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ABSTRACT

/THE DEVELOPMENT OF AN INSTRUMENT

TO IDENTIFY SOCIAL SUPPORT FACTORS LIKELY
TO INFLUENCE THE ATTENDANCE OF UNWED, PREGNANT
ADOLESCENTS AT PRENATAL CLAsses/
by

Valerie A. Shedd

The development of an instrument to assess social
support factors likely to influence attendance of unwed
pregnant adolescents at prenatal classes was the focus of
this scholarly project. The factors assessed include
sociodemographic factors, sources cflf support, satisfaction
with support, timing of support and two types of support,
emotional and/or tangible support.

Discriminant analysis was suggested as a means of
analyzing the data. A profile of unwed pregnant adolescents
"at risk“ for non or poor attendance at prenatal classes
could. then. be identified. The nursing intervention was

based on self-care concepts as described by Orem.

ACKNOWLEDGMENTS

The completion of this scholarly project could not have
occurred without the support and encouragement of many
peOple.

A special thanks to Barbara Given, Ph.D., Chairperson
of my committee. I will always remember her tireless
support and belief in my ability. I am also grateful to
Jacqueline Wright, M.S.N., whose encouragement sustained me
through my literature review and to Patricia Peek, M.S., for
helping me keep a healthy perspective on the entire project.
I also wish. to thank Bryan. Coyle for his. patience and
explanation of statistics.

To my parents Gertrude and Peter Vermiere who provided
me with an undergraduate education and the desire to build
on that base.

To my husband Bob, who allowed me the room to grow and
whose love and encouragement were always present, thank you.

To my two children, Aaron and Ryan who helped me keep

my life in perspective.

ii

THE DEVELOPMENT OF AN INSTRUMENT
TO IDENTIFY SOCIAL SUPPORT FACTORS LIKELY
TO INFLUENCE ATTENDANCE OF UNWED, PREGNANT
ADOLESCENTS AT PRENATAL CLASSES

by
Valerie A. Shedd

A Project

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

MASTER OF SCIENCE IN NURSING
College of Nursing

1985

LIST OF FIGURES O O O O O O O O O O O O O 0

CHAPTER

I.

II.

III.

IV.

TABLE OF CONTENTS

THE PROBLEM . . . . .
Introduction . . . . . . . .
Goal . . . . . .
Purpose . . . . . . . . . . .
Relevance to Practice . . . . . .
Conceptual Definition of Concepts
Limitations of this Project . . .
Assumptions . . . . . . . . . . . .
Overview of Remainder of Project.

CONCEPTUAL FRAMEWORK . .
Introduction . . . . . .
The Adolescent. . . . .
The Pregnant Adolescent . .
Unwed Pregnant Adolescent .
Prenatal Learning Situation .
Social Support . . . . . . .
Conceptual Framework . . . .
Orem's Nursing Theory of Self
Summary . . . . . . . . . .

r

'36

0000000000

LITERATURE REVIEW . . . . . . . . .
Introduction . . . . . . . . .
Prevalence of Adolescent Pregnancy
The Pregnant Adolescent . . . . .
Prenatal Classes . . . . . . . .
Social Support . . . . . . . .
Social Support and the Adolescent
Social Support and Self— -Care . .
Conclusion . . . . . . . . . . .

METHODOLOGY . . . .
Overview . . . . .
Sample . . . . . .
Study Site . . . . .
Operational Definitions
Instrument Development

iii

Page

\DmmGUIUIIbl-‘H

Page

Instrument . . . . . . . . . . . . . . . 83
Proposed Methodology . . . . . . . . . . . . 84
Data Collection Procedure . . . . . . . . . . 86
Human Subject's Protection . . . . . . . . . 86
Scoring . . . . . . . . . . . . . . . . . . . 87
Data Anlysis . . . . . . . . . . . . . . . . 88

V. SUMMARY AND CONCLUSIONS . . . . . . . . . . . 91
Introduction . . . . . . . . . . . . . . . 91
Summary . . . . . . . . . . . . . . . 91
Limitations of the Study . . . . . . . . . 94
Implications for Nursing Practice . . . 95

Implications for Nursing Education . . . 104
Implications for Future Nursing Research . 109
smary O O O O O O O O O O O O O O O O O O 114

APPENDICIES O O O O O C O O O O O O O O O O O O O O O O 115

APPENDIX . . . . . . . . . . . . . . . . . . . . . . . 115
QUESTIONNAIRE . . . . . . . . . . . . . . . . 115

PART A - BACKGROUND INFORMATION . . . . . . . . . 115

PART B - SOURCE AND SATISFACTION . . . . . . . . 119

PART C - TYPES OF SUPPORT . . . . . . . . . . . . 128

LIST OF REFERENCES 0 O O O C O O O O O O O O O O O O O 130

iv

LIST OF FIGURES
FIGURE

1. Social Support Model

2. Supportive-Educative System Model

3. Integration of Social Support
Model and Supportive-Educative
Nursing System Model

Page

29
33

35

CHAPTER I

Introduction

 

Adolescent pregnancy is an increasingly serious health
and sociological problem in the United States today. One in
five births in the United States is to a teenager (Mercer,
1979). The birth rate is declining in all other age groups
but in 1977 an alarming 570,000 unwed teenagers gave birth.
The teenage birth rate increased in 1977 for the first time
in seven years despite the increasing availability and use
of contraceptives by teenagers, increases in federal
expenditures for family planning services and an increase in
the abortion rate (Guttmacher, 1981). The illegitimacy
rate, however, is more reflective of current ‘trends in
adolescent childbearing than the birth rates. The
illegitimacy rate for females 15-19 years of age rose from
12.6% in 1950 to 22.4% in 1970 (McAnarney, 1978). Recent
data from the National Center for Health Statistics shows
that the illegitimacy‘ rate for females 15-17 years old
increased from 13.1% in 1966 to 19.5% in 1975. While the
total number of births has dropped since 1975 the most
recent figures from the National Center for Health
Statistics are still striking. In 1981 and 1982
respectively there were 548,703 births and 523,531 births to

women under age 20. Of these births 49% in 1981 and 51% in

1982 were illegitimate births. The fertility rate decreased
less among teenagers than among older women, so that the
percentage of births to teenagers as compared with total
births increased (Mercer, 1979).

The magnitude of the problem, however, is greater than
these numbers suggest. That pregnant teenagers are a high
risk has been known for some time. Many pregnant
adolescents experience complications during their
pregnancies. The complications of pregnancy most frequently
reported for young mothers are toxemia, prolonged labor and
iron deficiency anemia. Poor diets, late or inadequate
prenatal care, and emotional and physical immaturity may
well be contributing factors. Biological immaturity of the
adolescent mother appears to be a problem for some while the
teenager is still growing (Chilman, 1980). Infants born to
teenage mothers show a higher incidence of low birth weight,
neonatal. mortality, infant. malnutrition. and. other' health
problems (Levenson, 1979).

Adolescent pregnancy also carries with it a number of
sociological risks. The pregnant adolescent is more likely
to have additional children during adolescence. Difficulty
in pursuing education is also a risk leading to potential
delay or termination of education putting them at a later
economic disadvantage. If the pregnant adolescent marries,
an increased risk for divorce exists potentiating an

unstable family situation (Mercer, 1979).

Teenage pregnancy also carries psychological risks. In
addition to the pregnancy, the pregnant adolescent must deal
with the developmental task of adolescence. Pregnancy may
result in conflict with other goals of adolescence. These
goals may be excelling in school, achieving honors in
sports, pursuing independence, or testing oneself in a
particular role. Pregnancy' may' also interfere ‘with. the
development of body image. The accomplishment of the tasks
of adolescence may be delayed due to the increased physical
and. emotional. energy' needed to deal with the pregnancy
(Johnson, 1979).

Multiple physiological, social and psychological risks
exist, then, for the pregnant adolescent. In order to help
meet the needs of these pregnant adolescents, many larger
communities have set up prenatal classes. These classes are
most often associated with existing health facilities such
as public health departments, prenatal clinics, and visiting
nurses associations. Others are associated with the
educational system by means of alternative education for
pregnant high school students. It would appear then, that
attendance at these classes would benefit the pregnant
adolescent by helping to reduce the physiological, social
and psychological risks previously discussed. However,
there is a paucity'of literature that cites statistics
regarding attendance rates or the effects of attendance at
prenatal classes. From experience, this investigator notes

that these classes are poorly or erratically attended by the

unwed, pregnant adolescent. It follows then, that a large
segment of the pregnant adolescent population has multiple
unmet needs. A service that has the potential to meet these
needs is available, but this service is not fully utilized.

In this study the author intends to develop an
assessment ‘tool that. could. be used to identify factors
likely to influence attendance at a prenatal learning
situation for unwed pregnant adolescents. This tool will
enable the Family Clinical Nurse Specialist to provide this
unique population group with improved quality of care.
Recommendations for further study in this area can also be
made.

A study done by Nancy Nuismer (1982), examined the
characteristics of unwed pregnant adolescents who attended a
prenatal class and compared the results with the
characteristics of unwed pregnant adolescents who did not
attend classes. It is the intent of this study to describe
factors from this previous work and the literature that
contribute to attendance at prenatal class. Since Nuismer
(1982) identified supportive factors as very influential in
class attendance, this study will have a heavy emphasis on

the development of an instrument to assess social support.

Goal Statement
To develop an assessment tool to determine the
influence of social support on attendance of unwed pregnant

adolescents at a prenatal learning situation.

Purpose

The purpose of this study is to build on previous work
through review of previous literature to determine the
influence of social support factors on the attendance of

unwed pregnant adolescents at a prenatal learning situation.

Relevance to Practice

Several factors can be cited that substantiate the need
for a relevance of this research topic to nursing practice.
As health professionals, nurses have access to this client
group, since most prenatal classes are taught by nurses.
Therefore, it is important to understand factors influencing
class attendance for this client population.

Since Nuismer has indicated support to be an important
factor in class attendance, this precipitates a need to
develop a. tool to adequately assess the influence of this
support (Nuismer, 1982). Further study' of this concept
would contribute to a better understanding of the effects of
social support and identify' components that. impact
significantly on social behavior of pregnant adolescents, as
it correlates ‘with.;prenata1 class attendance. There is
little in the literature that discusses social support in
relation to prenatal class attendance. Therefore, results
from this study would add' to the knowledge base for
professional nursing and provide an avenue whereby future
research could be accomplished.

The results of this study could provide information

that would enable the Family Clinical Nurse Specialist to

change imploding forces on health care delivery to the unwed
pregnant adolescent. Recommendations for improved quality
of care to this client population can then be formulated
from the data collected from the tool to be developed as the

goal of this project.

Conceptual Definitions of Concepts

Many definitions of adolescence exist in the literature
each focusing on a different aspect of this period. For the
purpose of this study, adolescence will be defined according
to Rogers (1977) as "a process rather than a period, a
process of achieving the attitudes and beliefs needed for
effective participation in adult society" (p. 3). Process
is a more global term. Adolescence, viewed as a process,
infers a form of interaction, a constant adjustment and
reevaluation as the adolescent progresses to adulthood.

Pregnancy for the adolescent is an additional stress
and may interfere with the "normal" developmental processes.
Some authors divide adolescence into two periods, early and
late adolescence, and define tasks that must be accomplished
in each stage. Early adolescence begins with the onset of
puberty and lasts until age 15 or 16. Late adolescence
begins at age 15 or 16 and lasts until age 18 or 19.
Because of this differentiation between early and late
adolescence only one period is included in this project.
For the purpose of this project "pregnant adolescent" will

be defined as first-time pregnant 15-19 year olds who have

had the pregnancy confirmed. Further discussion of these
dimensions of adolescence follows in Chapter II.

Marital status of the adolescent imposes additional
problems during this developmental stage. The unmarried
adolescent faces different problems and decisions than the
married adolescent. For the purpose of this project then,
only the unwed, pregnant adolescent will be used.

