenatal care. And although the educational level,
less than a high school diploma and under 18 years of age, only had two
participants, surprisingly this group did not report any barriers to prenatal
care. Interestingly, pregnant women with post secondary education reported
the highest variation of different types of barriers, i.e., seven different barriers
as compared to pregnant women with a high school diploma, who reported
six different barriers, while pregnant women with less than a high school
diploma reported four different barriers to prenatal care. This may be due to
the possibility that women with more education may have more barriers

with respect to employment issues, such as trouble scheduling prenatal

34

appointments, unable to take time off from work, and not having a babysitter.
All three groups of women reported not knowing how to pay for prenatal
care and transportation as barriers; this would be consistent for this
population, i.e., low income (Harvey 8: Faber, 1993).
U .j. i -. _-._ .-..’A,-._ at": .1. (w. _,--, -- {feeg‘e p; .
Battier

Since research questions 1 and 2 describe the most frequently identified
barrier and the most frequently reported type of barrier these are discussed
together. Discussion for the three age appropriate educational level groups
which identified barriers is also provided.

Question #1 asked about the most frequently identified barrier by age
appropriate educational level. It was observed in this study that there were
relatively few barriers reported by any of the rural low income pregnant
women by age appropriate educational level. The first educational level, less
than a high school diploma 18 years of age or younger, did not report any
barriers to prenatal care. It was found that pregnant women with less than a
high school diploma 19 years or older reported transportation most often,
while pregnant women with a high school diploma or post secondary
education reported that the inability to pay for prenatal care was their most
often. Research question #2 asked what was the most frequently reported
type of barrier in each age appropriate educational level. Women in the other
three age appropriate educational levels most often reported the economic
barrier to prenatal care. This is consistent with the literature (Harvey 8: Faber,
1993).

Transportation was the primary barrier for pregnant women with less
than a high school diploma 19 years or older. Perhaps this group of women

may not have the finances to support owning an automobile since results

35

indicated that only one of the women worked outside the home and held a
part-time position.

The inability to pay for prenatal care was the most frequently identified
barrier to receiving prenatal care for the women with a high school diploma
or post secondary education. The majority of these women worked outside of
the home and worked full-time. Sixty percent of pregnant women with a
high school diploma and 58% of pregnant women with post secondary
education worked outside the home; 44% of the women with a high school
diploma indicated working full-time, and 21% of women with post secondary
education working full-time. Cooney (1985) reported that educational level
represented an economic factor and played a key role in employment. This
may be a similar factor in this study, such that pregnant women with higher
levels of education were more likely to be employed. Although the majority
of the pregnant women with high school diplomas and post secondary
education indicated that they had full-time jobs, they still indicated the
economic barrier as the primary barrier to prenatal care.

Rural communities may not offer health care benefits and / or provide
the same salary scale offered in urban settings. Employed rural women even
though they have a high education level, may have lower salaries and
minimum health care coverage. Sixty percent of the women with a high
school diploma in this study had Medicaid coverage and 63% of the women
with post secondary education also had Medicaid coverage. Forty percent of
the the women with a high school diploma indicated having private
insurance, while 38% of pregnant women with a post secondary education
indicated they also had private insurance. Only one woman with a post
secondary education indicated self pay as a method of prenatal care payment.
Supposedly, with higher levels of education come better paying jobs and

36

better benefits; however, in this study the women with higher educational
levels still had difficulty paying for prenatal care.

Even though some of the working women with a high school diploma
or post secondary education had private health insurance, not all women did;
and even if they reported having private medical insurance, it was not
deemed sufficient to cover the cost of prenatal care. These women indicated
that the economic barrier inability to pay for prenatal care was the primary
barrier to receiving prenatal care. Perhaps this was due to copayments or
deductibles associated with private insurances. It is difficult, however, to
draw generalizations due to the fact that each age appropriate educational
level had a small number of participants; further analyzes with larger
samples may yield more information.

An item of interest is that pregnant women with less than a high
school diploma and 18 years or younger did not report any barriers; however,
there were only two participants in this educational level. Perhaps one
reason these two women did not report economic barriers was due to the fact
that these participants were 15 and 16 years of age and may have been
supported by their guardians. This group also did not report any
organizational or attitudinal barriers to care. This could be a result of the low
number of participants but could also be due to positive family/ home / school
support. These young women may not have faced the barriers to prenatal
care older women faced, due to the fact they may have been taken to their
prenatal visits, were adequately covered by Medicaid, did not have other
children or employment, so scheduling and child care issues were not
present. These two women may also have received positive support and
attention from their prenatal care providers, making this a positive

experience.

37

 

The third research question explored an association between age
appropriate educational level and the number of barriers to prenatal care.
The findings did not support an association between the number of barriers
and age appropriate educational level; perhaps no association occurred since
the number of participants in each age appropriate educational level was
small. With more participants in each educational level an association may
have been found. Sable et al. (1990) and Harvey and Faber (1993) in their
studies found that less educated pregnant women were three times more
likely to report barriers to prenatal care. However, in this study it was found
that few women reported barriers, and the educational level with less than a
high school diploma and 18 years of age or younger did not report barriers to
prenatal care. Another consideration for lack of an association may be the
nature of the instrumentation used in the primary study. The Ten-Item
Checklist may not have tapped the appropriate barriers to prenatal care for
rural low income pregnant women or women may not have understood
completely what the item was referring to, and may not known that they
could write in their own barriers. In addition, this sample may not have had
the multitude of barriers to prenatal care compared to those pregnant women
that did not obtain prenatal care. An indication for further study with
inclusion of a qualitative component may provide additional insight into any
association between age appropriate educational level and perceived barriers
to prenatal care for rural low income pregnant women.

