THE EARLY REPEAT ADOLESCENT PREGNANCY ‘
RISK ASSESSMENT TOOL FOR THE AFN ' ‘

Scholafly Project for the Degree of M. ‘3‘ N. -~
MICHIGAN STATE UNIVERSITY
CHERYL G. MILLS &- DEBRA S. PERRY-PHILO

‘ 1999 '

 

 

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THE EARLY REPEAT ADOLESCENT PREGNANCY
RISK ASSESSMENT TOOL FOR THE APN

BY

Cheryl G. Mills
8
Debra S. Perry-Philo

A Scholarly Project

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

MASTER OF SCIENCE IN NURSING

College of Nursing

1999

ABSTRACT

THE EARLY REPEAT ADOLESCENT PREGNANCY
RISK ASSESSMENT TOOL FOR THE APN

BY
Cheryl C. Mills 5 Debra S. Perry-Philo

As many as fifty percent of adolescent mothers deliver
a second child within 24 months of an initial delivery
(Jones & Mondy, 1994). A second child is strongly
associated with an increased risk of failure to complete
high school and an inability to become economically self-
sufficient. While risk factors which influence the
likelihood of an early repeat adolescent pregnancy have been
identified in the literature, no assessment tool currently
exists which identifies adolescents at risk for an early
repeat pregnancy (Seitz & Apfel, 1993). Thus, The Early
Repeat Adolescent Pregnancy Risk Assessment Tool (ERAPRAT)
has been designed as an assessment tool, for use by the
Advanced Practice Nurse (APN) in the primary care setting,
to identify adolescent females at risk for an early repeat
pregnancy. The Health Promotion Model, described by Pender
(1996), provides the conceptual framework for the
development of the ERAPRAT. Practice, education, and
research implications regarding the use of the ERAPRAT are
described.

ACKNOWLEDGMENTS

We both would like to thank all who guided and
supported us in the development of this project. Initially,
thanks to our committee Chair, Joan Wood, RN, PhD, whose
patience and support kept us focused throughout the process
and helped us attain our end goal as well as those along the
way. Secondly, thanks to our other committee members, Mary
Jo Arndt, RN, EdD and Kate Lein, RN, MSN, FNP, whose
knowledge and experience lent to the richness of our project
by widening our scope of thought.

We would also like to thank our families, whose
understanding and patience fueled our endurance:

From Cheryl: Thanks to my husband John, and daughter
Kasey, for your support, understanding, confidence, and
love. Thank you for the short-term sacrifices we have had
to make for this accomplishment. Also, thanks to my
parents, Dave and Marilyn Gillum, my sisters, Beverly and
Michele, as well as other family members and friends whose
support and prayers have been deeply appreciated. I know
that this accomplishment will benefit our family with many
positive outcomes. Thank you! I love you!

From Debra: Thanks to my husband Joe, children Andrea
and Jacob, and parents Bob and Judy Perry. I know the long-
term benefits from helping me with this endeavor will
outweigh any short-term sacrifices. Thanks also to Howard

and Louise Philo, as well as other family members and

iii

friends whose thoughts and prayers helped me persevere. I

know your lives will be enriched from my personal growth.

iv

TABLE OF CONTENTS

LI ST OF F I GURES O O O O O O O O O O O O O O O O O O O
INTRODUCTION O O O O O O O O O O ' O O O O O O O O O O
Statement of the Problem ,. . . . . . . . . . . . . .
The PrOj eCt O O O O O O O O O O O O O O O O O O O O O
Conceptual Framework . . . . . . . . . . . . . . . .
Application of the RPM to the Project . . . . . . . .
Cognitive-Perceptual Factors . . . . . . .
Perceived Benefits of Health-Promoting Behaviors
Modifying Factors . . . . . . . . . . . . . . .
Conceptual and Operational Definitions . . . . . . .
Literature Review . . . . . . . . . .
Estimates of Repeat Pregnancy in Adolescence .
Predictors of Repeat Pregnancy in Adolescence

Impact of a Repeat Pregnancy on Adolescents .
Programs for Pregnant Adolescents . . . . . .

Project Development . . .
Need for the ERAPRAT
ERAPRAT Format . . .
Use of the ERAPRAT .
Items on the ERAPRAT

O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O
O O O O O

Implications . . . . . .
Practice Implications .
Educational Implications
Research Implications .

conc1us ion O O O O O O O O O O O O O O O O O O O O O
LI ST OF REFWCES O O O O O O O O O O O O O O O O O
Appendix A: Guidelines for use of the ERAPRAT . . . .

Appendix B: The ERAPRAT . . . . . . . . . . . . . . .

Page

O O O O
p
O

18
2O
20
22
26

31
32
32
33
36

48
48
55
56

Figure 1:

Figure 2:

LIST OF FIGURES

The Health Promotion Model . . . .

The Modified Health Promotion Model

vi

INTRODUCTION

Teenage pregnancy is not a new phenomena; for decades
it has remained one of our nation's major public health and
social concerns. The United States ranks as one of the
nations in the Western World with the highest number of
adolescent births, i.e., one million adolescent females
become pregnant annually (Stevens-Simon & Beach, 1992;
Stevens-Simon & White, 1991). For many years it was
believed that poverty and social disorganization were
consequences of adolescent pregnancy rather than the cause.
However, it is now believed that the relationship is
reciprocal (Kirby, 1997). Fertility among females less than
20 years of age appears linked to changes in society's
perception of adolescent pregnancy; what was once viewed as
unacceptable is increasingly tolerated and even embraced in
some circumstances (Glazer, 1993).

Parenting can be a challenge at any age, however,
adolescents are a particularly vulnerable group based on
their developmental stage. Tasks of adolescent development
include achieving independence from parents and other
adults, selecting and preparing for an occupation of
interest, establishing a satisfying and socially acceptable
gender role, and developing partner relationships based on
love rather than infatuation (Murray & Zentner, 1997).
Adolescent developmental tasks are interrupted by pregnancy

and premature parenting. Until these tasks are

accomplished, the adolescent remains immature regardless of
chronological age and development is arrested. Thus,
adolescents often lack the emotional maturity and knowledge
to demonstrate positive parenting characteristics and
develop appropriate adult behaviors (Murray & Zentner).

Adolescent pregnancy and parenthood often result in a
cycle of disadvantage for a young woman and her child (Jones
& Mondy, 1994). A pregnancy in adolescence is related to a
greater risk of failure to complete high school, poor labor-
market performance, single parenthood, long-term welfare
dependence, and an increase in mortality and morbidity of
both the infant and mother (Auterman, 1991; Maynard &
Rangarajan, 1994). The adolescent who gives birth faces an
obstacle for continuing her education and becoming
economically self-sufficient (Seitz & Apfel, 1993).

For these reasons, prevention of adolescent pregnancy
is of national importance, and demands significant attention
and numerous intervention strategies. However, primary
prevention of adolescent pregnancy is difficult for many
reasons. Sexual beliefs, attitudes, perceived norms, self-
efficacy, actual skill, and intentions related to sexual and
contraceptive behavior remain ever changing (Matsuhashi,
Felice, Shragg & Hollingsworth, 1989). Also, many differing
social attitudes and environmental constraints inhibit
promotion of abstinence and contraceptive use by the
adolescent population and males over 20 who are involved

sexually with adolescent females. Lastly, the developmental

2

stage of the adolescent contributes to risk taking
behaviors, including those related to sexuality, often
without thought of consequence (Kirby, 1997).

Compounding this issue is the fact that adolescent
mothers often have a repeat pregnancy during adolescence
(Jones & Mondy, 1994). One of the most important mediators
related to long-term outcomes for an adolescent mother and
her child is the spacing of a subsequent birth (Kalmuss &
Namerow, 1994). Having a subsequent pregnancy potentiates
the risk for disadvantage. Recidivism is likely to expend
available support systems a young mother has established,
forcing her to postpone or prohibit further education or
employment. Many adolescents become overwhelmed with
multiple responsibilities and abandon hope for personal
achievement (Seitz 8 Apfel, 1993).

Adolescent fertility control following an initial
delivery has been linked with educational completion and
long-term economic success (Rubinstein, Panzarine, &
Lanning, 1990). Many studies show that a repeat adolescent
pregnancy is unintentional (Stevens-Simon, Parsons, Cha, &
Montgomery, 1986). When considering support for women who
begin childbearing in adolescence, those adolescents who
desire to prevent a second pregnancy and pursue education
and career goals should be identified and supported to
realize their goals (Stevens-Simon, Kelly 8 Singer, 1996).

When exploring why some adolescent mothers fare better

on a range of outcomes, empirical evidence supports the

3

importance of understanding and identifying indicators of
early repeat pregnancies. While all adolescents who give
birth are considered ‘at risk', few programs have the
resources available to address these risks and maintain
contact with young women and their children to ensure
adequate support. Therefore, those adolescents who would
most benefit from intervention, i.e., those adolescents at
risk for an early repeat pregnancy, should be identified and
receive support to optimize long-term outcomes, and utilize
available resources most efficiently (Kalmuss & Namerow,
1994).

Statement of the Problem

Twenty-five to fifty percent of adolescent mothers
deliver a second child within 24 months of an initial
delivery. A second child further potentiates the incidence
of poverty and is associated with an even greater risk of
failure to complete high school and an inability to become
economically self-sufficient (Jones & Mondy, 1994).

Given the issues which adolescent mothers face, there
is a need to have a tool to identify adolescent females at
risk for an early repeat pregnancy. However, no tool has
been designed for this purpose. Identification of those at
risk for an early repeat pregnancy could facilitate intense
and appropriate interventions, optimize outcomes for
adolescent mothers and their children, and utilize resources

more effectively.

The Project

The risk factors for an early repeat adolescent
pregnancy are known and can be linked to several less than
positive outcomes. Programs which offer immediate and
intense interventions contribute to long-term success.
Therefore, it is essential to identify adolescent mothers
who would benefit from intervention; an assessment tool
could illuminate adolescents at risk for recidivism (Kalmuss
8 Namerow, 1994).