For the purpose of this study, a prenatal learning
situation will be a group experience. This prenatal
learning situation will occur over an extended period of
weeks or months. The content of the prenatal learning
situation will include anatomy and physiology of pregnancy,
such as expected bodily changes and development of the
fetus, nutrition, exercises, and hygiene during pregnancy,
labor and delivery, what to expect postpartum, baby care,
and family planning information. This information will be
presented by formal lecture, informal discussion, pamphlets,
books or other written or audio-visual material.

Social support is a broad and familiar concept and has
received considerable attention in the social and behavioral
sciences. "Although there are areas of agreement regarding
definitional asPects of social support, no single definition
is completely agreed upon by writers in this field" (Dimond
& Jones, 1983, p. 235). For the purpose of this project an
eclectic definition of social support will be used. Social
support will be defined as the degree to which a person's

basic social needs are gratified through interaction with

8

others. Basic social needs include affection, esteem or.
approval, belonging, identity and security (Thoits, 1982).
Using this definition, the following specific dimensions of
social support can be identified:

1. These needs may be met by a variety of persons or
groups of persons such as mother, father, priest,
peer groups or work groups.

2. These needs may be met through the provision of two
basic types of support, emotional support or the
communication of concern, warmth, respect and
self-esteem, or tangible support which refers to
the provision of material aid and information.

Further discussion and expansion of these dimensions of

social support follows in Chapter II.

Limitatations of this Project

1. This study will examine only 15 to 19 year old, unwed
adolescents experiencing a first pregnancy and is
therefore not representative of all pregnant
adolescents.

2. The specific dimension of social support as it relates
to prenatal class attendance will be the focus of this
project. This dimension is not all inclusive. There
may be other factors affecting the adolescent's
pregnancy and class attendance that are not examined.

3. This study will examine and use data from a previous
work. There may be differences in the factors from the

previous study and this study.

Assumptions

 

1. It is assumed that adolescents going through this stage
of development with the additional burden of pmegnancy
would be able to identify accurately what factors
interfere with prenatal class attendance.

2. It is assumed that factors likely to influence prenatal
class attendance can be labeled and elicited by a
questionnaire.

3. A basic assumption of this project is that attendance at
prenatal learning situations do make a difference in the
outcome of the unwed adolescent's pregnancy.

4. Pregnancy, for the adolescent, is an additional stress

and may interfere with the normal developmental process.

Overview of Remainder of Project

In Chapter II a conceptual framework for this project
is presented and supported by a review of pertinent
literature. Chapter III contains a review and critque of
research literature pertinent to this study. A proposed
methodology for implementation of this project, operational
definitions and instrument development are provided in
Chapter IV. In Chapter V a summary is presented and
implications for nursing practice, nursing education and

nursing research are discussed.

CHAPTER II

CONCEPTUAL FRAMEWORK

Introduction
In this chapter the conceptual framework for this
project is presented. The main concepts pertinent to this
study include: "adolescent", "pregnant adolescent", ”unwed
pregnant adolescent", "prenatal learning situation", and

"social support".

The Adolescent

 

Adolescence is the developmental stage which culminates
the child becoming an adult. During this period, the
individual experiences many changes :hi physical,
psychological and social growth and masters a series of
developmental tasks necessary to function as an adult.

Physiological development during adolescence begins
with an increase in the individual's growth and development
of secondary sexual characteristics. These growth changes
during adolescence occur in the same sequence but the time
of onset, the rate, and the quantity of these changes varies
from individual to individual. There are many factors that
affect growth. Some of these include genetic inheritence,

sex, race, nutrition, environment and previous illness.

10

11

The growth spurt in most girls begins at about age 12
and is almost over by age 13 1/2. These rapid skeletal
changes lead to an obvious increase in height due to
lengthening of the legs and trunk. Shoulder breadth also
increases. In addition, muscle strength and size also
increases. The time of menarche indicates the end of
increasing muscle strength for girls. Other, tissues and
organs, including the heart, liver, spleen, kidneys, and
digestive tract also change during this time, as well as fat
accumulation and rearrangement. At the end of the
adolescent growth spurt, girls have proportionately more fat
than boys.

Other obvious physical changes occurring' during this
period include the rapid development of the reproductive
organs. Historically, in girls, the onset of menarche has
been the criteria used to establish the beginning of
puberty. With the start of menarche, development of other
secondary sex characteristics appear. These include pubic
and auxilary hair growth and breast changes. The end of the
growth spurt and the completion of sexual maturation
establishes the last period of rapid physical change.
However, this period is also associated with psychological
and sociological development.

During psychological development, a new cognitive style
evolves. According to Mercer (1979), "the adolescent
progresses from the egocentric thinking of childhood to

abstract conceptualization and the development of an ability

12

to view the world from another person's perspective" (p. 7).
Developing a sense of identity and dealing with feelings,
attitudes and values are important to the adolescent as she
attempts to discover her goals in life.

Socially, the adolescent. must break away from
dependence on her parents and assume more
self-responsibility. Emancipation from parents is a major
problem of these adolescent years from two standpoints. The
parents may not be ready for their child to be totally
independent, and the child is not sure she wants to be
independent. Many battles over control of the adolescent's
life will ensue. These battles are important in the sense
that when the adolescent wins she is allowed a measure of
independence in which to test her impending adulthood.
However, the existence of reasonable rules maintained by
parents help the adolescent to accept responsibility that
must come with independence. Achievement of emancipation by
the adolescent should be a gradual process. In making this
transition from childhood to adulthood old ideas and
practices are called into question. These old ways and
ideas have been largely acquired from parents and other
influential adults. It is not surprising then that
adolescents exhibit a certain amount of resistance to
parents and most often other adults as well as to old ways
of thinking and behaving. Adolescents, however, do not go
into isolation but instead turn to another group as the

source and evaluation of ideas, values, attitudes and

13

behaviors. The peer group thus serves the function of
helping the adolescent lessen their reliance on parents for
guidance and approval by providing a kind of social
laboratory in which experimentation and new learning can
take place (Howe, 1980). I

Adolescents show great fervor in their need to be with
friends. When they are not together physically, close
contact is maintained via the telephone or written
communication. This constant contact is important in order
to share what is going on, to see how everybody feels about
it and to find out how the adolescents themselves fit in.
Loyalty and conformity to the group is strong. "Peers are
major sources of feedback regarding normality, emotional
support in the struggle for independence, companionship for
shared activities, and models of age-appropriate behavior."
(Howe, 1980, p. 13).

Membership in the peer group structure has great
importance on self-concept. Being different is not
generally valued by adolescents. It is very important to
wear the popular style of clothing, frequent the current
hangout and use the current vocabulary. The peer group
often defines appropriate behavior quite differently than
adults do. Doing what everyone else does within the peer
group structure is very important. As the adolescent
progresses through this stage, self-identity becomes more

established, the need for the peer group lessens and more

11+

adult-like self-reliance and interdependence with one person
or a small number of others develops.

Many definitions of adolescence can be cited in the
literature. Some authors identify adolescence as an age
group beginning with the onset of puberty (Danial, 1977).
Others discuss adolescence as a process evolving into,
adulthood (Howe, 1980). Still others identify adolescence
as a rather new phenomena of industrialized, developed
societies (Mercer, 1979). To others, adolescence is a "rite
of passage" into adulthood. Roger's definition. of
adolescense as "a process rather than a period, a process of
achieving the attitudes and beliefs needed for effective
participation in adult society" (Howe, 1980) is more global
than some of these definitions. Adolescence, viewed as a
process infers a form of interaction, a constant adjustment
and reevaluation as the adolescent progresses to adulthood.

This psychosocial development of adolescence is
accomplished through a series of tasks. Mercer (1979)
identifies six tasks which include.

A l. acceptance and achievement of comfort with body
image

2. determining and internalizing sexual identity and

role

3. development of a personal value system

4. preparation for productive citizenship

5. achievement of independence from parents

6. development of an adult identity

15

The adolescent works hard accomplishing these tasks and is
helped or hindered by her interaction with society. Some
adolescents complete these tasks with few problems, while
others meet obstacles that prevent or delay the
accomplishment of all tasks. Because of the need to
accomplish. these developmental tasks, and the difficulty
with which this is done, adolescence is considered, by many,
to be a trying time. The primary purpose of adolescence is
becoming an adult and this period of transition can be a
major cause of crisis (Mercer, 1979).

In summary, then, adolescence can be viewed as a
process culminating in the achievement. of ‘physical
characteristics as well as psychological, and social
attitudes and beliefs. This process occurs over a period of
years and is enhanced by the mastering of a number of
developmental tasks. One factor that can interfere with the
accomplishment of these tasks and thus interfere with the

process of adolescence is pregnancy.

The Pregnant Adolescent
Pregnancy, for the adolescent, is an additional stress
and may interfere with the "normal" developmental processes.
As discussed previously, the adolescent's body is
undergoing rapid, physical change. This immature physical
development at this time of pregnancy can contribute to a
variety of complications. Mercer (1979) suggests that the
increase in premature births of pregnant adolescents may be

attributed to "incomplete development of the myometrium and

16

a structurally and functionally less proficient uterus" (p.
247).

Poor dietary habits and the adolescent's rapid growth
rate are factors that lead to inadequate nutrition. As a
result of inadequate nutrition, anemia among pregnant
teenagers is a problem as well as low birth weight babies.
Lower birth weight babies are also a problem in women who
smoke. According to the August, 1979 Surgeon General's
Report on Smoking and Health, the more a mother smokes, the
less her baby can be expected to weigh at birth. Twice as
many low Edith weight babies are born to mothers who smoke
than to those who do not.

Use of drugs during pregnancy can have a grave effect
on. the 'unborn. baby. Illicit street drugs, prescription
drugs, over the counter medications and alcohol are all
potentially harmful to the unborn baby (Mercer, 1979). Due
to incomplete skeletal growth the adolescent's pelvis may be
smaller resulting in complications. The teenager's cervix
and genitalia may be more vulnerable to laceration, placing
them at risk of possible cervical injury (Mercer, 1979).
These physical effects of pregnancy on the growing, changing
adolescent are dramatic, but they are not the only effects.
Pregnancy also affects the adolescent's psychological and
social development.

Pregnant adolescents face major psychosocial problems.
One-third to one-half of pregnant adolescents drop out of

school because of the pregnancy (McAnarney, 1978). Without

17

a high school education, these young women may have
difficulty finding adequate employment to support themselves
and their child, resulting in increased family dependence.

Many adolescents are not prepared to cope with the day
to day demands of motherhood. "While other youths are
gaining in their quest for independence, young parents
become tied down, setting them apart from their peers"
(Polley, 1978, p. 466). This may lead to negative family
attitudes that interfere with the application and practice
of newly acquired skills.

Pregnancy makes it more difficult for the young woman
to accept and be comfortable with her body image and sense
of femininity (Petrella, 1978). She not only has to adjust
to the normal physiological changes of adolescence, but, in
addition, must adjust to the physiological changes of
pregnancy.

Age is also a factor in the ability of the adolescent
to physically, psychologically and socially cope with her
pregnancy. Usually, the older the adolescent, the more
physically mature she is. She has also progressed toward
accomplishing some of the tasks of this developmental

period.

Unwed Pregnant Adolescent

 

Marital status of the adolescent imposes additional
problems during this developmental stage. The unmarried
adolescent faces different problems and decisions than the

married adolescent. The decision to keep the baby or give

18

it up for adoption is an extremely difficult one. The
unwed, pregnant adolescent must decide whether to continue
or terminate an unplanned pregnancy. However, the option of
marriage as the best solution must also be considered by the
teen. If the teen decides not to marry but to continue the
pregnancy the difficult decision of being a single parent or
placing the child up for adoption must be faced.