Perhaps study limitations may have affected the results. Using a
secondary data analysis the sample utilized was small for the research
undertaken, and the numbers of participants in each educational level varied.

The respondents did not report many barriers to prenatal care in any of the

38

educational levels which decreased the size of the study; for example, the first
educational group was excluded in the analysis of this study. Often research
with rural populations poses a problem for an adequate sample since
numbers are small often making it difficult to obtain adequate numbers for
meaningful analysis. A larger sample may have provided different results.
Additionally, the Ten-Item Checklist, though used in other studies, was
without adequate reliability and validity. As indicated previously the
instrument, itself, may have been flawed nor captured the true barriers for
rural low income women or women may not have been sure what was being
asked by the Ten-Item Checklist.

ConcenmaLEramenLQrk

The Health Promotion Model (Figure 2) provided an excellent
conceptual framework for this study. It guided the investigation of the
barriers to prenatal care for rural low income pregnant women and the
association between barriers to prenatal care and age appropriate educational
level. However, following the analysis of the data, modifications are
suggested to better explain the findings of the study in terms of the association
between the variables under investigation (Figure 3).

In this rural community not many of the women reported barriers to
prenatal care; however, the women in the three age appropriate educational
levels that did report barriers identified the economic barrier most frequently.
Different economic barriers were selected by the women based on their age
appropriate educational level. Rural low income pregnant women with less
than a high school diploma 19 years or older selected the transportation
barrier most often, while those with a high school diploma or post secondary
education reported the inability to pay for prenatal care most frequently.

39

It was discovered in this study that age appropriate educational level
also reflected certain situational influences, such as employment and
insurance coverage. Pregnant women with higher levels of education were
more likely to be employed with health insurance. Although all pregnant
women in this study indicated some form of medical coverage including
Medicaid or private insurance, the economic barrier still remained the most
frequently identified barrier for low income pregnant women in this rural
community. Since age appropriate educational level was not found to
influence barriers, other factors need to be considered, perhaps it is a part of
other situational factors that may have a direct relationship with barriers to
prenatal care. Prior related behavior and biological, psychological, and
sociocultural personal factors were added to the model to display the complex
association of individual characteristics and experiences on economic barriers.

Implications for the APN in Primary Care

The APN must be aware of the multitude of factors that play a key role
in barriers to prenatal care for rural low income pregnant women, one may
be age appropriate educational level. The APN in the role of assessor can
utilize information obtained physically, psychosocially, and demographically
to identify those rural low income pregnant women who have barriers to
prenatal care. Appropriate assessment of any economic barrier for all women,
regardless of educational status, is indicated and includes assessment of
employment, finances, health insurance, child care, and transportation.
Assessment of other available economic support from family members, the
community, or local churches is also indicated. Based on the assessment the
APN is able to develop a plan to minimize economic barriers to prenatal care.

Information regarding Medicaid and W1C as well as community resources

can be provided along with assistance for applying for available programs

40

 

 

 

 

 

Behavior-Specific

 

 

 

Behavioral
Outcome

 

 

 

 

 

 

 

i

 

 

 

 

Individual
Characterietlce Cognitions
and Experiences and Affect
Perceived Benefits
of Prenatal Care
r" Having a Healthy
_>i Baby
Prior Perceived BarrIere
related to Prenatal Care
behavror . _> ECONOMIC
" Transportation
' inability to pay for
Prenatal Care
ORGANIZATIONAL
Biological
P | logical ATTITUDINAL
Sociocultural: .
AGE APPROPRIATE ‘
EDUCATIONAL LEVEL —> Situational Influences
Flue than HS, 19 years or older __> -Low Income
High School Diploma -Rurai Community
Poet Secondary

 

 

 

 

 

Obtains
Prenatal Care
A I

 

 

 

 

 

 

Em}. Modification of the Health Promotion Model Based on Study

Findings: Application to the Health Promotion Model for Rural Low Income

Pregnant Women (Pender, 1996)

41

within the community. Barriers of transportation need to be assessed with
alternative options provided, such as carpools within the community and the
expansion of prenatal care services at various sites within the community.
Rural communities are in need of APNs to be change agents and to
develop programs that will decrease barriers to prenatal care. In this study it
was found that pregnant women from all but one of the age appropriate
educational levels were concerned with the economic barrier to prenatal care.
The APN has the opportunity to mobilize resources with community leaders
and activate a plan to decrease barriers to prenatal care for pregnant women
in the community such as cooperative child care, transportation assistance
through the local church, and civic organizations and the provision of
accessible prenatal care services within the rural community for all women.
There is clearly a need for a comprehensive and multidisciplinary
approach to overcome barriers to prenatal care for rural low income pregnant
women. The APN alone can not assume responsibility for changing an entire
community; however, as a leader in the community, the APN has the
opportunity to have a direct impact on decreasing the barriers of prenatal care
for rural low income pregnant women. As a role model for the health care
community, the APN can initiate steps to investigate barriers to prenatal care.
While few low income pregnant women in this community identified any
barriers to prenatal care, those who did reported the economic barrier most
frequently. This knowledge allows the APN the opportunity to share with
other community leaders information as to where further assistance is
needed and allows the health care community the opportunity to develop
ways to alleviate the economic barrier for low income pregnant women of all

educational levels in this rural community. Evaluation is needed of the

42

effectiveness of implemented programs and policies to assess if the goal of
decreasing barriers to prenatal care is accomplished.
Implications for Research