The Advanced Practice Nurse (APN), a primary healthcare
provider, is in a key position to identify adolescents at
risk for an early repeat pregnancy. Upon identification of
risk, the APN can develop or implement protocols of care
that enhance adolescent acceptance of parental
responsibility and fertility control by assuring adequate
client counseling, teaching and support in decision making
(Jones & Mondy, 1994). Thus, the goal of this project is
the development of an assessment tool, for use by the APN in
the primary care setting, which identifies adolescents at
risk for an early repeat pregnancy.

Conceptual Framework

The Health Promotion Model (HPM) has been selected to
guide the development of the assessment tool in this
project. A description of the model follows.

The Health Promotion Model described by Pender (1996),
[Figure 1], is a competence or approach oriented model which

attempts to explain predictors of health behaviors and

5

PARTICIPATION IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COGNITIVE PERCEPTUAL MODIFYING HEALTH-PROMOTING
FACTORS FACTORS BEHAVIOR
Importance
of ‘-*
health Demographic
characteristics
Perceived
conuol __ I
of . .
Biologic
health characteristics
Perceived l
self-efficacy _ Interpersonal
influences A
Definition Likelihood of
of ._ I ' engaging in
health health~promoting
Situational behaviors
faunns ~
Perceived ‘_ A
health I '
status I
, Behavioral _ I
Perceived factors .
benefits I Cues to action I
of ‘__
health-promoting
behaviors
IPerceived barriers
to _
health-promoting
behwndors

 

 

 

 

 

Figure 1. The Health Promotion Model (Fender, 1996)

6

beliefs. While based on the Health Belief Model, another
paradigm for explaining health protective behavior developed
by Rosenstock in the 1960's, it does not include fear or
threat as sources of individual motivation for behaviors
directed toward enhancement or retention of health (Fender,
1996).

The HFM is a framework which integrates nursing and
behavioral science perspectives related to the factors
influencing health behaviors. It is an attempt to depict
the multidimensional nature of persons interacting with
their environment as they pursue health; it views the
pursuit of health as desirable. The major assumptions of
the HFM emphasize the active role of the client in shaping
and maintaining health behaviors, and in modifying the
environmental context for health behaviors. This model
places major emphasis on self-direction, self-regulation and
perceptions of self-efficacy as internal and external
stimuli which work together to shape behavior (Fender,
1996).

The HFM integrates a number of constructs from
Expectancy-Value Theory and Social Learning Theory
(currently referred to as Social Cognitive Theory) within a
nursing perspective of holistic human functioning (Fender,
1996). Expectancy-Value Theory views human behavior as
rational and economical, e.g., people will engage in an
action if the outcome is positive, if the personal gain

probable, and if the course of action is likely to result in

7

the desired outcome. Social Learning Theory is an
interactional model of causation in which environmental
events, personal factors, and behavior act as reciprocal
determinants of each other (Fender, 1996).

The HFM views the likelihood of engaging in health
promoting behavior as being influenced by three groups of
factors. These factors are: modifying factors, cognitive-
perceptual factors, and cues to action. The modifying
factors are demographic characteristics, biological
characteristics, interpersonal influences, situational
factors, and behavioral factors. Modifying factors are
related to prior behavior and experience, as well as
personal situational influence related to birth status,
acculturation, socioeconomic status and attitudes, and the
beliefs and behaviors of others affiliated with an
individual. When implementing interventions, many of these
factors can not be changed (Fender, 1996). Cognitive-
perceptual factors include the individual's perception of
importance of health, control of health, self-efficacy,
definition of health, health status, benefits of health-
promoting behaviors, and barriers to health-promotion
behaviors. These factors for an individual are influenced
by the modifying or background factors. Combined, they
ultimately affect the likelihood of engaging in health
promoting behaviors. Additional transient stimuli are

catalysts, or cues, to action (Fender, 1996).

Application of the HFM to the Project

The HFM states that although threats to the
individual's immediate future action are sources of
motivation, threats of the distant future lack the same
motivational strength. This model is applicable to the
adolescent population as adolescents often possess little
regard for the future and believe they are invulnerable to
health deficit (Fender, 1996). .Therefore, the HFM is an
appropriate theoretical basis for the development of the
assessment tool in this project; it addresses the
adolescent's need for timely feedback regarding immediate
consequences.

During the assessment phase of the nursing process,
which would incorporate this tool, the APN can identify
factors influencing the adolescent, and implement a plan
with the adolescent to change those factors amendable to
change, within the modifying or cognitive-perceptual
factors, so that promotion of health is attained. The APN
can assist the adolescent to identify benefits of behavior,
and can teach the adolescent how to overcome hurdles, or
barriers, to the practice of health-promoting behaviors.
The AFN can also serve as a catalyst to action, i.e., the
individual who facilitates action directed toward behaviors
that promote health (Fender, 1996).

Risk factors that influence the likelihood of an early
repeat adolescent pregnancy which were identified in the

current literature are incorporated into the HFM and appear

9

in The Modified Health Promotion Model [Figure 2]. The
areas of relevance to this project have been shaded in this
figure. The assessment tool developed, which identifies
female adolescents at risk for an early repeat pregnancy, is
based on these risk factors and their integration into the
HFM. Although some risk factors may overlap concepts, their
influence on the adolescent guides their inclusion in the
model.
MW

2e:geixgd_ggn;zg1_gf_heal;h. Perceived control of
health is one's perceived ability to influence health
outcomes based on behavior (Rankin & Stallings, 1996). When
considering early repeat pregnancy, many adolescents at risk
have a sense of hopelessness and powerlessness with regard
to control of health outcomes. Many feel they have little
control over themselves, little control over life events, or
believe they face bleak futures. Therefore, an initial as
well as repeat pregnancy are either planned or not
prohibited; these adolescents ‘live in the here and now'
(Glazer, 1993). Adolescents who perceive control over their
lives, and emulate behavior based on this belief, have
become more successful overall (Horwitz, Klerman, Kuo, &
Jekel, 1991).
WWW

Perceived benefits of health-promoting behaviors is the
belief that one's health behavior will positively affect
outcomes with self-gain likely (Rankin & Stallings, 1996).

10

PARTICIPATION IN
COGNITIVE °PERCEPTUAL MODIFYING HEALTH-PROMOTING

FACTORS FACTORS BEHAVIOR

4,

Importance , _, .
of T "3???i%£2¥¥Demographici'ii???

 

 

 

 

 

   

Perceived control r

0f health

' Perceived control
over life events .-;;.;=-

 

 

 

V Biologic
characteristics

 

 

 

 

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self-efficacy

 

 

 

 

Definition Likelihood of
of - and after Initial engaging in
health _'-?:.'ei~pregnancy ' F) health-promoting
VIP-.Famdy patterns behaviors
.. Somal network!

 

 

 

 

 

Perceived 19:8th status A
health — T

I
Status ‘ ...... Situational """ I
I

 

 

Perceived benefits IIIIIII faCtors I

of health+promoting ‘Adolescent’s parents

helm level of education """"" .
Intention: (1:813th SoaOétmnomic status Cues to action
to miss} - . H -: of family of ongm ...........

pregnancy; was it 'Years 01' 99110011118
planned? . 1, completed by
. Return to school adolescent at initial
‘Fitt'ure aspirations} birth . -
I
Perceived barriers Behavmral ~~--;;-;;;;- 
to factors 55‘-
health-promoting '.. Contracephve

behaviors ‘ Behavxor

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

Figure 2. The Modified Health Promotion Model (Fender,
1996)

11

 

Intentions which facilitate the initial pregnancy, i.e., a
planned pregnancy, not intending to return to school
following an initial pregnancy, and lack of future
aspirations, are all related to an increased incidence of an
early repeat adolescent pregnancy (Kalmuss & Namerow, 1994;
Stevens-Simon, Dolgan, Kelly, 8 Singer, 1997). When
considering behaviors related to these risk factors, it is
believed that prohibiting a repeat pregnancy is not
perceived as desirable and beneficial. Many of these
adolescents are in the family building stage, thus, they
value family building as opposed to continued education and
career. Others show depressive symptoms and ‘want someone
to love' in order to fulfill an emotional need or are
apathetic regarding contraceptive use, thus, they engage in
unprotected sex (Linares, Leadbeater, Jaffe, Dato, & Diaz,

1992).

MW
Demeszanhis_sharacteristics. Demographic factors,

i.e., personal factors, are relevant influences on health
behavior in a given target population (Fender, 1996). The
adolescent's age at the time of an initial birth affects
subsequent fertility outcomes as it is often related to the
adolescent's degree of educational attainment. Adolescent
females less than 16 years of age are more likely to have an
early repeat pregnancy, more likely to have completed less
education, and use contraceptives less effectively or not at

all. Becoming sexually active at a young age results in

12

increased long-term exposure to more risky sexual behaviors,
which increases the incidence of pregnancy (Kalmuss 8
Namerow, 1994; Matsuhashi et al., 1989; Stevens-Simon et
al., 1996).

Interpersonal_inf1nences. Interpersonal influences are
how others influence behavior (Fender, 1996). Family
support received by the adolescent during and after the
initial pregnancy, family patterns, social network and
habits, and marital status have been identified as
influencing the incidence of an early repeat adolescent
pregnancy. Other contributing factors are related to family
support, i.e., financial and emotional support. Family
support facilitates return to school, continued life
development, and the desire to postpone second pregnancies
(Seitz 8 Apfel, 1993). An intact family tends to deter
repeat pregnancies and is linked to greater stability
(Matsuhashi et al., 1989).

Family patterns are related to race, ethnicity, and
socioeconomic status; they determine acceptance of
childbearing behavior and can shape fertility behavior based
on family tradition. Those adolescents who come from a
large family are more likely to produce more children
overall, and start family building at a young age (Kalmuss &
Namerow, 1994).

Social networks often affect an adolescent's definition
of acceptable behavior, influence decision-making, and

dictate reactions to life events. If an adolescent has many

13

peers involved in family building, the adolescent is more
likely to perceive this as the norm and adapt to this life
choice (Horwitz et al., 1991). If peers use and abuse
illicit substances, the adolescent is more likely to do the
same. These circumstances have also been linked to an
increased risk of early repeat adolescent pregnancy
(Stevens-Simon et al., 1996). Conversely, if peers value
and support education and career goals, the likelihood of an
early repeat adolescent pregnancy is lower (Stevens-Simon et
al., 1997).