In contrast to the usually planned nature of marital
pregnancies (Westoff, 1976), those occurring to unmarried
teenagers are overwhelmingly unplanned (Hudis and Brazell,
1981). With a planned pregnancy there is usually some
consideration given to how childbearing will affect future
life. However, among teenagers 'who experience unplanned
pregnancies little thought has been given to the myriad of
life changes that will subsequently occur. Confronting
these unanticipated changes, especially at this early age is
a difficult task for the unmarried adolescent.

Widely divergent social values surrounding pregnancy in
married women vs. unmarried adolescents exists (Hudis and
Brazell, 1981). The unwed adolescent is less likely to seek
early prenatal care and receive intervention if problems
arise. This may be attributed to the adolescent's fear of
losing peer group approval, support and respect, making it
difficult for her to accept her pregnancy. Because of the
fear of parental reSponse the unwed adolescent may delay
care for as long as possible. Lack of information or

misinformation may contribute to the adolescent ' s

19

unawareness of signs of pregnancy or symptoms of
complications which may also result in the delay in care.

Development of the adolescent's own value system is
impeded by the immediate physical and psychological
reactions to the pregnancy. An adult identity is thrust
upon her before she is ready to accept it or integrate it
(Petrella, 1978).

Pregnancy can pose many problems for the unwed
adolescent especially in the area of social support.
Pregnancy for the unwed adolescent greatly affects the
relationship between parents, partners and peers. Family,
friends and spouse generally grant the pregnant married
woman much support. Even if the pregnancy is unintended the
spouse can generally be relied upon for encouragement.
These reactions reflect a generally supportive role
concerning marital pregnancies. Because of this generally
positive response, parents, friends and spouse can provide a
significant positive influence on a married woman who
becomes pregnant.

Normal responses, especially those of family, partners,
and peers are often quite the opposite for an unwed pregnant
adolescent. Several studies address the social stigma
associated with a premarital pregnancy, Farmer, 1971;
Pearson, 1973; Hudis and Brazell, 1981. This stigma greatly
affects the support given these unmarried pregnant teenagers
by family, partners and peers. Specifically many unwed

adolescents are fearful of their parents' negative reactions

20
and delay or refuse to inform them of the pregnancy. This
can lead to poor pregnancy outcome due to delayed prenatal
care, inadequate diet, use of drugs, or alcohol and a myriad
of other problems.

The role of unmarried partners in the pregnancy of an
unwed teen is also different from that of husbands in a
marital pregnancy. Although some partners may respond
positively to the pregnancy, especially if the relationship
is strong, many unmarried young men are ambivalent about
their partner's pregnancy. These young men may be caught up
in the potential alteration of their own educational and
career plans. Because of his own concerns, the male partner
may be incapable of providing adequate support to the
pregnant partner. At the very worst, the pregnancy may
produce a complete deterioration of the relationship and
leave the pregnant partner isolated and alone, without
support.

Peers can also have a big effect on an adolescent's
pregnancy. Friends can serve as significant role models,
since few teens want to be different. If the pregnant
adolescent is part of a group where pregnancy is frequent
and accepted, not being pregnant or having never been
pregnant may make her different. On the other hand, if the
pregnant teen is part of a group that is looking toward
college or a group where out-of-wedlock pregnancy means "bad
girl", being pregnant may be highly stressful. "Decisions

that are shaped by friends' experiences are especially

21

problematic if the friend has chosen single parenthood as
the outcome, because such peer role models tend to
legitimize an outcome that has extensive negative
consequences for both the pregnant teenager and her child."
(Hudis and Brazell, 1981, p. 172). In summary then, marital
status can impose additional stress on the pregnant
adolescent. Prenatal classes have been developed to inform
pregnant women of normal needs and responses to pregnancy

thus, hoping to decrease some of the stresses during this

period.

Prenatal Learning Situation

Traditional health teaching for all prenatal patients
occurs most commonly in county health departments. The
subject matter for these classes is based primarily on
information the health personnel consider to be important.
The classes are usually implemented in a highly structured
manner covering such topics as personal hygiene, nutrition,
labor and delivery, the postpartum period, baby care and
family planning.

For the purpose of this study, a prenatal learning
situation will be a group experience occurring over an
extended period of weeks or months. The content of the
prenatal learning situation may include anatomy and
physiology of pregnancy, such as expected bodily changes,
and development of the fetus, nutrition, exercise and
hygiene during pregnancy, labor and delivery, what to expect

postpartum, baby care, and family planning information.

22

This information may be presented by formal lecture,
informal discussion, pamphlets, books or other written
material or audiovisual material. The purpose of these
classes is to inform the pregnant woman of normal needs and
responses to pregnancy, thus preparing her for the process
of birth and motherhood. In addition to knowledge, prenatal
classes may also provide support to the pregnant adolescent.
A supportive environment may be critical in the development

of the infant as well as the mother.

Social Support

 

Support is a familiar word to many of us in the health
field. Psychosocial literature purports that "social
support is a major factor in adaptation to stressful life
events" (Dimond & Jones, 1983, p. 235). Increasingly,
nurses and other health care providers are acknowledging the
important place of social support in health and illness.

A vast amount of literature exists on the concept of
social support, however, no single definition is completely
agreed upon by writers in this field. Dimond & Jones
(1983), have summarized social support into four major
categories. These categories include support as relational
provisions, support as information, support as structure and
support as interaction.

Weiss (1974), (p. 235) defines social support. as (a
combination of six categories of relational provisions.

These six categories include:

1.

provided

23

attachment or a sense of security and place

by intimate dyadic relations

social integration provided by group relationships
opportunity for nurturance provided by adults
taking responsibility for the well being of a child
reassurance of worth provided by work relationships
sense of reliable alliance provided by kin
relations

the obtaining of guidance provided by access to a

trustworthy authoritarian figure.

Social support is conceptualized by Cobb (1976) as

"information that allows the subject to believe that he or

she is cared for, esteemed, and a member of a network of

mutual

obligations" (p. 236). Cobb (1976) divides

"information" into three categories:

1.
2.

information that one is cared for and loved
information leading the individual to believe that
he/she is esteemed and valued

information that one belongs to a network of

communication and mutual obligation.

Mitchell (1969) describes a third category for social

support as a "specific set of linkage among a defined set of

individuals that can be of use to understand the social

behavior

of persons involved" (p. 236). Emphasis here is on

the structure of the social network and can help determine

the availability of social support Opportunities. ”These

structural properties of an individual's social network

24

provide evidence of accessibility or availability of
opportunity for social interaction". (Dimond & Jones, 1983,
p. 237).

Mitchell (1969) also conceptualizes support as
interaction by summarizing three dimensions of interaction
within social network (p. 237). The first dimension is
content which refers tx> the meanings that individuals give
to their relationships. The second dimension, directedness,
refers to the amount of mutual sharing. The third dimension
is intensity, which refers to the strength of the bond
between two people.

Norbeck, a leading nurse researcher in the area of
social support bases her conceptualizes of social support on
the definition of social support proposed by Robert Kahn.
Kahn (1979) defines support as "interpersonal transactions"
that can include expression of positive affect, affirmation
of another's behavior and/or giving material aid. Thus,
Norbeck (1981) identifies affect, affirmation and aid as the
three components of supportive transactions. The vehicle
through.‘which. social support. is provided is termed the
"convoy" according to Kahn (1979). Kahn (1979) views this
as a reciprocal relationship with the individual relying on
a set of persons for support and conversely the ”set of
persons" rely on the individual for support. Norbeck (1981)
modifies this however, and measures the perceived support
available to the individual rather than the reciprocal

support inherent in Kahn's definition.

25

From the foregoing discussion of social support, the
diversity of definition is obvious. Using an eclectic
approach, some common areas emerge. The first area is that
social support is aa multidimensional phenomena, the
provision of which comes from various sources. These
sources can be individuals such as partner, spouse,
counselor, clergy, sister, mother etc. or groups such as
peer groups, clubs or work groups (Dimond & Jones, 1983).

Another common area is that social support involves two
basic dimensions. The first dimension involves some
communication of positive affect. People in supportive
relationships display a sense of warmth, caring and
expressed concern. This is referred to in the literature by
a variety of terms; the expression of positive affect,
expressive support, qualitative support and emotional
support (Dimond & Jones, 1983). The second dimension is
that social support can involve the provision of material or
tangible aid. This is referred to as instrumental,
quantitative or tangible support and means providing
concrete assistance (Dimond & Jones, 1983). Loaning money,
providing transportation, giving specific information and
providing housing are some examples of tangible support.

On the basis of this discussion and for the purpose of
this project, then, social support will be conceptualized as
the degree to which a person's basic social needs are
gratified through interaction with others. Basic social

needs include affection, esteem or approval, belonging,

identity and security (Thoits, 1982, p. 147). These needs
may be met by a variety of persons and by the provision of
one of two types of support, emotional support or tangible
support.

The focus of this study is on the factors likely to
influence attendance at prenatal classes. Results from a
previous study (Nuismer, 1982) identified several factors as
having an impact on class attendance. These factors include
financial support, living arrangements, marriage plans,
education level and health care behavior. All of these
factors except educational level can be defined as areas of
social support and can be categorized in one of the eclectic
dimensions of social support as discussed previously in this

chapter.

Conceptual Framework

The conceptual framework utilized in this study is
adapted from Dimond & Jones (1983). Social support,
regardless of the definitions used, functions to "buffer" or
protect individuals from the effects of stressful life
situations. For the adolescent, an unwed pregnancy can be
classified as a stressful situation. The nature of this
situation is one of crisis. According to Dimond & Jones
(1983) a crisis "represents a severely upsetting situation
of limited duration in which the individual's resources must
be hastily summoned to c0pe with threats to emotional,

social and sometimes physical stability" (p. 239). How the

27

pregnant teen views this "crisis" will affect the kind of
support most appropriate to her.

The nature of support offered. is another important
component of this framework. It includes the source of
support, i.e. parents, peers, professional care-giver, the
type of support provided, i.e. emotional vs. tangible and
the timing" of support, i.e. support. given. one time ‘vs.
continuous support.

In pregnancy it is sometimes assumed that a spouse is
the appropriate source of support in all situations.
However, the unwed, pregnant adolescent has no spouse. In
this situation it is important to be able to identify
another support person such as a peer or family member that
may provide the support needed.

The same type of support may not be needed in all
situations. The unwed pregnant adolescent may have all the
emotional support needed from a variety of network members.
However, due to lack of transportation, may be unable to
attend class. In this situation, tangible support is
needed. Therefore it is important to identify the type of
support needed.

The perceived adequacy of the support is another
important factor, since a critical factor in determining the
outcome of a stressful situation is the extent to which an
individual perceives the environment to be supportive.
"very often practitioners consider only the objective

support environment and fail to determine whether an

28

individual perceives the sources as apprOpriately or
adequately supportive." (Dimond & Jones, 1983, p. 244)

Demoqraphic variables must also be considered to
influence the relationship between the stressful situation,
support and attendance at a prenatal learning situation.
These extraneous variables may include age, socioeconomic
level, education level and culture, amount of prenatal care
received, previous health care received and religion.
(Norbeck, 1981). These demographic variables may influence
how much social support may be needed by a person as well as
how much might be available to them.

Figure 1 illustrates the relationship between the

variables of this study just discussed.

29

 

 

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Orem's Nursinngheory of Self-Care

In this study, as a means of relating nursing
intervention with the conceptual framework, Orem's
conceptual framework of self-care will be used. Orem (1980)
defines self-care as "the practice of activities that
individuals initiate and perform on their own behalf in
maintaining life, health, and well being" (p. 35). This is
a two dimensional process involving both decision and action
on the part of the individual. "Deliberate action is
essentially action to achieve a foreseen result that is
preceded by investigation, reflection, and judgment to
appraise the situation and by a thoughtful, deliberate
choice of what should be done"~ (Orem, 1980, p. 68).
Self-care activities are learned by individuals according to
cultural beliefs, habits, and practices that characterize
the group to which this individual belongs.