While this study failed to demonstrate an association between age
appropriate educational level and the number of barriers to prenatal care,
previous studies have linked lower educational levels with inadequate
prenatal care (Sable et al., 1990). This study found that few rural low income
pregnant women who did attend prenatal care identified barriers. Although
the sample of low income pregnant women reported that they had Medicaid
or private insurance coverage, the economic barrier to prenatal care was still
the most frequently reported barrier. The failure of the present study to find
an association may be in part due to the small sample size in general and the
even smaller number of subjects who actually reported barriers to prenatal
care. In addition, there was no comparison between reported barriers to
prenatal care and age appropriate educational level for rural low income
pregnant women that received prenatal care and those women that did not
receive prenatal care. Few rural low income pregnant women in this study
reported barriers to prenatal care. Further research needs to be done to
develop an understanding of why certain women in this community
reported barriers to prenatal care and others did not.

The APN needs more information about barriers to prenatal care and
which women are most likely to report barriers. One recommendation is to
expand the assessment to include: (1) support systems, (2) if prenatal care was
considered needed, (3) its importance and why, (4) the benefits of prenatal
care, (5) self-concept, and (6) expectation of access to prenatal care in the rural
community. The Ten-Item Checklist needs to be reevaluated; it may not

have ideally identified barriers for the rural low income pregnant women in

43

this community. Although the women were given an opportunity to write
in any barrier that may not have been included, the women may not have
been able to specifically identify in writing their barriers to prenatal care.

The issues of transportation and inability to pay also need to be further
investigated. For example, transportation issues such as road conditions,
travel distance, travel time, availability of adequate transportation, weather,
and condition of automobile need to be included in the assessment. Payment
issues such as insurance deductibles and copays, as well as the women's
willingness to accept and receive outside support from federal and local
organizations needs to be assessed. Perhaps a qualitative study where rural
low income pregnant women are interviewed individually regarding barriers
to prenatal care may better capture their perceived barriers to prenatal care
and better understand the complex economic and transportation issues of
rural populations. By tapping into other facets of information, the APN may
be able to predict which women are more likely to report barriers to prenatal
care, and by acknowledging this possibility can institute a plan of care to assist
rural low income pregnant women to overcome barriers to prenatal care.

Educational level and its true impact on barriers need to be further
investigated. Education plays a major role in pregnant women's lives, it
impacts their jobs, available resources, and their attitudes regarding self worth
and importance of prenatal care (Cooney, 1985; Harvey 8: Faber, 1993; Johnson
et al., 1994). In order to better understand barriers to prenatal care and if rural
low income pregnant women will obtain prenatal care, further research is
needed on education and its influence on other aspects of rural low income
pregnant women's lives. With further investigation of educational levels
affect on prenatal care, the APN has the ability to gather information and

44

design programs aimed at women of all educational levels to enroll in

prenatal care early.

Summary

The following conclusions can be drawn from this study:

A.

In this rural community, low income pregnant women with less
than a high school diploma, 19 years of age or older reported
transportation to prenatal care as the most frequently identified
barrier to prenatal care, while pregnant women that had an high
school diploma or post secondary education most often indicated
inability to pay for prenatal care as the primary barrier to
prenatal care.

Low income pregnant women in this rural community most
frequently reported the economic barrier as the main type of
barrier to prenatal care.

No association between the women of age appropriate
educational levels and the number of reported barriers

was found.

In summary, three of the age appropriate educational levels identified

the economic barrier most frequently. The educational level of less than a

high school diploma, 18 years of age or younger did not report any barriers to

prenatal care. Although educational level was not found to be associated

with the number of barriers to prenatal care, it may indirectly affect the

economic barrier to prenatal care. Pregnant women with less than a high

school diploma 19 years and older were less likely to be employed and were

most likely to be on Medicaid. They reported the transportation barrier most

frequently possibly because they lacked the financial resources to pay for

expenses such as transportation to prenatal care. Pregnant women with

45

higher levels of education were more likely to be employed but still 60%
qualified for Medicaid and while the other 40% had private insurance, they
still reported the inability to pay for prenatal care as a major barrier. By
further investigating the economic barriers for rural low income pregnant
women in all age appropriate educational levels, the APN with other health
care professionals and community leaders, can develop programs to decrease
economic barriers. By decreasing economic barriers to prenatal care, the APN
is promoting access to prenatal care and insuring a better chance for rural low
income pregnant women to have less complicated pregnancies and healthy

infants.

46

 

References

Augustyn, M., 8: Maiman, L. (1994). Psychological and sociological
barriers to prenatal care. WWO), 20-28.

Aved, B., Irwin, M., Cummings, L., 8: Findeisen. (1993). Barriers to
prenatal care for low-income women. W6),
493-498.

Braveman, P., Bennett, T., Lewis, G, Egerter, S., 8: Showstack, J. (1993).
Access to prenatal care following major medicaid eligibility expansions.

mmmmwmmmessam. 1285-1289.
Burks, J. (1992). Factors in the utilization of prenatal services by low-

income black women. WM), 34, 46-47.

Cooney, J. (1985). What determines the start of prenatal care? Prenatal
care, insurance, and education. Medical mm), 986-997.