Marital status following an initial delivery affects
the incidence of an early repeat adolescent pregnancy. The
presence of a spouse is more likely to result in a planned
birth and a desire to continue with family building, if this
is valued by the spouse (Kalmuss 8 Namerow, 1994). Also, a
spouse is more likely to supply an income making the
perception of attaining education and career goals less
important. Frequency of sexual behavior may also be greater
with a spouse present, making pregnancy more likely (Ford,
1983).

Situational_fantgrs. Situational factors are ‘where
one is at' in life based on their history of existence and
experience (Fender, 1996). Situational factors which have
been identified as increasing the incidence of an early
repeat adolescent pregnancy are the adolescent's parents'
level of education, the socioeconomic status of the family

of origin, and years of schooling completed by the

14

adolescent by the time of the initial birth. Lack of
educational attainment of both the adolescent and her
parents, and being of lower socioeconomic status have also
been linked to increased risk of early repeat adolescent
pregnancy. Increased educational attainment has been
positively associated with contraceptive use and negatively
associated with family size (Kalmuss 8 Namerow, 1994).
Linares et al. (1992) believes this is the result of
decreased family emphasis on education and career
development, which results in family building at an earlier
age.

Behayigral_fagtgzs. Behavioral factors are assessed by
considering an individual's prior experience with various
health promotive choices (Rankin 8 Stallings, 1996). When
considering behavior related to contraception, adolescents
at risk for an early repeat adolescent pregnancy have been
shown to use contraceptives inappropriately or not at all
(Kalmuss 8 Namerow, 1994; Maynard 8 Rangarajan, 1994). This
behavior may be the result of not being offered the
contraceptives, lacking the skill for proper use, or not
finding the contraceptive methods available, acceptable and
compatible with use (Jones 8 Mondy, 1994).

(Conceptual and Operational Definitions

Definition of the concepts used throughout this project
leads to a greater understanding of the basis for tool
development and tool implications. In general, there are

variations in the literature regarding conceptual

15

definitions; consideration of these definitions resulted in
the operational definitions used for this project. The
conceptual and operational definitions are as follows:

Adglgsggn;_2zggnangy. Kalmuss and Namerow (1994) refer
to adolescent pregnancy as any female under age 17 who
conceives a pregnancy. Ferino (1992) uses age < 20 and
Glazer (1993) uses age < 19 when referring to pregnant
adolescent females. Horwitz et al. (1991) refer to ‘school-
aged' expectant females as between the ages of 13-18, while
Folit and Kahn (1986) define pregnant adolescents as
pregnant females under the age of 17, without a diploma.
Most sources refer to pregnant adolescents as those that
follow through with a pregnancy and deliver at viability.

As ‘risk' is greatest for those females who have not
completed high school, the definition of adolescent
pregnancy for this project is a female 13-20 years of age
who has not completed high school, is pregnant, and intends
to deliver an infant.

RW- Linares et al-
(1992), Stevens-Simon et al. (1996), and Stevens-Simon et
al. (1997) describe an early repeat adolescent pregnancy as
delivery of an infant to an adolescent female within 12
months of an initial delivery. They found that as many as
30% of repeat adolescent pregnancies occur during this
period of time. Jones and Mondy (1994), Kalmuss and Namerow
(1994), and Matsuhashi et al. (1989),_refer to the same

definition, but do so within a 24 month time period. They

16

found that 25% to 50% of repeat adolescent pregnancies occur
within two years of an index delivery. Since long-term
outcomes are the most positive when an adolescent female
delays a subsequent delivery for 24 months (Seitz 8 Apfel,
1993), this project defines early repeat adolescent
pregnancy as delivery of an infant, by an adolescent female,
within two years of an initial delivery.
Adyanged_2rag;1ge_flnzsg_1A£N1. In 1993, The American
Nurse's Association Board of Directors defined an advanced
practice nurse as a " professional nurse who has
successfully completed a graduate program of study in a
nursing specialty or related health care field that provides
specialized knowledge and skills forming the foundation for
expanded practice roles in health care” (O'Conner, p. 66,
1994). Fagin (1978) stated that APNs use a holistic
approach when assessing actual or potential health problems
of individuals, families and the community, with optimal
health and wellness as the goal of advanced nursing care.
Collado (1992) stated APNs are nurses in advanced practice
who combine health promotive with curative aspects of health
care, thus being natural allies of primary health care
goals. This project defines AFN as a nurse who has
successfully completed a graduate nursing specialty program
and uses a holistic approach when caring for patients,
families, and the community to assess actual or potential
health problems and facilitate attainment of optimal health

and wellness.

17

Assessmgnn_mggl. Fender (1996) states that assessment
provides a database for making clinical judgments concerning
client strengths and client health problems, and for making
decisions regarding desired health or behavioral outcomes.
Rankin and Stallings (1996) refer to assessment as a
collection of data to identify actual or potential health
problems, while realizing client strengths and limitations
related to achieving health outcomes.

Fender refers to the mechanism which provides the
assessor with information to develop an individually
tailored plan for health promotive care as an assessment
instrument.

Rankin and Stallings refer to an instrument as a guide
to a set of criteria that will direct the assessor to areas
of intervention, and emphasizes the importance of
maintaining a holistic approach within the context of the
client's family and environment. This project defines an
assessment tool as an instrument, used in collaboration with
the client, which provides the APN with information
regarding client strengths and limitations, and identifies
areas of needed intervention to promote holistic health
outcomes for the client within the context of family and
environment.

Literature Review

Adolescent pregnancy represents a complex issue

involving many factors and results in many negative outcomes

for the adolescent, her child, and society as a whole.

18

Adolescent pregnancy and parenting constitute major societal
problems and present significant medical and psychosocial
risks that accompany adolescent births (Rubenstein et al.,
1990). Hardy and Zabin (1991) along with Maynard and
Rangarajan (1994) identify school dropout, single
parenthood, the early repetition of pregnancy, employment
difficulties, and poor labor-market performance as
commonplace for adolescent mothers. The current literature
reflects factors which influence an early repeat adolescent
pregnancy.

Kalmuss and Namerow (1994) identify three categories
which impact early repeat pregnancy: background
characteristics before an initial birth, adolescent
characteristics at the time of an initial birth, and
experiences following an initial birth. The background
characteristics before the time of the initial birth include
the adolescent's parents' level of education, the
socioeconomic status of the family of origin, family support
received by the adolescent during the initial pregnancy,
family patterns, and the attitudes toward contraceptive
behavior of the adolescent. Adolescent characteristics at
the time.of the initial birth include the age of the
adolescent at the birth, the number of years of schooling
completed by the adolescent at the time of the birth, and
the birth mother's intentions related to the birth. The
experiences following an initial birth are related to

whether or not the adolescent returns to school, marital

19

status, social network/habits, future aspirations, and
perceived control over life events.
W

The incidence of early repeat pregnancies is high with
the rates ranging from 19% to 66% depending, in part, on the
adolescent mother's participation in post-partum
intervention programs (Stevens-Simon et al., 1986).
Likewise, according to Stevens-Simon et a1. (1996) fifty-
eight percent of repeat pregnancies occur during the initial
six month post-partum period; Kalmuss and Namerow (1994)
report that 24-31% of adolescent mothers have a second birth
within 24 months of the initial delivery. Similarly,
Linares et al. (1992) found that 39% of adolescent mothers
repeat pregnancy and Ford (1983) reported that about one-
third of repeat pregnancies occur within 12-months of the
first delivery. Folit and Kahn (1986) reported that
regardless of race or ethnicity early repeat pregnancies
occurred in one out of five adolescent mothers within 12
months of their first child.
W

Stevens-Simon and White (1991) cite the absence of
post-partum follow-up care as being an important factor in
the prevalence of repeat pregnancy among adolescents. An
average of 30% of pregnant adolescents will be pregnant
again within their first post-partum year and 25-50% will
become pregnant again within the second year (Stevens-Simon

8 White). Other factors which seem to be associated with

20

repeat adolescent pregnancy include being 16 years old or
younger at first conception, not living with parents, being
below the expected grade level or dropping out of school,
pregnancy viewed as a socially and culturally acceptable
means of achieving adulthood, and leaving the hospital
without birth control (Stevens-Simon et al., 1996).
Berenson and Wiemann (1997) found that the adolescents who
failed a grade in school, who experienced depressive
symptoms, or lived with a new partner, were less likely to
be reliable users of contraception and more likely to become
pregnant again. Another important predictor is the degree
of contact and quality of contact these young mothers have
with key people who provide support, assistance, guidance
and confirmation of their self worth (Berenson 8 Wiemann,
1977). Kalmuss and Namerow (1994) found that adolescents
with more educated parents and those who continued with
schooling after the birth of their first child were less
likely to have an early repeat birth. Similarly, Horwitz et
al. (1991), found that women who had completed more
education when they became pregnant were 18 times more
likely to be successful later in life.

Maynard and Rangarajan (1994) and Ford (1983) cited
that most of the repeat pregnancies in adolescents occurred
in those not using a contraceptive method at all or using
one inconsistently. Within the follow-up period, which
averaged 29 months, 64% had at least one pregnancy and 21%

had two or more repeat pregnancies (Maynard 8 Rangarajan).

21

Atkin and Alatorre-Rico (1992) cited another important
factor, i.e., the adolescents' mothers themselves having
been pregnant as an adolescent. The intergenerational
influence on adolescent pregnancy increases the likelihood
of a repeat pregnancy primarily because the environment
promotes the repetition of the cycle of closely spaced
repeat pregnancies (Atkin 8 Alatorre-Rico, 1992). Nearly
70% of the participants' mothers in Maynard and Rangarajan's
(1994) study had been adolescent parents themselves; 42% of
these parents grew up in a single-parent household and 63%
were raised in a household that received welfare at some
point.