There are a number of general factors that affect the
individual's ability to perform self-care. Some of these
factors include age, developmental state, health, family
position and role. An individual's established pattern of
respondingy as ‘well. as her 'values and goals, will also
affect the selection and performance of self-care.
"Self-care measures compatible with a person's goals and
values are likely to be seen as beneficial. Their practice,
however, is dependent on the person's judgment of whether he

can perform the measures" (Orem, 1980, p. 71).

31

Normally, individuals voluntarily care for themselves.
When problems arise that interfere with the individual's
ability to participate in self-care, assistance and support
is needed from others. Disease, disability or the other
changes in normal functioning are problems which can
interfere with self-care. It is at this point that the need
for nursing intervention exists. The role of nursing is to
assist the individual and/or family in overcoming these
limitations imposed by an existing situation or develop new
ways of providing self-care. Thus, self—care is a dynamic,
purposeful process involving interaction between the
individual and the nurse. The development of self-care
capabilities in the individual becomes the focus of care
which is consistent with an holistic approach to man.

The nurse acts to help individuals meet self-care needs
within the framework of three systems. In the first system,
the wholly compensatory system, the individual has no active
role in the performance of her care. In the partly
compensatory system, the individual is able to perform some
aspects of self-care but needs assistance from the nurse in
other areas. In the supportive-educative system, the nurse
assists the individual with support, guidance, provision of
a developmental environment, and teaching to perform the
required self-care measures that the individual can or
should learn to do.

In fulfilling the nursing role, the nurse must also

consider the individual's perspective or the health

32

situation and four central components. These components
include abilities and/or disabilities in providing
self-care, state of health, health results sought, and
requirements for therapeutic self-care. Thus, following
this framework for self-care, the individual is required to
play a central role in the implementation of this care with
the nurse acting as a facilitator to the individual's
decision-making process. Respect for the individual is
emphasized by the important role the individual plays in her
own care. (See Figure 2)

In applying this theory to the self-care practices of
pregnant, unwed adolescents, the nurse must consider the
issues just discussed. The adolescent is capable of
participating in self-care but the self-care activities she
chooses will be affected by her cultural background, what
she learned to be important from her family, and her own
values and goals as an adolescent. The goals and values of
the adolescent's peer group will also impinge on her choices
of self-care activities. The developmental tasks of
independence and self-identity are strongly influenced by
the adolescent's peer group. If the attendance of prenatal
classes is compatible with the adolescent's goals and values
then she is likely to attend. Attendance, however, also
depends on the judgment of the adolescent as to whether she
can "perform the measure." The adolescent may feel it is
important to attend prenatal classes but does not, due to

lack of transportation, or time of day classes are held.

33

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34

The nurse would assist the unwed, pregnant adolescent
in self-care through the supportive-educative system. She
would support the adolescent by creating a trusting
atmosphere, allowing expression of both positive and
negative feelings, allowing the adolescent to make her own
choices, and being available when needed. Guiding the
adolescent regarding her future health by providing
consistency and stability is also important. Building the
adolescent's self-esteem and reinforcing her self-value are
important to the development of independence and
self-identity. Providing the adolescent with knowledge
about pregnancy, child birth, care of the newborn, and
family planning provides the adolescent with information on
which to base decisions. The goal of nursing care under the
supportive-educative system would be to assist the pregnant
adolescent to overcome limitations to self-care. Therefore,
the adolescent is able to function at a higher level of
health and well-being during her pregnancy and following

delivery. (See Figure 3)

Summary

In summary, a conceptual framework, adapted from Dimond
& Jones (1983), illustrating the relationship between social
support, the unwed pregnant adolescent and attendance at a
prenatal learning situation is presented. Nursing
intervention is presented based on the self-care concepts as

described by Orem (1980). Literature pertinent to social

 

 

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36

support and attendance at prenatal classes by the unwed,

pregnant adolescent will be reviewed in Chapter III.

CHAPTER III

LITERATURE REVIEW

Introduction

 

In this chapter relevant literature pertaining to the
affect of social support on the attendance of unwed pregnant
adolescents at a prenatal learning situation will be
reviewed. This chapter will be divided into the following
categories: prevalence: of adolescent pregnancy, the
pregnant adolescent, prenatal classes, and social support.
A summary of the literature and implications of the

contributions of this current project will be included.

Prevalence of Adolescent Pregnancy

As discussed in Chapter I, pregnancy among teenagers is
recognized as a serious national problem. Both from a
medical perspective as well as a psychosocial perspective
(Mercer, 1979; Petrella, 1978; Allison-Tomlinson, 1982; and
Smith, Weinman & Mumford, 1982), and the upward trend of
teenage pregnancies from the 1950's to the 1970's is clearly
documented. One in five births in the United States is to a
teenager (Mercer, 1979).

In 1950, 12% of all children were born to females under
age 20. In 1975, they bore 19% of all children (Moore, et

a1., 1978). By 1973 there were over a quarter of a million

37

38

births to females under age 18. Almost one-half of these
births were to unmarried teens (Klerman, 1980). By 1978, a
total of 554,000 babies were born to teenage mothers. More
than one-half of these adolescents were not married. Eleven
thousand of these mothers were younger than 15, and 203,000
were between 15 and 17 (Smith, et a1., 1982).

From these statistics then, it is obvious that pregnant
adolescents are becoming a more prevalent phenomena in this
society. These teenage pregnancies cause a range of issues
and problems extending across academic, socioeconomic and
medical desciplines. However, in order to understand the
pregnant, unwed adolescent, one must first understand the

adolescent.

The Pregnant Adolescent

Adolescence is a period of transition from childhood to
adulthood. It is characterized by hormonal changes that
alter not only physical structure but also thoughts, desires
and emotions. All these changes that characterize
adolescence-physical, social psychological and. cognitive,
interact and compound one another (Howe, 1980).
Developmental literature refers to adolescence as a
developmental stage. In order to successfully complete this
stage, the adolescent must accomplish certain tasks during
these adolescent years. Successful completion of these
tasks must be accomplished for a healthy personality to

emerge.

39

Erikson (1963) considers the necessary’ psychosocial
crisis to be conquered in adolescence as the achievement of
a sense of ego identity, a feeling of coherence,
relatedness, and integration in one's interpersonal life.
Unsuccessful attainment of ego identity results in identity
diffusion. This implies doubts regarding one's physical and
sexual self, interferes with the ability to make decisions
and commitments. Katchardourian (1980) discusses three
developmental issues that must be resolved during
adolescence. These include establishing a personal
identity, developing interpersonal relationships, and
enhancing self-esteem. Piaget (1972) discusses an
additional task which he describes as gaining representative
intelligence by means of formal operations.

This process of identity develOpment involves
redefining and reintegrating the adolescent's view of
herself into a more autonomous, unique individual than she
viewed herself during childhood (Joint Commission, 1973).
Daniel (1979) stresses that full ego identity is not
achieved until late adolescence when adolescents are more
comfortable with their bodies, have set goals for themselves
and planned how to reach these goals and feel confident they
are able to do so.

In order to reach this full identity development, the
adolescent must make gains in many areas. Three common
areas discussed in the literature include body image,

independence and changes in emotional capacities.

40

Body image is an evolving, fluctuating concept of ones
physical being (Petrella, 1978). In contrast to other
phases of life, the physiological growth during adolescence
is very rapid. The onset of adolescence then, confronts
every individual with the task of revising body image to
accommodate the vast number of physical changes. Because of
this obvious growth and physical change, the adolescent
focuses increased attention on her body. Intense bodily
concerns arise and even minor ailments or blemishes are
serious. Constant worrying about physical growth, height,
weight and secondary sex characteristics are by no means a
small part of adolescent turmoil. The adolescent's peer
group plays an important part in the development of body
image. According to Mercer (1979) "a child who is different
from members of the group - because he is not as good
looking or comes from a different socioeconomic, racial or
cultural background - will be excluded" (p. 292). This
behavior seems immature but is a necessary way for the
adolescent to establish her identity.

Seeking increased independence is another important
area in the development of identity. Emancipation from
parents a is major problem of the adolescent years (Mercer,
1979). This includes emotional independence as well as a
beginning to economic independence. The family is no longer
the primary reference group but is replaced by the peer
group (Daniel, 1979). Peer group participation is

recognized as one of the most important needs during the

41

adolescent period in order to establish secure emotional and
social ties with others beyond the family tn: home
(Allison-Tomlinson, 1982). This process to independence is
frought with ups and downs. The successful progress of
adolescence can be recognized by a gradual decreased
preoccupation with issues of independence coupled with
increased concern regarding the future, such as issues of
education and occupation (Joint Commission, 1973).

Extreme emotional fluctuations are also characteristic
of this stage. Vacillating feelings and reactions are
common. As a result of hormonal changes the adolescent is
experiencing many new internal feelings and sensations.
Therefore an important task is to learn how to control and
yet be able to express her desire for sexual gratification
and intimacy in a way that is consistent with her own values
as well as her family's and society's values (Joint
Commission, 1973).

Pregnancy for the teenager is a disruptive event of
disastrous proportions and despite the lessening of societal
disapproval of illegitimate childbearing and in spite of the
increasing availability of abortion and contraception,
teenage pregnancies continue to be a problem.

Adolescent pregnancy is discussed in recent literature
in relation to its interference with the developmental
process (Block, et al., 1981; Allison-Tomlinson, 1982;
Fisher, et al., 1980; Smith, et al., 1982; Peterson, et al.,

1982). However, no .recent. research literature could. be

42

found that addressed this issue. Block (1981) states that
the occurrence of pregnancy out of the develOpmental
sequence becomes a distinct problem that disrupts
development, interferes ‘with life-style, and. can totally
change the future for many people. In identifying who is
the pregnant teenager, Block (1981) states "our experience
shows she is unlikely to have completed growth tasks,
especially the acquisition of independent thinking and a
mature understanding of self" (p. 77). A series of studies
by the National Institute for Child Health and Human
Development indicated that young parenthood had adverse
effects on the young parents' educational attainment and
economic self-sufficiency. Thus, interfering with the task
of emancipation.

A study done by Ralph, Lockman and Thomas (1984)
indicates that there is a difference in psychosocial
characteristics between pregnant adolescents and adolescents
who are not pregnant. Ralph, et a1. studied 19 first-time
pregnant and 20 nulliparous 15 and 16 year old black
teenagers at an adolescent clinic in Dallas, Texas. Each
group was administered three sets of assessment instruments:
The Offer Self-Image Questionnaire for Adolescents (OSIQA),
Focus of Control Scale for Children, and Personal and Family
History Questionnaire. A stepwise discriminant analysis was
carried out comparing' both. groups. This analysis using
family history and psychosocial adjustment variables had a

multiple correlation of 0.65, with. p= .008. The

43

discriminant function generated was able to correctly
classify 89.5% of the pregnant group and 80% of the
nonpregnant group. The results suggest that distinct
characteristics do exist for the pregnant adolescent, but
that such characteristics do not indicate either family or
psychological disturbance in the pregnant adolescents. The
findings however should be interpreted with caution. The
sample size was small and the population was not chosen
randomly. Further, since the pregnant adolescents completed
the psychosocial measures after they were pregnant, their
scores may’ have been a direct effect. of the pregnancy
itself, rather than indications of prior functioning and
attitude. Also, since the sample included only low-income
black patients in an adolescent clinic, the results may not
be generalizable to other ethnic and income-level groups.
All these factors tend to limit the findings.

This study is important because it contains information
not previously dealt with in the literature. If pregnant
adolescents are different than nonpregnant adolescents then
identification of these differences would appear to have
implications for the care of pregnant adolescents.