Curry, A. (1989). Nonfinancial barriers to prenatal care. W

W6), 85-98-
Donabedian, A., 8: Rosenfield, L. (1961). Some factors influencing

prenatal care. W1), 263-266.
Goldenberg, R, Patterson, E., 8: Freese, M. (1992). Maternal
demographic, situational, and psychosocial factors and their relationship to
enrollment in prenatal care: A review of the literature. W
12(2), 133-148.
Handler, A., 8: Rosenberg, D. (1992). Improving pregnancy outcomes:
Public versus private care for urban, low-income women. W26), 123-

130.

47

Hansell, M. (1991). Sociodemographic factors and the quality of

prenatal care. WWO). 1023-1028.
Harvey, M., 8: Faber, K. (1993). Obstacles to prenatal care following

implementation of a community-based program to reduce financial barriers.
WM). 32-36-

Higgins, P., Murray, M., 8: Williams, E. (1994). Self-esteem, social
support, and satisfaction differences in women with adequate and inadequate
prenatal care. W10), 26-33.

Johnson, J., Primas, P., 8: Coe, M. (1994). Factors that prevent women
of low socioeconomic status from seeking prenatal care. W
WW6), 105-111-

Joyce, K., Diffenbacher, G., Greene, J., 8: Sorokin, Y. (1983). Internal

and external barriers to obtaining prenatal care. WW
2(2), 89-96.

 

WM (1995). Lansing, MI: Michigan League for Human
Services.
Kieffer, E., Alexander, G., 8: Mor, J. (1992). Area-level predictors of use
of prenatal care in diverse populations. W6), 653-658.
Kotelchuck, M. (1994). The adequacy of prenatal care utilization index:
Its US distribution and association with low birthweight. W

WGM486-1488-
Lapierre, J., Perreault, M., 8: Goulet, C. (1995). Prenatal peer

counseling: An answer to the persistent difficulties with prenatal care for

low-income women. W1), 53-60.
Lee, S., 8: Grubbs, L. (1995). Pregnant teenagers' reasons for seeking or

delaying prenatal care. Clinicalhlursinafiesearchtea). 38-49.

48

Lia-Hoagberg, B., Rode, P., Skovholt, C., Oberg, C., Berg, C., Mullett, 8.,
8: Choi, T. (1990). Barriers and motivators to prenatal care among low-
income women. WM), 487-495.

Maloni, J., Cheng, C., Lieble, C., 8: Maier J. (1996). Transforming
prenatal care: Reflections on the past and present with implications for the

future. WWW}; 17-23.

McClanahan, P. (1992). Improving access to and use of prenatal care.
We). 280-283.

McCormick, M., Brooks-Gunn, J., Shorter, T., Holmes, J., Wallace, C., 8:
Heagarty, M. (1989). Outreach as case finding: Its effect on enrollment in
prenatal care. W20), 103-111.

McDonald, T., 8: Coburn, A. (1988). Predictors of prenatal care
utilization. W0), 167-172.

McManus, M., 8: Newacheck, P. (1989). Rural maternal, child, and
adolescent health. Wfi) 807-48.

Meilde, S., Orleans, M., Leff, M., Shain, R, 8: Gibbs, R. (1995).
Women's reasons for not seeking prenatal care: Racial and ethnic factors.

W2).81-86-
Melnikow, J., 8: Alemagno, S. (1993). Adequacy of prenatal care among

inner-city women. WW). 575-580.
Michigan Department of Public Health. (1989). W

W
Miller, M. (1992). Outcomes evaluation: Measuring critical thinking.

ImamalnLAdxancedMusingjz, 1401-1407.
Nesbitt, T., Connell, F., Hart, G., 8: Rosenblatt, R. (1990). Access to

obstetric care in rural areas: Effect on birth outcomes. WW
WW). 814-818.

49

Omar, M.A., 8: Schiffman, RF. (1992). W

WW3, Paper presentation at the International State
of the Science Congress. Washington, DC, August 6-8, 1992.

Omar, M., 8: Schiffman, R (1995). Pregnant women's perceptions of
prenatal care. Matemalfihfldflursingjomnalazafl). 132-142-
Omar, M., Schiffman, R, 8: Bauer, P. (1995). WM

--_-'1 .. our: 0‘0 0 0 0‘: .- r .-_-_n-_10.u.-.‘u--_-.u

' ° p ' ' ' (University Research Initiation
Grant Support Rep.) East Lansing, Michigan.

Passannante, M., Espenshade, J., 8: Weiss, G. (1994). Prenatal care use
at an inner-city university hospital: Why so low? WW
IntemafiQmLAM), 209-218.

Petitti, D., Coleman, C., Binsacca, D., 8: Allen, B. (1990). Early prenatal
care in urban black and white women. 518111.110), 1-5.

Pender, N. (1996). W (3rd ed.).
Stamford, CT: Appleton 8: Lange.

Poland, M., Ager, J., 8: Olson, J. (1987). Barriers to receiving adequate
prenatal care. WWW 297-303.

Poland, M., Ager, J., Olson, K., 8: Sokol, R (1990). Quality of prenatal
care; Selected social, behavioral, and biomedical factors; and birth weight.
thtetrissandfixnecelma). 607-611-

Reis, J., Robinson, D., Anderson, V., 8: Mills-Thomas, B. (1992).
Perspectives on pregnancy and prenatal care among inner-city men and
women. W(3),14-19. .

Richwald, G., Rhodes, K., 8: Kersey, L. (1987)._N9_p;gmm_camdy,
Unpublished manuscript, Los Angelos County/USC Medical Center
Women's Hospital, Los Angelos.

50

Sable, M., Stockbauer, J., Schramm, W., 8: Land, G. (1990).
Differentiating the barriers to adequate prenatal care in Missouri, 1987—88.