Furstenburg, Brooks-Gunn, and Morgan (1987) found that
family factors predicted intergenerational continuity of
adolescent parenting including low maternal education and
adolescent births in adolescents' mothers. Linares et al.
(1992) stated that the choice to have a second child is
consistent with traditional sex-role orientation in some
cultures, that is, parenting is seen as a positive route to
adult status and positive emotional bOnds are anticipated
from the mothering role.. . I I
1W

Maternal and infant morbidity and mortality are also
increased in the pregnant adolescent (Auterman, 1991). The
causes of adverse outcomes are complicated and are related
to social, educational, and health factors. Furstenberg et

al. (1987) reported that studies conducted over the years

22

indicated that girls will have repeat pregnancies, drop out
of school and rely on the welfare system to support their
family, unless there is a significant amount of intervention
and support for first time pregnant adolescents from a
multidisciplinary team approach. Adolescent mothers with an
early repeat pregnancy will experience a substantially
poorer socioeconomic and familial outcome (Kalmuss 8
Namerow, 1994; Jones 8 Mondy, 1994). Adolescent mothers
require continued intensive intervention in order to impact
mother and infant outcomes (Jones 8 Mondy, 1994). The
multidisciplinary team must function in a nonjudgmental,
warm and sensitive way, while focusing on the needs of each
individual adolescent (Taylor, Berg, Kapp, 8 Edwards, 1983).
Glazer (1993) and Stevens-Simon et al. (1996) discuss how
puzzling it is that even when adolescent girls have
knowledge and access to contraceptives, there is no
guarantee that they will use them.

Auterman (1991) attributed pregnancy to be the major
reason for girls dropping out of school. Robinson (1993),
Scott-Jones and Turner (1990) and Stevens-Simon et al.
(1986) recognized that the school drop-out rate of pregnant
adolescents increased as a result of their lack of academic
success and that these adolescents tended to experience
early repeat pregnancies. Their failure to complete their
education had an irreparable and cumulative economic impact
over their lifespan. Robinson further stated that because

dropout rates are much higher after the baby is born,

23

support services need to occur after the infant's birth at
an even higher level than those provided during pregnancy.
Rubenstein et al. (1990) stressed that it is important to
facilitate continued school participation with the
adolescent mother after the birth of her infant, since
staying in school has been identified as a major factor in
delaying repeat pregnancies.‘

- The problem of early repeat pregnancies among
adolescents is an important issue (Rubenstein et al., 1990).
An adolescent who gives birth to a second child soon after
delivering her first is faced with serious barriers for
continuing her education and becoming economically self-
sufficient (Seitz 8 Apfel, 1993). When pregnancy and
parenthood occur simultaneously, the process of normal
psychological and cognitive adolescent growth and
development are both retarded and accelerated. For example,
adolescent mothers who give birth to their first child
before the age of sixteen are more likely to have a second
child within the next two years than older adolescents
(Mott, 1986). Hopkins Adolescent Clinic program data
suggest proper education for young mothers is important in
reducing repeat pregnancies within 18 months of the birth of
their first child (Hardy 8 Zabin, 1991).

Based on a longitudinal study conducted by Furstenberg
et al. (1987) of urban black women who became pregnant as
adolescents, the length of time they received welfare also

emerged as a significant factor. This finding was

24

consistent with Maynard and Rangarajan's (1994) study which
revealed that half of the young mothers lived on their own
with neither a male partner nor a parent. Jones and Mondy
(1994) cite that having a second and subsequent birth as an
adolescent increases the risk for economic disadvantages.
Furstenberg's et al. (1987) survey also indicated that women
who gave birth to a second or third child within 5 years of
the first were almost three times as likely to be receiving
welfare as those who delayed having an additional child. It
is important to note that limited attention has been
directed towards prevention of repeat pregnancy in these
youth (Matsuhashi et al., 1989).

The initiation of prenatal care has been documented to
influence the outcome of pregnancy. Hardy and Zabin (1991)
discussed the importance of referring adolescents promptly
for prenatal care in order to meet their special needs,
counter the risks of adolescent pregnancy, and have optimal
outcomes. According to Auterman (1991), adolescents tend to
seek prenatal care later than older women and have fewer
prenatal visits. In particular, adolescents are less likely
to seek care in the first trimester of pregnancy (Auterman,
1991; Lee 8 Grubbs, 1995). It has been suggested that this
occurs for various reasons, i.e., denial of pregnancy, lack
of understanding of the importance of prenatal care, lack of
accessibility to prenatal services, and inappropriate
methods of services to meet the adolescents' needs (Lee 8

Grubbs, 1995; Ferino, 1992). rLee and Grubbs also found that

25

those adolescents seeking prenatal care in the first
trimester of pregnancy did so because of the family support
they received, along with their own beliefs that the care
was needed for a healthy outcome for themselves and their
infants.
W

Obtaining a better understanding of the sources of
strongly positive, ambivalent, and strongly negative
feelings regarding childbearing is vital for the APN in
order to develop a more useful approach in meeting the
developmental and emotional needs of adolescent mothers
(Stevens-Simon et al., 1996). Programs need to be tailored
to the specific needs of adolescents and special strategies
identified to enhance the motivation of adolescent mothers
with poor skills and limited social support (Furstenberg et
al., 1987). Hardy and Zabin (1991) reported that a
comprehensive program of care can serve to aid the
resolution of serious health problems by improving the
obstetric and neonatal outcomes for those teenagers that
participate. They emphasize the importance of education,
social services, and a team approach. The importance of
services aimed at keeping the adolescent mother in school
after the baby's birth also cannot be overemphasized.
Continued school participation has been identified as a
major factor in delaying a repeat pregnancy as well as
increasing the adolescent's opportunity for future economic

independence (Rubenstein et al., 1990).

26

Furstenberg et al. (1987) found in their longitudinal
study of teenage mothers that completing high school was one
of the most important variables contributing to a successful
outcome for these young women. Auterman (1991) cited that
many adolescent programs have documented that earlier and
more frequent prenatal visits are significant because the
adolescents are monitored more closely and frequently.

Seitz and Apfel (1993) state that school programs have great
potential ability to reach a large proportion of the high-
risk adolescents and therefore, would be a good choice as a
service delivery model. “School-based clinics provide a
wider range of services than prenatal care, but may promote
earlier and more consistent prenatal care because they are
readily accessible, have few financial restrictions and
provide confidential care and counseling’ (Auterman, p.
219.). Furstenberg et al. (1987) stated that alternative
schools help prevent disadvantage in later life and that
services that are provided at the time of the first
pregnancy and birth can lower the long-term risk of economic
dependency. .

Robinson (1993) believes that the development of
specific services within the school system for pregnant
teenagers would increase school completion rates and that
support services need to be more intense in the post-partum
period. Robinson demonstrated that alternative schools,
particularly those with day care, were successful in

assisting pregnant and parenting students to complete their

27

education. Taylor et al. (1983) indicated that the public
high school is an optimal location for adolescent prenatal
health services. It is in this environmental setting that
the educational, psychosocial, and medical needs of the
adolescent can be addressed. This finding is especially
important since Kelen, Hunt, Sibeko-Stones, and varga (1991)
found that adolescents seldom attend the traditional
prenatal classes. An example of a school-based program is
described by Chen, Fitzgerald, Destefano, and Chen (1991).
The program they developed focused on individual counseling
and health education for the pregnant adolescents. The
program's immediate goal was to provide prenatal care, but
the ultimate outcome was improved infant birth weights.

A comprehensive program for pregnant adolescents can
serve to aid in the resolution of serious health problems,
assist in obtaining a high school education, educate about
parenting skills, and provide problem solving skills to
assist these adolescents in handling real life situations,
i.e., financial and social. An example of a comprehensive
program is described by Hardy and Zabin (1991). Pregnant
adolescents at the Hopkins Adolescent Clinic (HAC), which
was established in 1973, experienced superior pregnancy
outcomes when compared with a group of similar adolescents
delivering in the same facility. Hardy and Zabin attributed
this outcome to both the separate and caring environment in
which the MAC adolescent mothers received their care, and to

the importance of the integration of case management,

28

intensive psychosocial support, and health education
provided in this setting. The goal is to provide
comprehensive adolescent-oriented prenatal and postpartum
care.-

Stevens-Simon and Beach (1992) identified the core
services of federally funded adolescent pregnancy programs
as pregnancy testing and options counseling; maternity
counseling and referral; primary and preventive prenatal and
postnatal care; nutritional information, counseling about
dietary intake, and the availability of supplements;
diagnosis and treatment of sexually transmitted diseases;
primary and preventive pediatric and adolescent health care;
education in sexuality and family life, including
independent living skills, decision-making skills, and child
and family development; referrals to appropriate educational
and vocational programs; counseling and referral services
for treatment of mental health problems, emergency housing,
child care, financial aid; and family planning.

Nichols (1991) described the goal of secondary
education prevention programs as either the elimination or
reduction of negative outcomes of adolescent pregnancy and
parenting. Nichols further stated that their primary focus
should be on improving obstetrical outcomes for the
adolescent and improving perinatal outcomes for the infant;
providing educational information regarding childbirth and
parenting skills; enabling options and support for the

29

pregnant adolescent; and reducing the reoccurrence of a
repeat pregnancy.

Giblin, Poland, and Sachs (1986) state that there are
few reports that describe the needs of adolescent mothers.
They examined significant variations in the health concerns
of adolescent mothers and urged the development of
information programs specific to the adolescents' identified
needs. They noted that these needs could be identified by
an assessment tool specifically designed for adolescent
mothers. Although not a current characteristic of programs
involving pregnant adolescents, they posed that such an
assessment tool could serve to provide information with
regard to each adolescent's health beliefs, as well as their
psychosocial and educational status. I

In summary, if support provided to an adolescent mother
can help to delay the occurrence of a second delivery for as
little as two years, the consequences are likely to
positively affect the adolescent's later life adjustment
(Seitz 8 Apfel, 1993). Most intervention programs for
pregnant adolescents focus on improving obstetrical and
neonatal outcomes. However, these programs alone have not
been shown to reduce early repeat pregnancies. Postnatal
services, which focus on factors that contribute to an
increased incidence of early repeat adolescent pregnancy,
appear more effective (Seitz 8 Apfel, 1993).