.A study by Smith, weinman and Mumford (1982) examined
social and affective factors associated with adolescent
pregnancy. The sample consisted of 104, 13 to 18 year olds,
primiparous low-income pregnant adolescents living in the
Southwestern United States. The adolescents were in their

second or third trimester of pregnancy. Each adolescent was

144

asked to respond anonymously to a questionnaire
administrated by the clinic instructor while waiting for
their routine prenatal exam. The instrument gathered
demographic data and information on birth control use and
knowledge, coital frequency, desire for pregnancy, affective
states, expected life-style changes and knowledge of the
fertility cycle. The majority of adolescents, although
experiencing an unplanned pregnancy, perceived minimal
negative social consequences associated with the pregnancy.
These findings underscore the immature thought processes of
the adolescent especially in the sexual domain. This tends
to support the fact that pregnancy interferes with future
development and may indeed arrest development at this point.
Limitations to the findings of this study could include the
fact that the majority of the sample (75%) consisted of
minorities. No discussion of the instrument in relation to
validity and reliability was attempted nor was the
statistical analysis discussed. These factors may have
important effects on the conclusions drawn.

. The pregnant adolescent then has enormous additional
psychological liabilities. She may be in the midst of
establishing a mature identity and have difficulty in
meeting the object—related task of pregnancy.
Simultaneously she may become more vulnerable because of her
own sense of identity. Rather than appropriately

concentrating on her own needs, the pregnant adolescent is

45

challenged to concentrate on another totally dependent
being, the fetus.

Instead of gradually disengaging herself from her
family and strengthening relationships with persons outside
the family, the pregnant adolescent may need to increase her
reliance on her own family. Rather than gaining a better
sense of a separate body, the pregnant adolescent may become
confused as she tries to resolve the issue of self and other
that all women face during pregnancy. Thus the
developmental tasks of adolescence; disengagement from the
family, an increasing sense of autonomy and individulization

are all at risk when the adolescent becomes pregnant.

Prenatal Classes

Traditionally in this country, pregnant women with or
without their partners have been encouraged to attend
prenatal classes as a way to increase knowledge about all
aspects of pregnancy. It was felt that. this increased
knowledge would lead to a better pregnancy outcome for both
mother and child, However, there is little in the research
literature that actually studies attendance at prenatal
classes as a way to improve the quality of labor and
delivery. A study done by Gunn, Fisher, Lloyd & O'Donnell
(1983) in New Zealand "found no evidence that attending
antenatal education classes will ensure an easy and less
complicated birth" (p. 51). In order to determine whether
class attendance improved the quality of labor and delivery,

Gunn, et al., studied 196 nulliparous women who delivered

46

over a two month period in West Auckland, New Zealand.
Outcome measures used were length of the second stage of
labor, need for forceps delivery, and pain relief required
while in labor. These researchers found that the group who
went to antenatal education classes had a longer second
stage of labor and required more low forceps assistance
during delivery. These results remained when the
confounding variables of race, age and socioeconomic status
were removed. These researchers also found no statistically
significant differences ix: the type of pain relief
medication required during labor and delivery by the
attenders or nonattenders. This study however may not
reflect the true effectiveness of prenatal classes because
of the irrelevant outcome measures used.

McCraw and Abplanalp (1982) suggest that women's
motives for taking childbirth preparation classes may not
include these outcomes that have been studied. Women may
attend childbirth preparation classes because the hospital
requires it in order to have husbands present at the birth,
for emotional support or for information, and because they
desire active participation in labor and delivery. MbCraw
and Abplanalp, (1982) interviewed 77 primiparas in order to
determine motives for attending Lamaze classes. The most
frequently stated motive for participation given by 42.9%
was to gain information for themselves and husbands. The
second most frequently given motive (24.7%) was to decrease

the amount of medication in labor and delivery and the third

47

most common reason was the desire of wife and/or husband to
be present and involved (20.8%). These motives may
influence the frequency of practice of childbirth exercises,
and ‘willingness of ‘women. to accept medication, thereby,
affecting results of labor and delivery when other
irrelevant outcome measures are used.

Women who chose not to participate in childbirth
education are of interest to those who provide health care
to the pregnant woman. However, little is known about those
who do not take classes or why.

In an attempt to find out more about women who do not
attend childbirth education and their reasons for not
participating, Vinal (1982) studied 201 married women with
normal obstetric courses who delivered at four private
hospitals in.rOmaha, Nebraska. Vinal's results indicated
that women who attended prenatal classes were younger,
tended to be in their first pregnancy, were more educated
and had been married for a shorter period of time than
nonparticipants. Women who did not attend classes were
evenly divided between those who had attended with a
previous pregnancy and those who had never attended but had
already born children. These women felt they already knew
about childbirth. Because of the sample size, the fact that
the study used only private hospitals, and the participants
were all married women, results are not generalizable.

Gunn, et a1. (1983) also looked at factors affecting

attendance at prenatal classes. Results indicated that of

48

195 women, 152 attended classes and 43 attended no classes.
The group of nonattenders were younger, smoked more, had a
lower socioeconomic status and few were married.

No studies could be found in.1flua published literature
that examined characteristics of attenders versus
nonattenders in the pregnant adolescent population.
However, Nuismer (1982) in a thesis submitted to Michigan
State University, examined discriminating characteristics of
attenders and nonattenders at prenatal classes for pregnant
adolescents. The characteristics included sociodemographic
factors, developmental level and health beliefs. The
convenience sample consisted of forty-two unmarried,
primipara adolescents age 15 to 19 who planned to keep their
baby and had been referred to a prenatal class. The data
was collected by means of a questionnaire which was
administered to the teen while she was attending a prenatal
clinic. Statistical analysis was done using Pearson Product
Moment Correlation and discreminant function analysis.

Several factors were identified that appeared to impact
class attendance for the pregnant adolescent. Nuismer
(1982) identified that a pregnant adolescent was more likely
to attend class if she was dependent on others for food and
housing, if she planned to marry during the pregnancy, and
if she sought prenatal care early in her pregnancy. Higher
educational level also contributed positively to class
attendance. Limitations to this study include a small

sample size primarily from a low socioeconomic background.

49

Unclear wording of some questions and only moderate
reliability coefficients on tum) of the scales make
interpretation. more difficult. Also the fact that some
teens may have already been attending prenatal classes when
data collection occurred may have biased the teens' beliefs.

Two studies have been found that address prenatal
classes specifically for the pregnant adolescent. Dickerson
and Quellette (1982) examined prenatal education for
adolescents in. a delinquent youth facility. These
investigators were attempting to measure the cognitive
changes of pregnant adolescents in the prenatal classes by
examining 12 primigravidas 15 to 18 years of age planning to
keep their babies. A pretest - post-test sequence was used.
Study results indicated the program was successful in
increasing course related knowledge of the subjects. Since
this study was conducted in a restricted environment with a
small. number' of subjects results. are not generalizable.
Also no mention was made regarding mandatory versus
voluntary attendance.

Copeland (1979) addressed the traditional
implementation of prenatal classes in a highly structured
format with minimal input from adolescents themselves. In
order to develop classes that would meet the adolescent's
needs, Copeland asked 15 primigravidas 15 to 19 years of age
to identify subject matter that they felt should be included
in a prenatal class. Findings revealed that these

adolescents tended to select topics that were self-oriented

50

with the most important topic identified as the labor and
delivery process. Sixty percent of the teens identified
group discussion as the type of class they prefer, in which
the girls can discuss anything' that is bothering them.
Eighty percent felt that prenatal classes are very important
or important. The small sample size of Copland's study
(1979) also prevents generalization. However, both
Copland's study (1979) and the study by Dickerson &
Ouellette (1982) seem to be much needed steps in the
direction of research conducted specifically on the

population of the pregnant teen.

Social Support

The term social support is a very broad term but is
generally referred to as the mechanism that functions to
protect individuals against the effects of life stress
(Wortman, 1984). In recent years, this concept of social
support has emerged as a major psychosocial variable in
health related research. Social support literature is
extensive and varied. Some areas that it addresses include
illness onset, utilization of health services, compliance,
recovery; rehabilitation" and adaption and. mortality
(Wallston, et al., 1983). Much of this literature suggests
that social support has a positive effect on a wide variety
of outcome which include physical health, mental well-being
and social functioning. However, there is much debate in
this area concerning the nature, meaning, and measurement of

the term social support.

51

It is not the intent of this author to review the
multitude of studies done on social support especially since
there are several excellent reviews and critiques of the
literature available (Dimond & Jones, 1983; Wallston, et
al., 1983; Wortman, 1984; Norbeck, 1981). However, several
classic studies will be discussed. A series of articles can
be identified that establish the importance of social
support, identify areas lacking and encourage further
research in the area. The classic of these articles is Cobb
(1976).

In reviewing the pertinent literature addressing social
support, Sidney Cobb is in the forefront for he publically
acknowledged the important effect of social support in
health and illness. Cobb's essay "Social Support as
Moderator of Life Stress" (1976) can be considered a
classic. Cobb emphasized that social support "acts to
prevent the unfortunate consequences of crisis and change"
(Cobb, 1976, p. 300). Cobb (1976) defines social support as
Winformation". He divides this information into three
categories: (1) Information that the individual is loved;
(2) information that the individual is esteemed and valued;
and (3) information that the individual is part of a network
of communication and mutual obligation. Cobb also states
that activities and material services are "not of themselves
information of any of the major classes mentioned above"
(Cobb, 1976, p. 301). He believes that "services do not in

themselves constitute such support because social support,

52

being information, cannot be measured as mass or energy"
(Cobb, 1976, p. 301). Information as opposed to goods and
services is central to Cobb's definition of social support.
While the information that Cobb based this article on is
inconsistent and not always accurate his contribution cannot
be diminished. He established the fact that social support
was a common phenomenon that existed in the life cycle from
birth to death, and that social support was protective. He
encouraged.rother researchers to rattempt studies on this
concept thus contributing to the knowledge base available.
While Cobb's definition of social support may be considered
narrow and the fact that he totally negates the area of
tangible support is questionable, his contributions should
not be overlooked.

Kaplan, Cassel and Gore (1977) also contributed to the
study of the social support concept by suggesting a number
of properties of social network which might be relevant to
health. These authors attempted to "unravel some important
dimensions of the social support concept and to help clarify
the place of the study of social support in biomedical
research" (p. 47). Kaplan, et a1. (1977) supported the fact
that social support was an important concept and attempted
to identify areas where interpretation and research were
lacking. They indicated that future research must be more
specific by acknowledging that previous research was limited
in. conceptualization and measurement. In: important

contribution of this essay was the suggestion of a different

53

approach to disease prevention. These authors suggest that
instead of focusing efforts on early case finding and
detection of disease, actions should be focused on attempts
to change the psychosocial factors of nature, strength, and
availability of social supports. The major limitation here
is that these are merely suggestions by the authors and are
not based on actual research conducted by these authors.
Some of the same problems that plagued Cobb (1976) were also
evident in Kaplan, et a1. (1977). The article does not
provide a concise definition of social support nor does it
clarify the nature of social supports. Also some
conclusions drawn by Kaplan, et a1. (1977), were based on
animal research which may not be generalizable to the human
population.

The biggest contribution of another important group of
authors, Dean and Lin (1977), is in the area of measurement
and design. Dean and Lin (1977) identified the lack of
social support scales with sufficient evidence of
reliability and validity. They related the obvious
difficulty in measuring social support but encourage
development of research in this area. Identification of
social support as a dynamic not a static variable and
encouragement to use a longitudinal design, further
contribute to approaches that would improve clarification of
the concept.

The authors previously discussed have all supported the

hypothesis that the individual's social support system helps

54

to moderate or "buffer" the effects of life events on his or
her psychological state. Thoits (1982) however, attempts to
refute this hypothesis. Thoits (1982) acknowledges that
evidence does exist that social support can. buffer the
impact of life changes. However, she insists that this
information must be interpreted with great caution. Thoits
(1982) identifies several serious problems with the
empirical literature that must be resolved. First, many of
the studies suffer from. inadequate conceptualization. and
operalization of social support. Second the direct. and
interactive effects of life change and social support may
have been confounded. The interrelationship between life
events and social support may be confounded by the
interaction of the two. She suggests this confounding may
bias the results in favor of the buffering hypothesis.
Thoits (1982) recommends that future studies have a
longitudinal design that measures support before as well as
after the occurrence of life events. Lastly, the
possibility that social support is an important etiological
factor in its own right has not been fully tested.