Wfih 549-555.
Scupholme, A., Robertson, E., 8: Kamons, S. (1991). Barriers to

prenatal care in a multiethnic, urban sample. WW
fie), 111-116.

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. WQ), 264-266.
United States Department of Health and Human Services (USDHHS).

 

W (DHHS Publication No. (PHS) 91-50213). Washington,
DC: US. Government Printing Office.

A -- -' .. _--.--.- l_.-_'0_j‘0._'j-1H.o.e . .a- If ' a
Language, (1989). New York, NY: Portland House.

Young, C., McMahon, J., Bowman, V., 8: Thompson, D. (1989).
Maternal reasons for delayed prenatal care. WW4), 242-243.

Zambrana, R, Dunkel-Schetter, C., 8: Scrimshaw, S. (1991). Factors

which influence use of prenatal care in low-income racial-ethnic women in

Los Angeles County. InurnalnLCnmmmfltLI-Iealthalsw). 283-295.

51

APPENDIX A

Subject: l: mte: ,

Ten Itan Cheddist

 

[memmmmorioMMJ

1.

Mommmmnfiomtgetpremtalcare) (getprenatal
carelateintheirpragnancy) intheUnitedStates. ArterI'vemad
thanalltpycu, I'dlikeyoutotellmmidicru, itany,keptym

frungettingoarpletecareduringthispmgmncy.

Ymmaydnosemrethanone. Itnauotthsereascmorocmems
eaqnlainytatrsitniatimorifyouhadotharmorm, please

'tallmeattarr'ver'aadthalist. [WAILANDGMAIL'DMAPPLYJ

m1 Ididn'tthinkpmtalmmmxyharlierinthe
W)

mz Ididn'tkrmmmgo.

mm Ididrfltlawhwimldpaytormtalm.

11344 Imildn'ttaketimotttrtnadtoolorwrk.
mars Icmldn'ttirdsanamietomtdtfludifldran.
ms Ididn'thaveawaytogattothedoctororclinic.

m7 Ihadtrwblesd'ndulirqanarpoinment.

mate Idm't like doctors, clinics, orlnepitala. .
I‘m-349 Imatraidlwmldbemtadtotlupolicaiflwntto

 

 

unnamym'wdumrmprmsmsansm1mimm
mkflnmfilaportantreamorm?mmfl

For gave, I'nqoirgtoaskymsaiemore
mammteltuaamatinportant
[mm1mmmmormmasmm,m

it
.5
55
g:

abject. I
ma W.

1. Didywuytofirdartabaitgettingprenatalcamwarlier) timigh
anyotthefollowing: [RFADANDGMYE’SGZm]:

 

 

1. Friends or family 5. aunt-h No Yes
no Yes 6. School No Yes
2. 'Delefimbcok 7. Didyuutrytof out
about: prenatal care in any
other: way?
3. Mediate internatim [IF YES, mm WON]
No Yes
4. Health clinic No its

2. Didymhaarabmtprenatalczrettuuighanyotthetonouing[momo
Grammars]:

1.(8) Radioor'N—No—Ya
2. (9) cmm_uo_ves
3. (10) Hamper—m—‘Yee
(11) Didyuéoriearab‘clagpranatalcaretrmanyouurm?

 

[IP as, mm: sauce]:

subject:

 

 

1. I'mgoingtoreadsanepossible reamthatnayexplainmyuunen
(receive prenatal are late in their pregnancy) (dm't think it is
moassarytogetprenatal care). midicreeexplainwhyywdidn't
think prenatal care was necessary (earlier)? .

[REEDANDQMAIL'DMAPPIX]
l. Iuasingoodhealthpriortoammrirgthispregnmcy.

 

2. Ihadmproblmainaprevimspregnarcy.

3. Ididn'tthinkprenatalcarewmldimoveuyhealthorthehealth
otmybaby.

4. Ittughtthatprenatalcarecaaldhammornybaby.

 

 

 

S. Sirnahavirgahabyisanautralammmlevent,ldidn'tthink
Imadadpremtalcare.

Doanyotttnsereasaseamlainutyywdidn'tthimcmtalcarewas
necessary (earlier)? MITPCRW'S M]

2.(6) Anothereanymfiamthatmyexplainmyymdidn'tthinkit
has warytogetprmatal care (earlier)? No Yes [IF YES,
manner]: -

 

 

 

abjectf
m3 1W-
1. Didymthinkthatpremtalcaremldccsttoonadrardtlutym

didn't: have er'nigh may for prenatal care? No Yes [IF YES,
WAAND B more]

 

A. How such did you think it would cost. for a single prenatal visit?
[WRPI‘E WM] $ _

B. mannidoymthinkywcmldhaveattordedtoram
prenatal visit? [WRITE W] s

2. Wereycuauanotanyotthetollwirguayatogetmtalcare
wittnrthavingcashforit? Wemymmot: [REEDANDQMYESOR

m]
l. Medicaid___No_Yes
2. Wereymauareotprivatedoctouuhotakedalayedpaymnts?

fro—res

3. Wereymauareotthecitypiblicaseistancewhereymaremt
diargad?
NORDWGJESI'IQS]

Ya [UAWTO”ABIIIIYTOPA¥"PLANISYE:J
I'ngohqtoreadsaneotttnreasa-peopledomtpmthemadicaid
plan. Pleasetellnemidiapplytoyw[mnhmcm<mnm
m1
A. (4) Idida'tiamtmapersmqmlifleatorfladiaid.