It is vital that the APN be able to assess risk factors

that may lead to an early repeat pregnancy with postnatal

30

adolescent mothers. If it is the adolescent's choice to
continue to build her family, then the APN being aware of
this can provide support and appropriate interventions to
promote positive outcomes. The goal is to assess and
individualize each adolescent's situation in order to
promote positive outcomes and decrease the number of
negative outcomes that occur with adolescent mothers and
their children. Smith-Battle and Leonard's (1998) research
supports the APN's role to provide positive recognition and
support which affirms the self and fosters the adolescent
mother's ability to communicate. The rapport that develops
between the APN and the adolescent mother should enhance the
adolescent's articulation of her priorities, goals,
accomplishments, and difficulties so that she can cope more
effectively with her challenges (Smith-Battle 8 Leonard,
1998).
Project Development

The goal of this project is the development of an
assessment tool, for use by the APN in the primary care
setting, which identifies adolescent females at risk for an
early repeat pregnancy. The tool developed is based on risk
factors identified in the current literature related to the
prevalence of early repeat adolescent pregnancy, and
utilizes the HFM as the conceptual framework. The tool is
referred to as The Early Repeat Adolescent Pregnancy Risk
Assessment Tool (ERAFRAT); it is composed of 32 items which

correspond to the identified risk factors. This section

31

describes the items on the ERAPRAT. The product and
guidelines for its use, are included in the Appendix.
N££d_£nr_th§_EBAEBAI

Twenty-five to fifty percent of adolescent mothers
deliver a second child within 24 months of an initial
delivery. A second child potentiates the incidence of
poverty and is strongly associated with failure to complete
high school and the inability to become economically self-
sufficient (Jones 8 Mondy, 1994). Given the issues
adolescent mothers face, there is a need to have a tool
which identifies adolescent females at risk for an early
repeat pregnancy. Currently, no tool exists for this
purpose. The ERAPRAT is an assessment tool which fulfills
this need.
EBAERAT_EQIEAL

The format of the BRAPRAT is based, in part, on review
of other assessment tools, i.e., The Burns Depression
Checklist, the Cheung-Leads Health Risk Assessment, and the
Nursing Assessment Tool: Potential for Impaired Skin
Integrity (Burns, 1990; Cheung 8 Leads, 1998; Fuller 8
Schaller-Ayers, 1990). Guidelines for assessment tool
development, described by Rankins and Stallings (1996), were
also considered. Like many of the assessment tools
reviewed, the completed ERAPRAT will serve as a source of
documentation; additional documentation will be required to
complete the nursing process, i.e., a problem list, plans

for intervention with expected outcomes, and evaluation

32

methods to be used (Murray 8 Zentner, 1997). The ERAFRAT,
along with all associated documentation should be included
in the adolescent's medical record.

The ERAFRAT begins with space provided for inclusion of
identification data; e.g., assessor's name (who is using the
ERAFRAT), date assessment is completed, adolescent's name,
adolescent's birthdate, and date of the adolescent's
delivery. Directions for use of the tool precede the items.
Risk factors incorporated into the ERAFRAT have been
organized into three categories; they are: adolescent
characteristics, family characteristics, and adolescent
perceptions.

The categories of risk factors in the ERAFRAT differs
slightly from organization of the factors in the literature
review. This is done for two reasons: a) to facilitate the
flow of the tool, and b) to provide a sensitive approach
when exploring information which may make the adolescent
uncomfortable; i.e., general information is asked first
while that which may require poignancy is asked last. Some
of the risk factors which influence the incidence of an
early repeat adolescent pregnancy are assessed in multiple
ways to better capture their multidimensional influence on
the adolescent. Other risk factors can be evaluated
succinctly and are assessed only once.

HB£_Q£_Ih£_EBAEBAI

Hhg_nill_n§g_the_ERAPBAIZ The ERAFRAT has been

designed primarily for use by the APN in the primary care

33

setting. However, other health care professionals, social
workers, and teachers could use the ERAFRAT if appropriately
educated regarding its use.

Hhat_is_ths_tarssI_nQnnlation_for_nse_sf_ths_EBAERAT2
Adolescents, who have recently delivered an infant, are the
target population for application of the ERAFRAT. They can
be identified through schools, local health departments,
social service agencies, prenatal clinics, provider offices,
and hospitals.

W The ERAFRAT is to be
used during the first two weeks postpartum of an
adolescent's delivery. However, administration of the
ERAFRAT would be beneficial at any point prior to a
subsequent pregnancy or delivery. Ideally, the APN will
have had the opportunity to develop a relationship with the
adolescent before using the ERAFRAT, however, this is not a
prerequisite for use (Rankin 8 Stallings, 1996).

W The ERAFRAT can be
utilized either in the hospital before the adolescent mother
is discharged, during home visits, during office/clinic
visits, or in the school setting. I

Hgu_u111_;hg_ERAEBAT_he_n§gdZ Guidelines for use of
the ERAFRAT should be reviewed before utilization of the
tool, and periodically as needed to ensure correct
application. The ERAFRAT may be duplicated for subsequent
use with other adolescent mothers, providing credit is given

to the authors, Mills and Ferry-Fhilo. Information for the

34

items on the ERAFRAT should be derived primarily from the
adolescent through interviews. The adolescent's family and
significant other(s) could provide additional information,
also through interviews. Chart review and communication
with other professionals, including other health care
providers, teachers, and social workers, could also supply
data.

Most items on the ERAFRAT provide numeric values (0, 1,
2) for responding; others provide a space for inclusion of
specific data which may facilitate identified interventions.
When using the ERAFRAT, the APN should circle the
appropriate numeric value or document the requested
information. The numeric values are subtotaled on the first
page of the ERAFRAT and subtotaled again on the second page
of the tool. The subtotals are added to obtain a total risk
score upon completion of the tool. The total possible score
ranges from 0 to 51. This score indicates risk for an early
repeat adolescent pregnancy; a higher score indicates
greater risk. However, use and validation of the ERAFRAT is
necessary to assign a definitive quantitative value of risk.

If the item does not apply to the adolescent, the
numeric value assigned'to that item should be “0". Those
risk factors which may influence the adolescent's return to
school have been assigned a numeric value of"2". The
current literature suggests these factors inhibit an
adolescent's return to school and thus significantly

increase the risk for an early repeat pregnancy (Jones 8

35

Mondy, 1994; Kalmuss 8 Namerow, 1994; Stevens-Simon et al.,
1996). These items are also identified by a double asterisk
(**), so that the APN can quickly identify the item as
indicating significant risk and facilitate intervention.
Other risk factors have been assigned a numeric value of
'1”. This indicates risk for an early repeat adolescent
pregnancy is present, but not to the extent as with those
risk factors assigned a “2".

Some items may require further evaluation or referrals
based on information received, as they may reveal complex
issues beyond the scope of the ERAFRAT. These issues
include lack of appropriate support systems, depression, or
substance abuse. These items are also identified by a
double asterisk (**), prompting immediate attention and
intervention by the APN.

W

The three organizational categories which divide items
on the ERAFRAT are: adolescent characteristics, family
characteristics, and adolescent perceptions. ‘Adolescent
characteristics' include 14 items which assess the risk
factors specific to the adolescent. 'There are eight items
which assess the risk factors within the context of ‘family
characteristics', and 10 items which assess the risk factors
involving the adolescent's impression of her life situation,
or ‘adolescent perceptions'. The following paragraphs
describe the items and provide support for their inclusion
in the ERAFRAT. I

36

WW. Younger age at the time of

an initial delivery is related to an increased risk of an
early repeat adolescent pregnancy. Specifically, initial
delivery by an adolescent less than 16 years of age has been
linked to an early subsequent birth and decreased
educational attainment (Stevens-Simon et al., 1996).
Therefore, assessing the risk factor ‘age at initial birth'
is important, and is included in Item #1 as: The adolescent
was <16 years of age at delivery. Numeric values included
for addressing this item are “0" and “2", with delivery
under age sixteen indicating an increased risk for an early
repeat adolescent pregnancy.

Item #2 assesses the risk factor ‘years of schooling
completed by the adolescent at the initial birth' and is
included as: The adolescent has completed < the 11th grade
at delivery. Adolescents who are at less than the expected
grade level or who have dropped out of school are less
likely to return to school following an initial delivery and
are more likely to have an early repeat pregnancy. Often
this is related to familial reproductive patterns and lack
of contraceptive use (Kalmuss 8 Namerow, 1994; Stevens-Simon
et al., 1996). As eleventh grade is the approximate
expected grade level for a 16 year old, numeric values
included for addressing this item are “0" and “2", with
delivery before eleventh grade indicating an increased risk

for an early repeat adolescent pregnancy.

37

Adolescents who are married are more likely to have an
early repeat pregnancy, i.e., spousal influence may promote
family building and decreased emphasis on education and
career attainment (Kalmuss 8 Namerow, 1994; Linares et al.,
1992). Consequently, Item #3 assesses the risk factor
‘marital status' and ‘future.aspirations' and is included
as: The adolescent was married at delivery. Numeric values
included for addressing this item are ‘0” and “2", with being
married indicating an increased risk for an early repeat
adolescent pregnancy.

Item #4 assesses the risk factors ‘social
network/habits' and ‘contraceptive behavior', and is
included as: The adolescent has a new partner post delivery.
Adolescents who report a new partner following an initial
delivery are less likely to use contraceptives consistently
and appropriately, and therefore, at risk for an early
repeat pregnancy (Stevens-Simon et al., 1996). Numeric
values included for addressing this item are “0" and “1" with
the presence-of a new partner indicating an increased risk
for an early repeat adolesCent pregnancy.

Item #5 assesses the risk factors ‘socioeconomic status
of the family of origin', ‘future aspirations', and ‘return
to school', and is included as: Employment of the adolescent
is necessary for selfésupport. 'This item assesses the need
for adolescent employment and possible financial resources
available to the adolescent. This may illuminate the

adolescent's ability to return to school, and consequently,

38

the likelihood of an early repeat pregnancy (Seitz 8 Apfel,
1993). Numeric values included for addressing this item are
‘0' and ‘2', with need for employment possibly prohibiting
return to school and, thus, indicating an increased risk for
an early repeat adolescent pregnancy.

Those adolescents planning to return to school exhibit
future orientation, generally perceive education and career
as important, and are less likely to experience an early
repeat pregnancy (Kalmuss 8 Namerow, 1994). Those that
experience barriers to returning to a traditional school
setting, and have an alternative school setting available,
are more likely to continue with their education (Seitz 8
Apfel, 1993). Therefore, Item #6 assesses the risk factors
‘return to school' and ‘future aspirations', and is included
as: The adolescent plans to discontinue education post
delivery. Numeric values included for addressing this item
are “0" and “2"; those adolescents who plan to’ discontinue
their education are at increased risk for an early repeat
adolescent pregnancy.