Most of the previous authors allude to some of the same
problems that Thoits (1982) discusses, however, they treat
them minimally. Thoit's (1982) contribution is that she
calls into question the acceptance of the entire buffering
hypothesis itself.

Much of the impetus for current research has come from

the theoretical statements interpreting the health

53

consequences in light. of the social support. hypothesis.
There are now a number of empirical studies in which low
social support has been implicated in negative health
outcomes. Four studies will be reviewed..

Berkman and Syme (1979) examined the relationship
between social and community ties and mortality. Four
thousand seven hundred twenty-five adults from Alameda
County ranging in age from 30-69 were randomly selected from
data collected by the Human Population Laboratory Survey,
part of the California State Department of Health.
Institutionalized population were not included. A survey
was conducted to gather demographic data and a health
questionnaire was left to be filled out by all persons age
20 or over and returned by mail. Mortality data were
collected for the 9 year period from 1965 to 1974 when a
follow-up survey was conducted. All but 302 respondents or
4% of the original sample were located. Those lost to
follow-up were not found to differ markedly on the health
measure questionnaire in the 1965 survey. Data was analyzed
using Chi square statistical analysis. The statistic was
adjusted for age, socioeconomic status and health practices
such as smoking, alcohol consumption, obesity, physical
activity, and utilization of preventive health services as
well as a cumulative index of health practices.

Four sources of social contact were examined. They
include: (1) marriage; (2) contacts with close friends and

relatives; (3) church membership; and (4) informal and

56

formal group associations. "Respondents with each type of
social tie had lower mortality rates than respondents
lacking such connections" (Berkman & Syme, 1979, p. 188).
In a separate multivariable analysis each of the four
sources of social contact was found to predict mortality
independently of the other three. This association between
social ties and mortality was found to be independent of
self-reported physical health status at the time of the 1965
survey, year' of death, socioeconomic status, and health
practices such. as smoking, alcohol consumption, obesity,
physical activity and utilization of preventive health
services as well as a cumulative index of health practices.
Berkman and Syme's study (1979) appears to support the
hypothesis that social factors may influence host resistance
and affect vulnerability to disease in general, however,
some limitations to this study exist. Procedure of data
collection. and sampling' is :not explained. in detail and
leaves room for error in this area. Another limitation may
be that people who died during the nine year follow-up
period may have been ill at the time of the initial survey.
Also the mechanisms by which network influence health
remains unclear. Some strengths of this study include the
fact that a large sample of a general population was studied
at two points in time. Most of the previous studies focused
on Special population groups at only one point in time.
Nukolls, Cassel and Kaplan (1972), studied the

relationship between psychosocial assets, social stresses

57

and the outcome of pregnancy. The data were collected at a
large military hospital on 170 white premigravidas, married
to enlisted men who registered for obstetrical care prior to
the 24th week of pregnancy. The stressors were measured at
32 weeks of pregnancy by the schedule of recent experience
as developed by Holmes and Rahe. Psychosocial assets were
measured at the time of the prenatal registration by a
self-administered questionnaire designed to measure the
subject's feelings or perceptions concerning herself, her
pregnancy and her overall life situation including her
relationships with her husband, her extended family and the
community. All medical records were reviewed following
delivery and all abnormal findings and any complications of
pregnancy or delivery were recorded. Following delivery,
all medical records were reviewed and all abnormal findings
for each mother and infant were recorded using previously
established criteria derived from a standard obstetrical
text. The total course and outcome of each pregnancy was
categorized as either normal or complicated.

I Taken. alone, neither' the life-change score nor the
psychosocial asset score were significantly related to
complications. However, when considered jointly it was
found that 91% of the women with a high life change score
but a low asset score had one or more complications where as
only 33% of women with equally high life change score but

with a high asset score had any complications.

However, interpretation of this data must be done with
care. The measure of psychosocial assets included items
concerning intrapersonal characteristics such as self esteem
and reactions toward pregnancy, in addition to items that at
face value appear to assess social support. Consequently,
it: is unclear to what extent social support alone can
account for the observed effects. The specificity and size
of the sample as well as scoring problems due to the variety
and severity of complications during a pregnancy pose
additional limitations to this study.

Another study by Lin, Ensel, Simeone and Kuo (1979)
also examines the role of social support in relation to
stressful life events and subsequent illness. Lin, et a1.
(1979) studied. 170 Chinese-Americans in ‘the District of
Columbia in the summer of 1972. The sample was selected
systematically from a non-repeated, alphabetically ordered,
master list of Chinese-American households and included 121
males and 49 females. Seventy-two percent of the sample had
a high school education or higher. The instrument used
consisted of a modified version of the Holmes-Rahe SRRS
scale, a psychiatric system scale consisting of 24 items
indicating ways a person might have felt or behaved in the
last six months. All coefficients were significant to the
.001 level with an alpha of .88. Social support was
measured using a scale of nine items that addressed the

respondents' interactions and involvement with friends,

59

neighbors, peOple nearby, and the subcultural community.
Correlations, means and standard deviations for all
variables was employed. Subsequent regression analysis were
then performed using this correlation matrix.

The findings of this study support previous findings
that a relationship exists between stressful life events and
illness. However, a second important finding asserts that
social support contributes significantly and negatively to
illness symptoms. "Compared to stressor, the social support
measure was much more significantly and negatively related
to psychiatric symptoms" (Lin, et al., 1979, p. 115). While
these findings are preliminary, they strongly suggest that
social support may be just as important as stressful life
events, if not more important in exercising an influence on
illness symptoms. Future research in the etiology of
illness may be incomplete unless social support is taken
into account.

While this study strongly suggests the importance of
social support in 'influencing illness symptoms, severe
limitations exist. One limitation is the definition or lack
of definition of social support. According to Lin, et a1.
(1979) social support is defined as "support accessable to
an individual through social ties to other individuals,
groups and the larger community" (Lin, et a1, 1979, p. 109).
In this sense social support is not really defined. Social
support defined as support is not an adequate definition.

The study population, consisting of Chinese-Americans may

60

not be generalizable to the general population. The study
population also had a much higher preponderance of males
with 121 males versus 49 females. This may also affect
generalizability. The social support scale is questionable
because of its sole focus on non-kin support and. poor
reliability and validity as demonstrated by an alpha
coefficient of 0.52.

Schafer, Coyne and Lararus (1981) studied the
relationships among life events, social network site,
various types of perceived social support and outcome
measures of nmmals, psychological symptomatology, and
physical health status. The sample p0pulation was 100
randomly selected men and women between the ages of 45 and
64 living in Alameda County, California. Participants were
selected randomly from among subjects in a previous
population survey conducted by the Human Population
Laboratory of the California State Health Department. The
sample was predominantly married, well educated and of high
income. Participants were interviewed in their homes once a
month for 12 months and were asked to complete two
self-report questionnaires. One questionnaire was to be
completed near the beginning of the study period and the
other near the end. Data were collected from six
questionnaires: The Social Support Questionnaire, the
Social Network Index, the Recent Life Events Questionnaire,
the Hopkins Symptom Checklist, the Bradburn Morale Scale,

and The Health Status Questionnaire.

61

Overall, results indicated that perceived social
support showed stronger association with both symptomatology
and morale than the Social Network Index. Another important
finding was that tangible support was significantly but
inversely correlated with depression and negative morale.
Emotional support was shown to have a separate but equally
important function in reducing or averting depression.
Limitations to the findings in the Schaefer Study (1981)
include the use of a small sample of all middle class people
and low internal consistency of the tangible support scale
with an alpha coefficient of only 0.31. Future research
using a tangible support measure should seek to improve
internal consistency. The major contribution of this study,
however, is the focus on the multidimensionality of support
and the attempt to address three types of perceived social
support namely tangible, emotional and informational.

In summary, then, social support can be identified in
the literature as an important factor in the management and
resolution of stressors associated with disease and other
life events. Evidence indicates that a positive response to
stressful events is facilitated by socially supportive
environments. In the absence of socially supportive
environments, the maintenance of personal and social
functioning is difficult. A ‘variety of conceptual
definitions of social support exist but there does seem to
be agreement that the concept is multidimensional. Some

studies associate support with simple contact or presence of

62

another. Cobb (1976) defined support as information that
leads persons to believe they are loved and esteemed.
Others include the exchange of material goods and services
(Dean & Lin, 1977). All of these diverse definitions appear
to be equally interpreted as evidence of the effectiveness
of social support in ameliorating stress. Various
approaches to assess these key dimensions of social support
exist. Some measures appear quantitative while others
appear qualitative. Few measures have been systematically
developed and repeatedly tested with different populatidns.
Because of these factors social support deserves further
attention. Since assessment is an integral part of the
nursing process, nurses are in an ideal position to be able
to assess the availability of social support as well as the
clients' perception of and capacity to utilize this
resource. With the advent of further refining of the
concept and improved methodological approaches and
replicated studies nursing may significantly contribute to
an increased knowledge base and advance understanding of the
role of social relationships in health as well as disease.
Should such approaches be successful, the implications for

intervention could be of considerable importance.

Social Support and the Adolescent
Even with the volume of literature available on social
support, relatively little current research can be
identified that specifically addresses itself to social

support and the adolescent. Jay, DuRant, Shoffitt, Lender

63

and Lett (1984) addressed peer support. In a prospective
study, Jay, et a1. (1984), tested the effect of a peer
versus nurse counseling program on adolescent compliance
with the use of oral contraceptives. Fifty-seven females
ages 14 to 19 years from a lower socioeconomic background
were randomly assigned to a peer or nurse group. Subjects
received Ortho Novum 1/35 combined with a tablet marker and
were counseled at the initial visit and at one, two and four
month follow-up visits. Outcome measures of noncompliance
were (1) avoidance of pregnancy, (2) appointment adherence,
(3) pill count, and (4) urinary flourescence for riboflavin.
Analysis of variance with a regression approach was used to
analyze the data.

The results did not indicate across the board that
peers had a significant effect in decreasing noncompliance.
The peer counseled group had significantly lower levels of
noncompliance than the nurse counseled group in the first
two months after beginning oral contraceptives. Adolescents
with a more stable relationship, having only one sexual
partner over a three month period had the same level of
compliance regardless of whether counseled by a nurse or a
peer. On the other hand, adolescents in the nurse counseled
group who expressed feelings of hopelessness about the
future had significantly higher levels of noncompliance
while adolescents with feelings of hopelessness who had been
counseled by a peer had a significantly lower level of

noncompliance. Limitations to this study include the fact

6dr

that no controls were used regarding type, amount and length
of counseling given by the peer versus nurse counselors. In
addition, the subjects did not necessarily see the same
nurse or peer counselor at each visit. Sample size, length
of the study and population used also limit
generalizability. While the focus of this study was not
social support per se, it is significant in that it focused
on one source of social support, that of peer support, which
is touted in the literature as having great influence with
this age group.

Two studies were identified that specifically address
social support and adolescent mothers. Colletta (1981)
examined 50 adolescent mothers ages 15 to 19 years and the
effect sources and kinds of support would have on maternal
rejection of the child. The sample was selected from.birth
records of a mixed rural/suburban county outside Washington,
D.C. The first 50 adolescents located were used in the
study. The majority of the sample had one child, had not
completed high school, were unemployed and single, separated
or divorced. Data were obtained by a structural interview
in the participants' home using the Stress, Support and
Family Functioning Interview and the Parental
Acceptance-Rejection Questionnaire. Correlational
statistics were used to analyze the data.