B. (5) 'meproceaa torarplyirq tormdicaiduaa lagarrl
duplicated.

c. (6) IM'tgtanamoimmtmcartthetorm.

 

(7) Are ttnre any other reasons that year didn't man applicatim for
Medium? No Yes '

\

[IP ‘13, m man's Wt]

 

 

 

Subject!

#
—
—

 

rm“ WWW
Iumgojngtoreadsanapossiblereascnswhysanesmenmymtbeable
totaketimotttrmwrktpgetprenatalcare. midlamexplain
whyymcaildmttaketimeotftrunwcrktoryourpmtaldare?[mn
mmmmamx]

1. ttybcsswuildn'tallowmetotaketimeoffforanyreasm.

2. ItItooktimoftfrmwrk,Isnildlosemney.

3. Inesatraidrmldloseuyjcb.

4. number otmy family mldn't allowne to take of: trunmrk.

Doanyotthesereameiqalainmyymoouldmttaketimott
trunnrork?[mITI'-mm'5m1

2.

ArethereanyMreamthatmyeamlainmyymcmlm'ttaka
timotttzunuorktogatprmatalcare? No Yea[IFYFS,
MW]

 

 

 

Didyoutzytotirdprantalcaretlntmavailableinthemng
«mew No Yes

[Equal-ration: ]

 

 

 

adequate.m 56

 

abject-.3

 

I'IB‘IS

l. mmflywatdtesthedtildrenmvymlnvetogomt? [READAND
mmmam]

1. Family umber 4. my care center

2. .Relative or neighbor 5. No one is usually
available

3. Babysitter [IF YE, SKIP ‘10 #3]

2.’ Wasthispersmorthesepecpleavailabletomtdithekidswhileym
werrttorprenatalcare?

1. No (6) (summary, SIGPTDGJE‘SI'ICN a]
2. Yes [IF YES]:

Wasthispersmmmymcaildmtafiordtopayhimflierwhile
ycuwenttorpnnatalcare?

1. (7) No, paymrtwas not a pr'dolaln.

2. Yes, they were available'but I Guild not: afford to pay.
[more ' ' ' ‘

3. (arrrmaeunichadanamuuemmamtmmdmdmn

chmingymrvisit,wmldyurhavegautorpremtalare?
1.No ___2. Yes

 

57

 

abjectf
r1916 WW
1. mutisywrusnlmeansottrarmrtatim? [READANDGMAILTIM

APPLY]: .

1.‘0wncarortanilycar 4. macrotherpublic
—" tic-amputation

2. Serrated car 5. Walking

3. Taxi __ 6. Other [EXPLAIN]:

 

2. I'mgoingtoreadyousanepcssiblereamwhymdai'thave
trarsportatimtottndoctororclinictorprenatalcare. mummies
explainmyymdidmthaveawaytogattothedoctororclinic
durirqyourpragnarcy? [mmmmmm]

1. (7) Idm'thaveamr
2. (8) 'mepersmthatuaiallytakamwasmtavailable.

3. (9) AatarasIlau-t,thereianopablictransportatimto
ttudoctororclinictrmwhereIlive.

4. (10) I dm't: think it's safe to me public mum.

5. (11) while transportation: takes too am tine.

6. (12) I dm't. think it's sate-to walk to the doctor or clinic.
7. (13) Itastst’nondttouseahls.

Doanyottheeereamexplainmyymcmldmtgattothedoctoror
clinic? mum'sam;

3. Aretlmanyfilnrreamttntymdidr'thavetramportatimto
gettothedoctororclinictormtalcare? Yes
[nm,mm:

 

 

adequatemo 58

Sibject

 

rm: 8 1 guy; like' tigers. c 11mg . g: mtg];

l. I'mgoirqtoreadsanepcssible reasonsthatrnayesqalainwhywunen
dm't like clinics, doctors, or hospitals and so, dcn't go for prenatal
care(ear1yintneirpregnancy). mmmeplainwhyymdidmt
qo(earlier)? [mummmmam] .

l. I dm't like the long waits for care.

2. Itirrldoctorsardramarempleasant.

3. Idm't liketoqotomaledoctors torpremtal care.
4. People dat't urderstard me in the doctor's office or clinic.

5. Ianatraidotdoctorsormrses,orclinics,orhospitals.v

6. I'vehadabadeaqaerienceinttnpasttrmadoctor, clinic,
ortnapital.

Doanyortheeereameeqilainahyymdidmtobtainprenatalmre
(earlier)? mum's M]

2. (7) AreflnremryMreathtmyaxplainwhyymdm'tlike
clinic, doctors, or hospitals? No Yes [IF YES, m
m]: — ——

 

abject!

1.

 

m7

 

I'mgoirqtoreadsanepossiblereasomwhysnrenmayhavetrmble
sd-ierhilinganappoimm for prenatal care. midimesappliedtoym
durirqthispregnamy? [REEDAILANDGMYEQID]

l. Icuildn'tt'irdapmrambertocall. Doeethisamlytoycu?
Yes No

 

2. Icalledmtheptn'ebutcouldn'tgetthrctmmtheright
person. Doesthisapplytoyui? Yes No

3. Icalledtoranamoirrtmentaruwastoldtlntthenextsdieduled
appoinmentwastarinthetumre. Doesthisarplyto‘you?

Yes NO [IFYES,REIDAILANDGMA,B,C,CRDAEDEJ:

 

a. Soldidn'tmkeanarpointment. Isthismathappaned?
No Yes

 

. SoImadeanamoirmrthrttorgotabwtit. Isthiswhat
hemmed? No Yes

. Inedetheamointmntmtmybabymbomtirst. Isthiswhat
hammed?__t{o__Yes

Other [W]:

O’

0

9'

 

Horatarinttnmtnremstheamoinmant?