Item #7 assesses the risk factors ‘intentions related
to the initial pregnancy' and ‘social network/habits' and is
included as: The pregnancy was planned by the adolescent. A
planned pregnancy may be related to familial reproductive
patterns, partner and/or peer influence, or lack of
perceived benefits related to not conceiving. Those with an
initial planned pregnancy are at risk for an early repeat

pregnancy (Kalmuss 8 Namerow, 1994; Stevens-Simon et_al.,

39

1997). Numeric values included for addressing this item are
“0" and '2', with a planned pregnancy indicating an increased
risk for an early repeat adolescent pregnancy.

Adolescents who begin sexual experimentation at 16
years of age or younger are at an increased risk for
pregnancy, and at risk for an early repeat pregnancy if they
conceive and-deliver an infant.- Also, they are less likely
to use contraceptives consistently and appropriately
(Berenson 8 Wiemann, 1997; Stevens-Simon et al., 1996).
Therefore, it is important to assess age of onset regarding
sexual activity. Item #8 assesses the risk factors ‘social
network/habits' and ‘contraceptive behavior' and is included
as: The adolescent began sexual activity < 16 years of age.
Numeric values included to address this item are “0" and
'1", with sexual activity under age sixteen indicating an
increased risk for an early repeat adolescent pregnancy.

Item #9 assesses the risk factor ‘contraceptive
behavior' and is included as: The adolescent did not use
contraceptives, or did not use contraceptives appropriately
with past sexual encounters. Behavioral factors related to
contraceptive use need to be evaluated as those at risk for
an early repeat adolescent pregnancy frequently use
contraceptives inappropriately or not at all (Jones 8 Mondy,
1994). Numeric values included for addressing this item
include '0' and '1', with disuse or misuse of contraceptives
during past sexual behavior indicating an increased risk for

an early repeat adolescent pregnancy.

40

Item #10 assesses appropriate health care ‘cues to
action' since delivery, and is included as: The adolescent
did not receive follow-up health care post delivery.
Adolescent mothers who do not receive follow-up care for
promotion of optimal health following the delivery of an
infant, often ‘fall through the cracks', and therefore
receive inadequate supportive care for prevention of future
pregnancy (Stevens-Simon et al., 1996). Numeric values
included which identify previous provision of follow-up care
are “0" and “1", with no previous follow-up care indicating
an increased risk for an early repeat adolescent pregnancy.

Adolescent mothers who are discharged from the hospital
without a contraceptive, without receipt of appropriate
instructions related to the type of contraceptive selected,
or who don't use the contraceptive selected appropriately,
are at risk for an early repeat pregnancy (Stevens-Simon et
al., 1996). Hence, Items #11, #12, and #13 assess the risk
factor ‘contraceptive behavior' and are included as: The
adolescent did not receive a form of contraception before
discharge from the hospital following delivery (Item #11).
If the adolescent did receive a contraceptive before
discharge, she was not given instructions regarding its use.
Contraceptive given (Item #12). If the adolescent did
receive a contraceptive before discharge, she is not using
it appropriately (Item #13). Numeric values included for

addressing each item are “0" and “1". Space is provided to

41

document the form of contraceptive given so that educational
interventions may be facilitated if indicated.

Item #14 assesses the risk factor ‘social
network/habits' and is included as: The adolescent
uses/abuses illicit substances. Type of illicit substance
used/abused. Use and abuse of illicit substances is related
to decreased family support, depressive symptOms, and
inappropriate peer influence. Therefore, it is related to
increased risk for an early repeat adolescent pregnancy
(Stevens-Simon et al., 1996). Numeric values included for
addressing this item are “0” and “1" for substance use, with
admission of substance use/abuse indicating an increased
risk for an early repeat adolescent pregnancy. Type of
illicit substance used/abused needs to be assessed in order
to best facilitate appropriate intervention, therefore,
space is provided to document this information.

Eam11y_gharagtgriatigs. Assessing who lives with the
adolescent will illuminate who directly influences the
adolescent as well as who may be available to provide
financial and emotional support. If others living with the
adolescent are adolescents themselves with children, this
may delineate a pattern of influence and may also reveal
information regarding availability of support to facilitate
return to school (Seitz 8 Apfel, 1993). Therefore, Item #15
assesses the risk factors ‘family support received by the
adolescent during and after the initial pregnancy', ‘social

network/habits' and ‘future aspirations' and is included as:

42

Household members. Names, Relationship. Space is provided
for inclusion of data for this item.

Items #16, #17, and #18 assess the risk factors ‘family
support received by the adolescent during and after the
initial pregnancy' and ‘socioeconomic status of the family
of origin' and are included as: Father of the adolescent is
unemployed (Item #16). Mother of the adolescent is
unemployed (Item #17). significant other is unemployed
(Item #18). This information should reveal details
regarding functional ability of those involved with the
adolescent, the need for adolescent employment, as well as
financial resources available to the adolescent. This may
influence the adolescent's ability to return to school, and
consequently the likelihood of an early repeat pregnancy
(Seitz 8 Apfel, 1993). Numeric values included for
addressing each item 'are “0" and “2", with unemployment
status of those who are available for adolescent support,
indicating an increased risk for an early repeat adolescent
pregnancy.

Assessing the last grade completed by the adolescent's
parent(s) and significant other illuminates the value and
pattern of educational attainment of those most directly
influencing the adolescent. Less educational attainment by
the adolescent's parents has been associated with an
increased risk of an early repeat pregnancy. If others
closely associated with the adolescent haven't completed

high school and they are of an age when this would be

43

expected, this may be an indication the adolescent will not
value completing high school (Kalmuss 8 Namerow, 1994;
Stevens-Simon et al., 1997). Items #19, #20, and #21 assess

§

the risk factors ‘family patterns', the adolescent's
parent's level of education' and “social network/habits' and
are included as: Father of the adolescent did not complete
high school (Item #19). Mother of the adolescent did not
complete high school (Item #20). Significant other did not
complete high school (Item #21). ’Numeric values included
for each.item are “0” and “2" with incompletion of high
school by family members indicating an increased risk for an
early repeat adolescent pregnancy.

Item #22 assesses the risk factor ‘family patterns' and
is included as: The adolescent's mother was < 16 years of
age when she began childbearing. Total number of
children/age at delivery of each child. If the mother of
the adolescent began childbearing and family building during
her adolescent years, the adolescent may develop the same
reproductive pattern. This may be related to cultural and
ethnic patterns (Kalmuss 8 Namerow, 1994; Linares et al.,
1992). Therefore, early childbearing and family building by
the adolescent's mother may put the adolescent at risk for
early repeat pregnancy. Numeric values included for
addressing this item are “0" and 1'1" as childbearing by the
mother that begins before age 16 is more likely to result in

an early repeat adolescent pregnancy of the daughter and

promote increased family size (Stevens-Simon et al., 1996).

44

Space is provided to include documentation of the total
number of children and the age of the adolescent's mother at
each delivery as this might delineate a pattern prone for
repetition by the adolescent.

Adolescent_pezgeptigns.' The adolescent's perception of
others' views about the pregnancy as being acceptable or
unacceptable is important. If adolescent pregnancy is
accepted by others directly influencing the adolescent's
value system, this suggests an increased risk for an early
repeat pregnancy (Linares et al., 1992). Hence, Items #23,
#24, #25, and #26 assess the risk factors ‘family support
received by the adolescent during and after the initial
pregnancy', ‘family patterns', and ‘social network/habits',
and are included as: The adolescent perceives her father
accepts adolescent pregnancy as the norm (Item #23). The
adolescent perceives her mother accepts adolescent pregnancy
as the norm (Item #24). The adolescent perceives her
significant other accepts adolescent pregnancy as the norm
(Item #25). The adolescent perceives her peers accept
adolescent pregnancy as the norm (Item #26). Numeric values
included for addressing each item are “0" and “2", with
acceptance of adolescent pregnancy by family members and
peers indicating an increased risk for an early repeat
adolescent pregnancy.

Item #27 assesses the risk factor ‘family pattens' and
is included as: The adolescent perceives pregnancy during

adolescence as culturally acceptable. As culture and

45 °

ethnicity can affect the adolescent female's fertility
behavior and value foundation, it needs to be assessed when
evaluating acceptance of the pregnancy by others. Cultural
and ethnic background of the male involved may affect the
fertility behavior of the adolescent female, particularly if
the male and the adolescent are married (Kalmuss 8 Namerow,
1994; Linares et al., 1992).' Numeric values included for
addressing this item are ‘0' and “2", with cultural
acceptance of adolescent pregnancy being an increased risk
for an early repeat adolescent pregnancy.

The adolescent's perception of her relationship with
those closest to her greatly influences the likelihood of an
early repeat adolescent pregnancy; i.e., the lack of‘
appropriate support indicates an increased risk. Also, lack
of support for the adolescent is related to a decreased
likelihood of returning to school and arrest of continued
development thus potentiating the risk for an early repeat
adolescent pregnancy (Matsuhashi et al., 1989; Stevens-Simon
et al., 1996). Items #28, #29, and #30 assess the risk
factors ‘family support received by the adolescent during
and after the initial pregnancy' and ‘social
network/habits', and are included as: The adolescent
perceives her father as unsupportive (Item #28). The
adolescent perceives her mother as unsupportive (Item #29).
The adolescent perceives her significant other as‘
unsupportive (Item #30). Numeric values included for

addressing each item are “0" and “2", with perception of

46

decreased support indicating an increased risk for an early
repeat adolescent pregnancy.

Items #31 and #32 assess the risk factor ‘perceived
control over life events' and are included as: The
adolescent does not perceive control over life events (Item
#31). The adolescent perceives feelings of hopelessness
and/or depression (Item #32). Adolescents who perceive
little control over life events, perceive themselves as
depressed, have a poor self-concept, and/or feel powerless,
are at risk for an early repeat pregnancy. Many believe
they need to fill an emotional void by having children.
Others are apathetic regarding consequences related to
sexual behavior, thus do not use contraception appropriately
or at all (Kalmuss 8 Namerow, 1994; Linares et al., 1992).
Numeric values included for each item are “0" and “1", as an
affirmative answer for either item indicates an increased
risk for an early repeat adolescent pregnancy.