For the young mothers, the most consistent predictor of
maternal. behavior 'was the total amount of support they

received. When kinds of support were considered, emotional

65

support was found to be most highly related to maternal
behavior. With high levels of emotional support adolescent
mothers reported less aggressiveness and rejecting. These
relationships were the strongest when the adolescent's own
family was the source of emotional assistance. Next in
order of importance was emotional support from a partner or
spouse. It was also crucial for the adolescent to be able
to feel that she could communicate with her partner, that
she could count on her partner when she had a problem, and
that her partner was interested in her child. Friends were
a much less effective source of emotional support, however,
when friends did offer assistance, the mothers were less
aggressive and rejecting. There were no relationships found
between the amount of material, financial, community service
support or information and advice and the adolescent
mothers' maternal role performance. The biggest limitation
of this study has been discussed previously as plaguing much
of the literature on social support and that is the lack of
definition of the concepts. Nowhere is there a definition
cf social support in this study. Sources of support are
broken down into material aid, emotional support,
information/guidance and community services support,
however, no explanation of what is included in each of these
categories is given. Small sample size also limits
generalizability.

Zuckermanq Winsmore, and. Alpert (1979) also studied

social support and the adolescent mother. Zuckerman, et a1

66

(1979) conducted a prospective pilot study of inner city
adolescent mothers. A sample of 23 primiparous adolescents
was compared with 8 primiparous non-adolescents and 24
nulliparous non-adolescents. Data were collected by a
structured home interview at two weeks and 3 months
postpartum. The interview consisted of 114 open and forced
choice questions covering 13 content areas that included
perceptions of baby's behavior, spoiling, attachment,
discipline, breast feeding, support systems. and maternal
self-image to name ' a few. Analysis was by Chi square.
Results indicated that there were significant differences in
the support systems of adolescent and non-adolescent mothers
and in their self-image as mothers. The majority of
adolescent mothers lived in an extended family and perceived
and used them as a support by allowing members to do some
infant caretaking tasks or provide babysitting. Also
adolescent mothers were more likely to seek medical advice
from their mothers as opposed to health professionals. It
is also of interest that 81% of the single adolescents
stated that the father was helping with the baby. However,
conclusions of this study are limited due to the small
sample size. Also like entities were not compared. For
example, adolescents having their first baby were compared
with a sample that consisted of a majority of
non-adolescents who were having a second, third or fourth
baby. This could certainly have a significant affect on the

conclusions. The researchers did attempt to define

67

"support systems" however they did not attempt to break down
kinds of support.

In summary then, there are a limited number of recent
research articles that address social, support and the
adolescent. While the studies by Jay, et a1, (1984),
Colleta (1981) and Zuckerman, et a1. (1979) have limitations
they are a much needed step in the direction or research
conducted specifically on the adolescent population.

Research literature in the area of social support and
the pregnant adolescent is also lacking. Several articles,
although not research articles, can be found that mention
social support as an important aspect of prenatal care
and/or childbirth education. Moore (1984), in a paper
describing strategies in providing prenatal and childbirth
education to adolescent couples, discusses the importance of
encouraging the young women to attend classes with a
"support" person or partner. Moore (1984) also identifies
the childbirth class as supportive. Moore (1984) states
"for some adolescents, the childbirth class may be the
primary support group during the last trimester of
pregnancy" (p. 7).

Taylor (1984) 1J1 a. report on the St. Paul
Maternal-Infant Care Project (MIC) identified the importance
of a support person in prenatal class attendance. Part of
the project involved weekly prenatal classes offered at the
clinic site one hour before scheduled exam appointments.

Class attendance was expected so in that sense mandatory.

68

Adolescents ‘were urged to begin class at any point in
pregnancy and were encouraged to bring a "significant other"
to class. It was noted that many adolescents seemed more
willing to attend with a companion. Taylor (1984) states
that "this companion. might. well represent the patient's
primary source of emotional support and thus would be better
able to later reaffirm and interpret information
communicated in class" (p. 11). While these results cannot
be interpreted. as if they were research studies it is
apparent that the effect of social support on the pregnant
adolescent has at least been identified and appears to be a
concept worthy of testing in formally designed research.

One research article can be identified that does
address social support and the pregnant adolescent
specifically. Barrera (1981) examined the relationship
between social support and the well-being of pregnant
adolescents. The sample consisted of 86 primiparous,
ethnically diverse women less than 20 years old who were
attending an alternative school for pregnant high school
students and/or a county health department clinic. Eight
female research assistants interviewed participants and
administered four scales. The order of presenting the
scales was determined individually for each subject. These
scales included Negative Life Events, Social Support Network
Indexes, Receipt of Natural Helping (ASSIS) Behaviors (ISSB)
and Maladjustment. Correlation and Regression statistics

were used to analyze the data.

69

Results indicated that the measure of stressful life
events was positively correlated with the ISSB (p .001)
positively correlated with support need (p .001), and
negatively correlated with support satisfaction (p .001).
According to these results the ISSB reflects increased
supportive (activities that are in response to stressful
events. In addition, the presence of negative events may
diminish individuals' satisfaction.*with the support ‘they
receive. Also, according to these results, the qualitative
indexes of support, that of satisfaction and need for
support, prove to be the strongest predictors of
symptomatology. Barrera's study (1981) appears to be a
sound and much needed contribution to the literature in the
area of social support and the pregnant adolescent. Barrera
(1981) uses a definition of social support that is
mmltidimensional. The development of the instruments used
to identify these dimensions was explained in detail and
adequate validity and reliability were displayed.
Limitations to this study include the fact that no
indication was given as to how the sample was collected.
Also married and unmarried adolescents were used. It may be
that one or the other of these groups adjusts to pregnancy
differently. The fact that the study populations of the two
agencies overlapped may also have a bearing on the results.
All this in perspective, Barrera's contribution to the

literature cannot be diminished.

70

Social Support and Self-Care

Since prenatal education can be considered one aspect
of health education as well as a self-care practice, it is
important 1x) examine the literature in relation to the
effect of social support on these two areas. Hubbard,
Muhlemkamp, and Brown (1984) used a two study approach to
investigate the relationship between individuals' perceived
level of social support and their performance of specific,
positive health practices. The sample from the first study
consisted of 97 senior citizen volunteers, 55 to 90 years
old from a senior citizen's center in a southwestern
metropolitan area. Fifty-seven participants were female and
40 were male. Instruments used were the Personal Resources
Questionnaire (PRQ), Part II with an alpha of .89 and
validity coefficients of between .30 and .44 (p<(.001). The
Lifestyle Questionnaire was used to measure the following
six kinds of health practices: nutrition, exercise,
relaxation, safety, substance abuse, and prevention
practices. This instrument had an alpha of .76 and Validity
of Means and standard deviations were the statistics used to
analyze the data.

The second study consisted of 133 volunteers 15 to 77
years old attending a health fair in a large metropolitan
area. Fifty-eight. participants ‘were female and 73 were
male. The same instruments employed in the first study were
used in the second study. The results of both studies

indicated that social support was the most significant

71

indicator in positive health practices. Some limitations to
this study include the nonrandom nature and small size of
both samples. The settings of both studies may also have a
bearing on the results since Study I looked at social
support in a social setting. The individuals in Study II
were attending a health fair. These individuals' motivation
to attend such a screening service may have a bearing on the
results.

A paper by Minkler (1981) addresses social support
theory and health education for the elderly. Minkler (1981)
hypothesizes that the existence of a supportive network may
mean that an individual is being encouraged by his or her
social contacts to take preventive health action or to seek
needed medical treatment. Minkler (1981) identifies "social
marginality" of the elderly contributing to such problems as
inadequate nutrition, housing and medical care. Minkler
(1981) suggests that efforts to facilitate support among
these elderly persons may in. turn. facilitate their' own
impowerment and thereby increase their physical and mental
health. Obviously these hypothesis need to be tested and
generalizability from the elderly population to other age
groups may not be accurate however Minkler (1981) does pose
questions that need to be considered. In a sense, the unwed
pregnant adolescent may be considered "socially marginal".
Consideration of social support and its effect on social
marginalty may be important in increasing' attendance .at

prenatal classes for this younger age group.

72

In summary then , whi 1e not backed by social support
research studies , some literature can be identified that
suggests social support is a factor in self-care . This

suggests the need for further research.

Conclusion

 

The current literature pertaining to the pregnant
adolescent, prenatal class attendance, social support and
social support and the pregnant adolescent was discussed in
this chapter. This current project is important due to lack
of literature on the effect of social support on prenatal
class attendance in the specific population group of unwed
pregnant adolescents. Not only is adolescent pregnancy a
stressful event, but it is also an event that could
reasonably be influenced by the presence or absence of
social support. Nurses are in an ideal position to assess
this area of social support since assessment is the initial
step inherent in the nursing process. The methodology

employed in this project will be presented in Chapter IV.

CHAPTER IV

METHODOLOGY

Overview
In this chapter, an assessment tool to identify social
support factors likely to influence attendance of unwed
pregnant adolescents at a prenatal learning situation is
presented. Development of this instrument is discussed as

well as a proposed methodology for its implementation.

Sample

The sample selected for this study will include unwed,
primipara, adolescents between the ages of 15-19 who have
made the decision to keep their baby, are past the twelfth
week of gestation and have no known chronic disease,
documented psychiatric problems or documented mental
retardation.

Since younger adolescents, ages 12-14 are considered
different from older adolescents both in psychological
factors and physical maturity, younger adolescents will be
excluded (see Chapter I). In addition, because of the
different dynamics that exist between pregnant adolescents
who are married and pregnant adolescents who are single,
married adolescents will also be excluded. By choosing

adolescents in the second trimester of pregnancy perception

73

74

of the pregnancy may be more uniform. Also most normal side
effects of pregnancy such as nausea, vomiting and urinary
frequency have ceased by the second trimester and the
pregnancy has been positively confirmed.

Other factors that may affect the results of the study
include the adolescent's decision to keep the baby or give
it up for adoption, whether the adolescent had previous
pregnancies and her state of health. Because of these
factors, participants will include only those adolescents
who have decided to keep their baby, are in good health and
have no known chronic diseases such. as diabetes, heart
disease, kidney disease or epilepsy.

The sample will be chosen by convenience sampling. As
large a sample as possible is suggested to assist in
establishing reliability and validity of the instrument. To
limit generalizability, the sample must be chosen from
communities with similar characteristics. Time and actual
numbers ‘of unwed, pregnant adolescents available from
similar communities willing to participate in the study will
have a bearing on sample size used. It is suggested that a
sample size of at least 50 unwed pregnant adolescents would

be adequate.

Study Site

 

The study site for this project will be a tri-county
area in rural south-central Michigan. Data will be
collected from three County Health Department Prenatal

classes, and three alternative education classes for

75

pregnant. teens associated. with. the high schools 1J1 each
county. All classes are free.

The Health Department Prenatal classes are offered to
an expectant woman and are not specifically geared toward
the adolescent. The two hour sessions are held three times
a year, once a week for seven weeks in the evening. The
classes are taught by public health nurses in each county.
The goal of the classes is to increase the expectant
parent's knowledge and understanding of pregnancy,
childbirth and the new family. The primary method of
teaching is lecture. The content of the classes include
anatomy and physiology, expected physical and emotional
changes, nutrition, labor and delivery, prenatal exercises,
obstetric unit tour, postpartum care, infant care and family
planning. The last class includes information on "living
with a baby" such as immunizations, infant safety, effects
of a baby on family relationship and newborn growth and
development.

The other site for the data collection is the
alternative education classes for pregnant teens affiliated
with the local high schools. The goals, method of teaching
and class content are essentially the same as the classes
offered through the health department. The same health
department personnel teach these classes. Unlike the health
department classes, the alternative education classes are

offered during the school day as part of the pregnant teen's

76

cirriculum. Class attendance is encouraged but is not

mandatory.

II.

Operational Definitions

Sociodemographic questions are included to characterize

the sample obtained. Sociodemographic characteristics

include age, religion, present health stage or
pregnancy, income level, education level, and ethnic
background. (See Appendix A, Part A, questions 1 -

17.)

Nature of support refers to source of support, type of

support and timing of support.