"‘ weeksor mmmorwmsmmm
Imtoldlneedadtosdaemtleanamointmmttorflramialscreening
tirstarrildidn'tmnttodothat. meethisamlytoyou? Yes

No .
Iwastoldeaatootaralmginm'egnamytobeaem. Doesthis
myth“? __Yee__No
'nurewaemmtalcaremilablemmormmenl
oouldqa. Do-thiearplytoym? Yes No.

.AretlureartygflKmthatmyexplainmyymhadtrouble

Mimmamomtormtalcare?_hs_uo

 

[11" YES, mm ammtsn:

 

adecpatemo 60

abjectf

 

W9

 

1. I'mqoingtoreadsanepcssiblerieasa'sthatmyexplainwhyktnenam
arraidtheysuildbereportedtothepoliceiftheytriedtoget
prenatalczre. midiatesexplainwhyymdidmtgetprenatalcaxe?
[mmmmmm]

1. It I signed up'for prenatal carethepolice oculd findoutmy
address.
2. Ihavebeenmdnqa.

3. Ihavebeenintruiblebetore.

Doanyotttmereasmsexplainmywwareatraid muldbe
reportedtothepolioeitywtriedtngetprerutalcare?~[ ma.
W'SM)

2. (4) AntimanyQQgrmttutmyexplainmyymwemamm
ymzuildberapcrtedtothepoliceitymtriedtogetpmtal
care. -

No Yes [Ir rs, mat-mam”:

 

 

 

abject!

 

mix 10 Wigs-
1. I'm going to read you sane possible personal problem that: may prevent

mtrangettirqprenatalcare. midicneeuplainwhyymdidmt
cbtainprenatal (are? [READAILANDGMAIL'DMAPPIX]

1. Iwastoodepreesedduringmypregmmytoqatmre.
2. Instooetbarrassedbymypregnarcytogetcare.

3. Ididn'twanttohavethisbabyardthisqutnetmgetting
care.

4. Ihadaprtblanwithalccholordnagsthatkeptmetrun
gettirgcare.

5. Ididn'tuarrtotherpeopletolomeaspregnant.
6. Itelttooaickbogoartarfigatprerutalare.

manyotthesereameaqalainthepersaulprcblaathatkeptym
Mattingmmm? [MMW'SMJ

2. (7) Arettnreariygtmrper'saulprwlamttntmyhavepmentedym
trugettimprenatalm? No Yee[IFYES,mI‘I'E
mmrsn:

 

 

 

APPENDD( B

 

98.

100.

101.

102.

103.

104.

Counting this pregnancy, how many times have you been pregnant?

IF YOU ANSWERED 'l", SKIP TO QUESTION (99; IF YOU ANSWERED 2 OR MORE,
ANSWER QUESTIONS 98A AND 983.

98a. If you have been pregnant more than once, did you seek prenatal care at this office/clinic for m
of these pregnancies?
No - Yes

 

 

98b. How my living children do you have?
How did you make your first pmtal appointment?
by telephone

in person

other (please specify)

From the time you called or went to the office/clinic, how long did you wait for your first appointment?
Identifytheamountoftimccloscettothetimeyouwaited. Pleaaecheckonlymcetegory.

 

leesthanoneweek twowecks ' fourwecka

oncweek threcwecks morethen4weeks. Howmany ?

HowfaralonginyourpregnaocywcreyouwhcnyoucameforyourfivaiaiHCheckonlyone)

1-3 months
4-6 months

7-9 months
How many weeks pregnant are you now?

IdentifytheamountoftimthomeMamountoftimeyouumllyapandatyourclinicoroffice
visit.

lcesthanls minutes 31 minutcsto45 minutes 61mmm2hous
15 minutcsto30minutcs 46midutcet060minutee morcthanZhours

Check the one that best describes how my times have you been to the office/clinic for prenatal care.
1-5 times

6-10 times
11 or more times

PLEASE CONTINUE ON THE NEXT PAGE

63.

Now, we would like to know a little more about you. Please remember that all responses are
confidential at no time will the researchers release any information linking you to the survey.
For each statement, please check the response that best describes mu. Please answer all the
questions. Thank you for your help with this project.

 

92. Age (in Yeats)
93. Race (check only one)

Asian

Black

Hispanic

Native American
White (Non-Hispanic)
Other (Please Specify)

94. Mark the highest level of education you have M (check only one):

Less than high school

Some high school

High School GraduatelGED
Some College/Technical School
College Graduate '
Post College

95. Mark the use which currently describes your marital status (check only one):

«3

Single
Divorced
Married
Sepmted
Widowed
Other (please specify)

96. Are you working outside the home?

 

No

Yes If yes, Fulltime
Parttime

97. What kind of insurance do you have? (Check all that apply)

Medicaid

Private Insurance
Michcare

None (Self Pay)

PLEASE CONTINUE ON NEXT PAGE

61;

APPENDD( C

 

OFFICE OF
RSSEABCH
AND
IBRADUAJE
STUDflfli

Iniverslty Commas on
Research involving
lhmuaamhds
(UCRIHS)

mmmgmseuwmesw
25 Administration Building
East Lansing, Michigan
flwN4M6

517/355-21m
FAX: 517/432-1171

 

MICHIGAN STATE

UNIVERSITY

 

March 1, 1995

To: Mildred Omar
3230 Life Sciences Bldg.