In summary, the ERAFRAT is an assessment tool designed
for use by the APN in the primary care setting. However, it
could also be used in other settings such as a hospital,
school, or in the home during a home visit. The ERAFRAT has
been designed to be used within two weeks postpartum in
order for the APN to identify risks for an early repeat
adolescent pregnancy. The information collected should
assist the APN to mutually identify with the adolescent
future goals, and to develop nursing interventions which

meet the goals specified. The APN utilizing the ERAFRAT

47

should review the guidelines provided with the tool prior to
using it with the adolescent.
Implications

There are several implications regarding the-use of the
ERAFRAT in practice, education, and research. A discussion
of these three areas follows.

We

The ERAFRAT is designed for use by the APN in the
primary care setting, but could be used in a variety of
settings, such as the home, e.g., a home health nurse visit
with an adolescent mother recently released from the
hospital following the birth of her initial child, or the
school, e.g., in a school-based nurse-managed clinic. The
tool could be used at various intervals to assess if the
adolescent's perspectives or environmental situation have
changed. The key is to consistently assess whether or not
the adolescent is at risk for an early repeat pregnancy. It
is only when the APN assesses and evaluates the risks for an
early repeat pregnancy, that the APN can intervene by
education or reiterating the at-risk areas of concern with
the adolescent mother.

The ERAFRAT is a tool that provides quick and efficient
assessment when used with the adolescent. However, there
may be obstacles encountered with its use. One obstacle
that may arise is whether or not rapport has developed to
the degree that the adolescent feels comfortable enough to

disclose the information requested. Another obstacle could

48

be the AFN's lack of awareness of her own value system, so
that she is not able to provide adequate support and
guidance to the adolescent mother.

The primary goal when using the ERAFRAT is the
identification of risk factors for an early repeat
adolescent pregnancy. Once these are identified, the APN
can assist the adolescent in developing strategies that
promote positive outcomes for her and her family through
anticipatory guidance. For example, if the adolescent
chooses to prevent a repeat pregnancy and pursue education
and career goals, she can be supported to accomplish this
goal. Conversely, if the adolescent chooses to continue
with family building, the APN would want to emphasize the
importance of consistent prenatal care, nutrition, safety
issues, parenting skills, and stages of development, to
optimize immediate as well as future outcomes.

Another area of focus should be the adolescent's
available support systems, including those available to the
father of the child. Finances and availability of
healthcare insurance should be reviewed, as this information
may indicate support available to the adolescent mother.
This information may also assist the APN in identifying
specific resources needed by the adolescent mother. Once
the ERAFRAT is used with the adolescent and the APN
identifies risk factors for an early repeat pregnancy, the
APN can begin to identify those interventions which may be

appropriate.

49

Following the assessment phase of the nursing process,
results are summarized and nursing diagnoses are formulated
(Fender, 1996). While the ERAFRAT focuses on assessment and
identification of the adolescent at risk for an early repeat
pregnancy, once she is identified as being at risk, the APN
should begin to formulate goals and strategize specific
interventions.

The goal is for the APN and the adolescent to mutually
develop strategies that promote positive outcomes for the
adolescent and her family, with the adolescent maintaining
ownership of the plan regardless of direction taken. Mutual
goal setting is an important factor in order for the
adolescent mother to succeed. The AFN must put aside her
own value system and recognize the strengths and
competencies of the adolescent and her family. Each
adolescent and her family have practices compatible with her
culture of orientation; cultural practices should be
integrated into the health plan so that cultural and or
ethnic pride is maintained. The role of the APN is to
teach, guide, and support, as these existing competencies
are maintained and new ones are developed (Fender, 1996).
Goals include those formulated by the adolescent with the
assistance of the AFN.’ After identification, goals should
be prioritized. Clear identification of expected outcomes,
which are time specified and measurable, should then be
developed in order to guide the adolescent and the APN in
strategizing and achieving desired health behaviors. The

50

adolescent must be aware of and desire the benefits of the
health promotive change, i.e., behaviors integrated on an
ongoing basis into the individual's lifestyle such as
appropriate use of birth control methods, return to school,
activities which promote self-esteem, and development and
maintenance of social support systems (Murray 8 Zentner,
1997; Fender, 1996; Stevens-Simon et al., 1996). The goals,
interventions, and expected outcomes should be included as a
summary statement of findings, and documented in an
alternative format for the health record. This information
should remain separate from the ERAFRAT, but is placed in
the client's record along with the assessment data. Goals
and interventions may include those developed as a result
the ERAFRAT, as well as other assessments.

While the ERAFRAT assists the APN in the identification
of risk factors for an early repeat pregnancy in
adolescence, it is the relationship between the APN and the
adolescent which can result in a plan to decrease the
likelihood of an early repeat pregnancy. Smith-Battle and
Leonard (1998) discuss the importance of promoting a sense
of future for these adolescent mothers. After building
rapport and showing belief in the adolescent, interventions
and goals promoted by the APN will hold increased merit
(Murray 8 Zentner, 1997).

APNs are in an invaluable position to provide prenatal
and postnatal care for the adolescent female. Auterman

(1991) discussed several nursing practice implications in a

51

community-based secondary prevention program with pregnant
adolescents. The APN could: a) promote special heath,
educational, developmental, and social service needs of the
adolescent in order to effectively achieve more positive
outcomes, b) provide affordable, accessible heath services
to the adolescent, c) design clinic settings specifically
for the adolescent, d) create appropriate literature and
implement educational approaches for secondary prevention of
adolescent pregnancy, and e) motivate and create public
policy changes to improve the negative outcomes for
adolescent mothers and their children. For example, items
a)-d) could be addressed by setting up a specific group for
these adolescents that meets on a specific day and time.

The designated place should be accessible to the adolescent,
possibly in the school setting. Information and appropriate
educational materials could be presented to these young
mothers about parenting skills, contraception, and health
promotion for themselves and their children. If childcare
was an issue, the APN could look into requesting assistance
from a local Girl Scout Troop that may be willing to donate
their time to care for the children as part of their‘
community service commitment. If the adolescents were not
attending school, the APN could look into having them meet
in sn available room after-hours at a healthcare clinic, or
in a church meeting room. As for item e), public policy
changes, the APN could discuss issues with the public school

or alternative school administration, regarding provision of

52

childcare for these adolescents, in order to facilitate an
easier transition for their to return to school. A part of
the adolescent's educational curriculum could include work
programs so they could identify what career they may be
interested in pursuing, or skills they may desire to attain.

Thus, the APN could participate in a variety of roles
in the practice setting when providing services to the at-
risk adolescent. Although the primary role for the APN when
using the ERAFRAT is that of assessor, additional roles
could include case manager, counselor/advocate, educator,
and clinician/practitioner.

As an assessor, the APN collects subjective and
objective data, formulates a clinical impression, forms
diagnoses, and then develops interventions with the client
that should promote positive outcomes (Murray 8 Zentner,
1997). For instance, when reviewing the items on the
ERAFRAT with an adolescent mother, specific areas should be
identified by the APN as potential problems, and support
should be provided to facilitate optimal outcomes.

As a case manager, the APN identifies specific areas of
health needs and implements a plan ensuring continuity for
the adolescent. Community resources are utilized as needed.
The AFN plans, coordinates, monitors, and evaluates outcomes
of the services utilized by each adolescent, facilitating
revision of resource utilization as needed.

As a counselor/advocate, the APN provides support to

the adolescent and her family to facilitate coping

53

behaviors. The AFN collects information by listening and
observing during the interaction process, while using the
ERAFRAT. The APN conveys and validates her observation with
the adolescent, as well as provides support to her as she
may struggle with decision-making for herself and her child.
The APN advocates for specific services or resources needed
by the adolescent, assists the adolescent in exploring
options and resources available, and provides referrals on
an ongoing basis. These actions should improve the
adolescent's self-care abilities and support informed
decision-making. Various circumstances may require
assistance from the APN; these include finding childcare,
making plans for returning to school, obtaining information,
and/or completing forms for specialized support services.
As an advocate, the APN may get involved with the school
system in helping ease the transition for the adolescent's
return to school.

As an educator, the APN could provide information
regarding healthy lifestyle habits, health care and
pregnancy, along with specific information and skills
related to childbirth and parenting. The APN could also
educate the adolescent mother regarding the birth control
method of her choice. Education should be individualized
and dependent upon how each adolescent responds to the
ERAFRAT (Auterman, 1991; Rankin 8 Stallings, 1996).

As a clinician/practitioner, the APN conducts health

assessments and provides direct physical health care to the

54

adolescent and her child. The APN formulates diagnoses and
provides direct primary care which is based on sound theory
and advanced clinical judgment. The goal is to promote
self-care abilities, maintain health, prevent complications,
and promote coping skills to deal with problems that arise.
Interventions would be based on responses obtained when
using the ERAFRAT (Snyder 8 Mirr, 1995).
We

There are numerous educational implications specific to
the APN with regard to the ERAFRAT. An APN, who is
proficient in the use of the ERAFRAT, could present it,
discuss guidelines for its use, emphasize the risk factors
that may result in an early repeat adolescent pregnancy, and
relate these risk factors to possible outcomes for
adolescent mothers and their children. The ERAFRAT could be
presented to APNs at conferences, seminars, or special
inservice meetings. This could occur at national, state, or
local nurses' association meetings. Another option would be
to promote the ERAFRAT through the School Nurses'
Association. Presentations at various colleges of nursing
is another avenue to promote use of the ERAFRAT. Another
way of promoting use of the ERAFRAT would be to discuss the
long-term cost benefits that may be realized by utilizing
such a tool in practice. An article outlining the
development and significance of the ERAFRAT could be
submitted for publication to a professional nursing journal,

thus educating and informing other APNs of its availability

55

and the need for future evaluation of its merits. By using
the ERAFRAT and providing evidence of better outcomes with
adolescents, the APN could become a role model and advocate
for its use.

Education regarding appropriate practice areas for use
of the ERAFRAT would include pediatric and family practice
clinics, public health departments, and managed care
settings. If the adolescents at risk for an early repeat
pregnancy and their children are identified early, the cost
savings to managed care organizations, governmental
agencies, and private insurance companies could prove to be
significant. The important factor to consider when
presenting the ERAFRAT is to stress that the assessment of
each adolescent be done as early as possible to optimize
outcomes.