Rs: IRs#: 94-151

TITLE: BARRIsRs, sxPscrAIIONs AND PArIsNr SAIIS!ACTION
As PREDICTORS or PRENAIAL CARE UTILIzArION AND
NATERNAL AND INFANT ourcouss IN ssNzIs COUNTY,
MICHIGAN

REVISION REQUESTED: N/A

CAIEGORI: -c

APPROVAL DATE: 03/01/95

The University Committee on Research Involving Human Sub ects'(UCRIHS)
review of this project is complete. I am pleased to adv as that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed consent are appropriate.
lhegegore, the UCRIHS approved this project including any revision

s e above.

IIIIHIL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be and one year must use the green renewal
form (enclosed with t e original a roval letter or when a
pro ect is renewed) to seek u ate certification. There is a
max um of four such expedit renewals ssible. Investigators
wishing to continue a reject beyond tha time need to submit it
again or complete rev ew.

IIVISIOIS: UCRIHS must review an changes in rocedures involving human
subjects, rior to in tiation of t e change. If this is done at
the time a renewal, please use the reen renewal form. To
revise an approved protocol at an 0 her time during the year
send your wr tten request to the CRIBS Chair, requesting revised
approval and referencing the project's IRB # and title. Include
in our request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS

censuses, Should either of the followin arise during the course of the
work, investi ators must noti UCRIHS promptly: 11) problems
(unexpected s de effects comp aints, e c.) involv ng uman
subjects or 12% changes in the research environment or new
information n icating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If

we can be of any future help lease do not hesitate to contact us
at (517)355-2180 or rAx (517)3 é

- 171s

Sincerely,

   

avid 3. Wright, P
UCRIHS Chair

65

APPENDD< D

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
flmuuunmmwmg
Human Subjects

nmmwm

Michigan State University
246 Administration Building
East Lansing, Michigan
4&Qme

517/355-2180
FAX: 517/432-1171

rhe Michigan State University
IDEA IS Institutional Dimlty:
Excellence in ACIIOI'I.

MSU is an afimmtive-action,
eats/Wily institwm

 

MICHIGAN STATE

 

UNIVERSITY

February 20, 1997

TO: Mildred A. Omar
A-230 Life SCiences

RE: IRB#:
TITLE:

REVIS ION REQUESTED:
CATEGORY :
APPROVAL DATE :

97-088

THE RELATIONSHIP BETWEEN EDUCATION LEVEL AND
PERCEIVED BARRIERS TO_ PRENATAL CARE OF RURAL LOW
INCOME PREGNANT WOMEN

N/A

1

-E
02/19/97

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
rotected and methods to obtain informed consent are appropriate. .
herefore, the UCRIHS approved this project and any reVisions listed

UCRIHS approval is valid for one calendar year, beginning with

above. Investigators planning to

continue a project beyond one year must use the green renewal

approval and referencing the project's IRB # and title.

to continue a project beyond tha

e original approval letter or wfien a

T ere is a
ssible. Investigators
time need to submit it

certification.
renewals

UCRIHS must review an changes in procedures involving human

rior to initiation of t
renewal, please use the green renewal form. To
revise an approved protocol at anKCo

e change. If this is done at
her time during the year,
RIHS Chair, requesting reVised
Include

in our request a description of the.change and any revised
ins ruments, consent forms or advertisements that are applicable.

above.
RENEWAL :
the approval date shown
form (enclosed with t
project is renewed) to seek u date
maXimum of four such expedite
wishin
again or complete reView.
REVISIONS:
. subjects,
the time 0
send your written request to the
PRosLmts/ _
CHANGES: Should either of the followin

work, investigators must noti
(unexpected side effects,

arise during the course of the
SCRIHS promptly: (1) roblems
comp aints, e c.) involving uman

subjectsoor $2).changes in the research environment or new
information indicating greater risk to the human sub'ects than

existed when the protocol was previously reviewed an

approved.

If we can be of any luture help;2 please do not hesitate to contact us

at (517)355-2180 or FAX (517)4

Sincerely,

   

avid E. Wright, Ph.
UCRIHS Chair

DEW:bed

cci/shfista L. Holland

171.

66

APPENDIX E

Field Procedures

The following procedures were used in the original study by Omar,

Schiffman, and Bauer (1995) for data collection with the rural low income

pregnant women.

1.

Subjects were recruited from Benzie County Health Department, the

Grand Traverse County Health Department, prenatal providers in

Benzie county, Manistee county, and Grand Traverse county, and

childbirth education classes.

Subjects were approached by the data collector either in the waiting

room at their WIC appointment or by telephone. The project was

explained and informed consent obtained. Consent to access both the

mother's and infant's hospital medical records were obtained from the

low income women at the time of entry into the study.

Following written consent, the women then completed the

questionnaire packet either on-site at one of the recruitment sites or

during a home visit.

The data collector:

(a) assisted subjects to complete the Ten-Item Checklist, the PSPC
instrument, and the Maternal Self-Report Health and Prenatal
Care Utilization Survey.

(b) answered subjects' questions for clarification of instructions and
meaning of words only.

(c) recorded expected date of delivery for anticipated chart review.

67

(d) dispersed a cash incentive of $10.00 to each subject following
completion of the questionnaire packet.

The Data collector identified when subjects had delivered and recorded:

(a) hospital subject delivered, (b) date of delivery, and (c) outcome of

delivery.

A chart review was conducted to collect variables from the subjects'

and infants' records.

68

"IlllllllllIllllllllES