W

The ERAFRAT is an untested tool; due to the lack of
validity and reliability testing, items indicated as
significant are subject to reevaluation and modification
pending evaluation. An initial approach for testing would
be to have an expert panel of researchers possessing
experience regarding adolescent pregnancy review the tool;
areas to assess include: a) the accuracy and clarity of the
items, b) ease of use in the primary care setting, and, c)
the tool's overall layout and appearance. Subsequent
studies employing the ERAFRAT could evaluate the ERAFRAT's

reliability and validity as an instrument. For example, the

56

ERAFRAT could be used in a pilot study in several different
practice settings with a diverse group of adolescent mothers
from various cultural and socioeconomic backgrounds. One
research question, which addresses the issue of reliability
is, “Does the ERAFRAT predict adolescents at risk for an
early repeat pregnancy?” In addition to research value
issuesw tDoes the ERAFRAT validate the risk factors for an
early repeat pregnancy that have been identified in the
literature?" IResearch using the ERAFRAT could be
accomplished through collaboration of several researchers
and APNs as they assess and compare the information gathered
in a variety of practice settings. The data collected could
assess the relationship of the adolescents' educational
plans and how they impacted an early repeat pregnancy.

The APN as a researcher could analyze and calculate the
various responses possible on the ERAFRAT, and formulate a
variety of research questions.' These questions could
further expand the ERAFRAT and its use by developing
specific areas of intervention and guidelines for the APN.
Questions could be developed which assess factors and
interventions that are most effective in assisting the
adolescent mother's return to school and pregnancy
prevention. Examples of these questions are: fiAfter mutual
goal setting by the APN and the adolescent mother, were the
goals attained and was an early repeat pregnancy avoided?”,
“If the adolescent mother chose to have an early repeat

pregnancy and continued with family building, what positive

57

outcomes resulted for the adolescent and her family?", and
‘Are all adolescent mothers at risk for an early repeat
pregnancy because of their stage of development?”
Conclusion

The AFN can play a key role in assessing and
identifying adolescent mothers at risk for an early repeat
pregnancy. The factors, identified in the current
literature which place an adolescent female at risk for an
early repeat pregnancy are: a) being 16 or younger at the
time of first delivery, b) completing less than the expected
years of schooling at first birth, c) being married or
having a new partner, d) lack of desire or plans to return
to school, e) a planned initial pregnancy, f) discharged
from the hospital without a contraceptive, or not using, or
inappropriately using contraceptives, g) lack of follow-up
health care post delivery, h) adolescent family building
patterns, habitual school drop-out, and habitual substance
abuse by social network, 1) lower socioeconomic status of
family, j) lower educational attainment of family members,
k) familial pattern of family building in adolescence, 1)
lack of financial and emotional support by family, m)
perception of little control over life events, and n) lack
of future aspirations; lack of future hope (Berenson 8
Wiemann, 1997; Jones 8 Mondy, 1994; Kalmuss 8 Namerow, 1994;
Linares et al., 1992; Matsuhashi et al., 1989; Seitz 8
Apfel, 1993; Stevens-Simon et al., 1996). The ERAFRAT

incorporates these risk factors in order to identify

58

adolescent mothers at risk for an early repeat pregnancy; it
also provides an opportunity to identify goals and
interventions which promote positive outcomes for the
adolescent mother and her family. The AFN is a primary care
provider with a holistic focus and is in an excellent
position to efficiently and effectively facilitate services
for these young mothers so that optimal health is attained.

59

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63

APPENDICES

Appendix A

Guidelines for use of the ERAPRAT

Early repeat adolescent pregnancy is strongly associated with
noncompletion of high school and the inability to become economically
self-sufficient (Seitz 8 Apfel, 1993). Following identification of a
female adolescent's risk for an early repeat pregnancy, interventions
can be facilitated for an adolescent mother and her child which
facilitate optimal long-term outcomes (Kalmuss 8 Namerow, 1994).

Items which assess risk factors identified in the current
literature which influence the likelihood of an early repeat adolescent
pregnancy are included in the Early Repeat Adolescent Pregnancy Risk
Assessment Tool (ERAPRAT). Items on the ERAPRAT, as well as the risk
factors identified, are divided into three categories: adolescent
characteristics, family characteristics, and adolescent perceptions.
This is done to facilitate the flow of the tool and to promote comfort
the adolescent during the assessment process.

The ERAPRAT is a form of documentation: it may be duplicated for
subsequent use with other adolescents providing acknowledgment is given
to the authors, Mills and Perry-Philo. Numeric values (0, 1, 2)are
provided for items on the ERAPRAT, or a space is provided for brief
documentation which may facilitate interventions. When using the
ERAPRAT, the APN should circle the appropriate numeric value, or provide
the required information. As‘O' should be assigned if the item does not
apply to the adolescent. The numeric value “1" or “2" should be
assigned if the.item does apply to the adolescent. Numbers are
subtotaled on the first page, subtotaled again on the second page, and
both subtotals are added to obtain a total risk score. The possible
score range is 0 to 51. A higher score indicates increased risk for an
early repeat adolescent pregnancy, however, degree of risk will be
determined pending use and validation of the tool.

Items which may affect the adolescent's return to school have been
identified in the current literature as indicating a significant
increased risk for an early repeat adolescent pregnancy. These items
are given a numeric value of'12', and are identified with an double
asterisk (**) to prompt attention of the APN when using the ERAPRAT.
All other items are given a numeric value of “l", which indicates a
lower risk.

Other items may require assessment in addition to that which is
provided when using the ERAPRAT. These items are also identified with a
double asterisk (**). Additional assessments may be required due to
complex issues which are beyond the scope of the ERAPRAT. These issues
include lack of support systems, depression, and substance abuse.

All items identified by a double asterisk (**) are considered
priorities for intervention. A problem list, goals for intervention
with expected outcomes, and plans for evaluation should be included on a
separate form and attached to the ERAPRAT. The ERAPRAT, and other
documentation relating to its use, should be included in the
adolescent's health record.

64

Risk Factors for an Early Repeat Adolescent Pregnancy

ADOLESCENT CHARACTERISTICS
Being age 16 or younger at time of first delivery (Stevens-Simon, Kelly, & Singer, 1996).
0 Completinglessthanexpectedyearsofschoolingatfirstbirth (Stevens-Simon, etal.,
1996).
Being married or having a new partner (Berenson & Wiemann, 1997).
Lack of desire or plans to return to school (Kalmuss & Namerow, 1994).
A planned initial pregnancy (Kalmuss & Namerow, 1994).
Discharge from the hospital without contraceptives; not using or inappropriately using
contraceptives (Jones & Mandy, 1994).
Lack of follow-up health care post delivery (Stevens-Simon, et al., 1996).
0 Adolescent family building patterns, habitual school drop-out, and habitual substance
abuse by social network (Linares, Leadbeater, Jafi‘e, Date & Dias, 1992).

FAMILY CHARACTERISTICS
0 Lower socioeconomic status of family (Kalmuss & Namerow, 1994).
0 Lower educational attainment of family members (Stevens-Simon, et al., 1996).
- Familial pattern of family building in adolescence (Linares, et al., 1992).

ADOLESCENT PERCEPTIONS
0 Lack of financial and emotional support by family (Matsuhashi, Felice, Shragg,&
Hollingsworth, 1989).
o Perception of little control over life events (Berenson & Wiemann, 1997).
0 Lack of fixture aspirations; lack of future hope (Seitz & Apfel, 1993).

Berenson, A. & Wiemann, C. (1997). Contraceptive use among adolescent mothers at 6 months
Postpartum WW6). 999-1005

Jones, M. & Mendy, L. (1994). Lessons for prevention and intervention in adolescent
pregnancy: A five-year comparison of outcomes of two programs for school-aged pregnant
adolescents. MW, July-August, 152-159.

Kalmuss, D. & Namerow, P. (1994). Subsequent childbearing among teenage mothers: The
determinants of a closely spaced second birth. MW 26(4), 149-153,159.

Linares, L., Leadbeater, B. ”Jafl‘e L. Dato, P & Diaz, A. (1992). Predictors of repeat
pregnancy outcome among Black and Puerto Rican adolescent mothers. 1911M MW
WC). 89-94

Matsuhashi, Y., Felice, M., Shragg, P. & Hollingsworth, D. (1989). Is repeat pregnancy in
adolescents a “plannod” afl’air? WW5). 409-412

Seitz, V. & Apfel,N “(1993) Adolescent mothers and repeat childbearing: Bfl‘ects of a school-
basod intervention program WWW“) 572-581

Stevens-Simon, C. ,Kelly, L. & Singer, D. (1996). Absence of negative attitudes toward
childbearing among pregnant teenagers. A risk factor for a rapid repeat pregnancy? W
W10). 1037-1043

65

Appendix B
The Early Repeat Adolescent Pregnancy Risk Assessment Tool (ERAPRAT)

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l. Theadoleacentwas <l6yearsofageatdelivery.

2.1'headoleacent hascompleted<thc ll‘gradeatdelivery.

3. The adolescent was marriedatdelivery.

4.1‘headoleecer1thasanchartncrpostdelivery.

5. Employment of the adolescentisnecessm'yfor self-support.

6. The adolescent plansto discontimre education postdelivery.

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8.1'headolescentbcgansexua1activity<l6yearsofage.

9. Thcadoleecent didnotusecontraceptives,ordidnotusecontraceptives
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16. Father of the adolescent is unemployed

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18. Significant «he is \mernployed

19. Father ofthe sdolescentdidnotcornplete high school.

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23.1headolescentpaeeivesha'fmhawceptsadolescentpregnmcyasthenmm 0 2
24.1headolescentpaceiveshmmothaaccep8adolescentpregnmwyuthenam0 2
25. 'I'headolesccntperceiveshersignificant accepts adolescentpregnancyasthe

norm 0 2
26. Theadolescmtpaeeivesherpea'sacceptsdolescmitpregnancyasthenorm 0

27. The adolescent perceivespregnancy during adolescence as cultuully

acceptable.
28. The adolescent perceives her father as unsupportive.

29. The adolescent perceives her mother as unsupportive.

30. The adolescent perceives her significant other as unsupportive.

31. The adolescentdoesnotperceive control over life events.

32. The adolescent perceives feelings of hopeles-ess and/or depression.

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SUBTOTAL
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East Lansing. MI. April, 1999.

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