A. Source of support refers to the person or persons
who are providing the support. This may include
parents, peers, boyfriend, father of the baby,
professional care giver, to name a few. (See
Appendix A, Part B, Question A, l & 2; B, 1 & 2; C,
1 & 2; D, l & 2; E, l & 2; F, 1 & 2.)

b. Type of support provided differentiates between two
kinds of support available as discussed in Chapter
II. These include:

1. emotional support which involves serving as a
confidant and providing empathy as well as
acceptance and understanding. (See Appendix A,
Part C, Questions 1-4)

2. tangible support which is concrete "real"
assistance involving' material aid and/or

information. Examples include money, housing,

77

insurance, personal services i.e.,
baby-sitting, transportation, food and
explanation of procedures . (See Appendix A,

Part C., Questions 5-8)

c. Timing of support refers to support offered at one
point in time or continued, supportive interactions
over an extended period of time. (See Appendix A,
Part B; Questions A, 5; B, 5; C, 5; D, 5; E, 5; F,
5)

III. The adequacy of support refers to the extent to which
an individual perceives the environment. to be
supportive and is based on opportunity and need (See
Appendix A, Part B; Questions A, 3-4; B, 3-4; C, 3-4;
D, 3-4; E, 3-4; F, 3-4

IV. A. prenatal learning situation is a structured

interaction occurring at regular intervals for the purpose

of increasing the participant's knowledge of pregnancy,
labor and delivery, the postpartum period and any related

issues.

Instrument Development
Several instruments aimed at assessing social support
are available in the literature. No instrument can be
identified that assesses social support in the unwed
pregnant adolescent. Thus, the development of this
instrument is based on synthesis of material previously

developed in other instruments.

78

Brandt and Weinert (1981) developed The Personal
Resource Questionnaire (PRQ) which is a two-part measure of
the multidimensional characteristics of social support. The
definition of social support used in the develOpment of the
instrument is a synthesis of concepts with a strong emphasis
on Weiss's (1974) model of relational functions. The
following five functions are included: (1) The indication
that one is valued, (2) that one is an integral part of a
group, (3) the provision for attachment/intimacy, (4) the
opportunity for nurturance, and. (5) the availability «of
information, emotional and material help. Both parts of the
questionnaire measure sources of support. Part I provides
discriptive information. regarding resources, satisfaction
with these resources and whether or not there is a
confidant. Part II consists of a 25 item scale, with
responses made in a 7 point Likert foremat, developed to
identify five dimensions of social support proposed by Weiss
(1974); intimacy, social integration, nurturance worth and
assistance.

The PRQ was used as the measure of one independent
variable in a study that examined the impact of social
support on the "well" spouses' ability to sustain the
functioning of the family system during a long-term illness.
An internal consistency reliability coefficient of G<3= .89
was obtained for Part II. In establishing validity the
correlations between the scores on each criterion measure of

family integration and the PRQ - Part I and the scores on

79

each criterion measure and the PRQ Part 2 were modest. For
Part I the validity coefficients was .30 to .44 (p < .001).
In testing the distinctiveness of the subscales in the
PRQ-Part II a moderate intercorrelation ranging from .58 to
.62 (p < .001) was obtained for the subscales of intimacy,
social integration, worth, and assistance. Some overlap of
these scales is suggested with these results. Relatively
low correlations of .26 to .38 (p < .001) for the nurtuance
subscale with the other four dimensional subscales indicates
that nurturance is an independent scale. This suggests
there may be only two statistically defined dimensions
rather than the five proposed initially. Continued
evaluation of the instrument should be done with a larger
sample and more diversified groups.

Norbeck, Lindsey and Carrieri (1981) developed the
Norbeck Social Support Questionnaire (NSSQ) to measure
multiple dimensions of social support based on Kahn's (1979)
definitions of social support and definitions from network
theory. The questionnaire was developed for self
administration. Each respondent lists each significant
person in his/her life, up to a maximum of 20 people. Next
the respondent categorizes each person from a list of
categories presented in the instructions. The respondent is
then asked to rate each network member on a five point
Likert scale ranging from 1=not at all to 5=a great deal,
according to affect, affirmation and aid. Two questions

were developed for each category. Duration of the

80
relationship, frequency of contact and recent losses were
also assessed.

In testing the instrument, two groups of subjects were
used. One group was composed of 75 first-year graduate
students. The second group included 60 senior nursing
students. Subjects were recruited in the classroom. The
NSSQ was administered to 75 group one subjects initially and
to 67 of the same subjects in a retest one week later.
Affirmation, affect and aid and network property items had a
high degree of test - retest reliability (range = .85 to
. 92) . Internal consistency was tested thru
intercorrelations among all items. Correlations between the
two affect items was .97; between the two affirmation items
.96 and between the two aid items, .89. The affect and
affirmation items were also highly related (.95 to .98)
which strongly suggests that these two functions are not
distinct. The aid items had lower correlations between the
affect or affirmation items (.72 to .78). Evidence for
concurrent validity was obtained through moderately high
correlations with another questionnaire, The Social Support
Questionnaire ( Schaefer, et al., 1981). The results of
this study suggest that the NSSQ may be a useful research
tool but additional work is needed.

In the attempt to further develop this questionnaire a
second phase of testing was designed (Norbeck, J. S.;
Lindsey, A. M. & Carrieri, V. L., 1983). Three studies were

conducted to provide a formative data base and to further

81 _
test validity. The first study examined 136 employed adults
and described the amount, type and sources of support
available. This enlarged the data base from college
students to include male and female adults functioning in
work roles. Study 2 examined the sensitivity and stability
of the instrument over a seven month period. The
correlations ranged from .58 to .78, which represents a
moderately high degree of stability over time. The third
study tested concurrent validity with another social support
questionnaire, the Personal Resource Questionnaire (Brandt
and Weinnert, 1981) and predictive validity in relation to
the stress-buffering role of social support described in the
literature. Further testing of this instrument in other
clinical investigations with varied populations will
contribute to the establishment of an accurate validity for
measurement.

Barrera (1981) developed a two scale instrument to
measure social support. The definition on which the
development of the instrument was based describes social
Support as "activities directed at assisting others in
mastering emotional distress, sharing tasks, giving advice,
teaching skills, and providing material aid" (Barrera,
1981, p. 73). The first scale, The Inventory of Socially
Supportive Behaviors (ISSB), is a behavioral measure of
social support. The scale consists of 40 items of helping
behaviors to be rated by the respondents according to

frequency of occurrence on a 5-point Likert scale ranging

82

from "not at all" to "about every day". An internal
consistency alpha coefficient (.93 and .94) was obtained for
the first and second administration. of the scale
respectively. A second scale, The Arizona Social Support
Interview Schedule (ASSIS) was developed to assess the
people who supplied resources and the subjective appraisal
of the adequacy of support. Six support functions formed
the basis for questions that were used to elicit names of
network members. These functions were (1) private feelings,
(2) material aid, (3) advice, (4) positive feedback, (5)
physical assistance, and (6) social participation. In
addition, sources of interpersonal conflict were assessed.
To assess support satisfaction and need, subjects were asked
to use a 3-point scale for rating their satisfaction with
the support they receive and how much they needed that
support during the past month. Test-retest correlations
showed that total network size was a stable indicator (.88
p < .001). Conflicted network size had a significant but
lower test-retest correlation (.54 p <1 .001). The support
satisfaction measure suffered from a skewed distribution
that favored high satisfaction scores. A moderate
test-retest correlation (.69 p <: .001) was obtained. This
two scale instrument was used in a study to assess the role
of social support in the adjustment of pregnant adolescents.

See Chapter III for a review and critique of this study.

83

In summary, several previously developed instruments
have been found that assess various aspects of social
support. All studies addressed social support as a
multidimensional concept. Reliability_ and validity are
inadequate. However, the dimensionality of social support
has not been clearly established. The instrument used in
this project is a synthesis of previously developed
instruments. Since no instrument has been found that
specifically addresses the assessment of social support in
the unwed pregnant adolescent population, development of
this instrument would increase research aimed at better
understanding social support and its role in self care

practices.

Instrument

 

The following questionnaire evolved from the literature
review and is adapted from previously developed tools. Part
A of the instrument describes demographic data such as age,
educational level, ethnic background and employment status.
(See Appendix A)

Part B is a modification of the A8818 developed by
Barrera (1981). (See Appendix A) This tool was discussed
earlier in this chapter. The purpose of this section is to
identify people who specifically serve a supportive
function, in addition to assessing the subject's
satisfaction with and need for support. Barrera (1981) used
"the past month" as a time reference for having received

support. This researcher feels this is too narrow a time

84

frame for the unwed pregnant adolescent and that six months
would be a greater indicator of true support. Because major
sources of support could also constitute major sources of
strain an additional question is asked (See Appendix A, Part
B, Section G, 1-2). To allow for distinctions between
strictly supportive network members and those who are in
addition sources of interpersonal conflict, two questions
are asked. One question identifies people with whom the
teen might expect to have negative interactions. The other
question identifies with whom the teen actually had a
negative interaction. (See Appendix A)

In Part C of the instrument, two types of support are
measured. (See Appendix A) This part of the tool was
adapted from the Norbeck's Social Support Questionnaire
(NSSQ) (Norbeck, J. S.; Lindsey, A. M.; Carrieri, V. L.,
1981), also discussed previously in this chapter. The

complete Questionnaire can be found in Appendix A.

Proposed Methodology

Pre-testing the instrument

The first step in utilizing the questionnaire would be
to pre-test it for clarity and readability. This
pre-testing can help identify areas of unclear terminology
and poor understandability before the questionnaire is used
for the full-scale study. It may also identify areas where
additional questions are needed. As a result of the
pre-test other questions may be eliminated. Subjects

participating in the pre-test should be similar in

85

characteristics to those who will be involved in the final
study. After the pre-test, discussion of the questions with
the participants is helpful to determine any unforeseen
problems or reactions-to the instrument. Revision of the
instrument would follow.

Reliability

 

"The reliability of a measuring instrument is a major
criterion for assessing its quality and adequacy" (Polit &
Hungler, 1978, p. 424). Essentially, reliability can be
defined as the degree of consistence with which the
instrument measures the attribute it is supposed to
measure." (Polit & Hungler, 1979). The less variation an
instument produces in repeated measures of an attribute, the
higher its reliability. Thus, reliability can be equated
with the stability, consistency or dependability of an
instrument over time or over multiple items. Internal
consistency or the degree of interrelatedness among items
will be determined by the coefficient alpha.

Validity

Validity means that an instrument measures what it is
intended to measure. One type of validity, content
validity, refers to how representative the questions are of
all questions that could be asked about a particular topic.
Are the questions in this instrument representative of all
the questions that could be asked about social support of
pregnant adolescents? The content validity of an instrument

is based on judgment and cannot be measured objectively. To

86

assure content validity test items should be written after
careful review of the literature and analyzed by experts in

the content area.

Data Collection Procedure

Adolescents meeting the criteria for inclusion and
stating they are planning on attending prenatal classes will
be approached by an office nurse during a clinic/office
visit about participating in this study. The purpose of the
study will be explained and confidentiality and anonymity
assured. An estimation of the amount of time and effort to
complete the questionnaire will also be given. The
participant will not be told that her attendance at the
prenatal class will be recorded. After this explanation and
a willingness to participate in the study is expressed, a
signed consent form will be obtained. A copy of the
questionnaire in a sealed envelOpe will then be given.
After completing the questionnaire the participant will
return it to the clinic nurse in a second sealed envelope.
Frequency of attendance will be recorded at the prenatal
classes by the instructor. At the end of the study a

debriefing letter will be sent to each participant.

Human Subject's Protection
A complete explanation of this study will be presented
to the University Committee on Research Including Human

Subjects. Guidelines and procedures of this committee will

87

be strictly' adhered to and no actual research will be
conducted until approval is given.

Participants will be assured of freedom to refuse, and
freedom to withdraw from the study without having their
health care affected. Confidentiality and anonymity will be
strictly maintained. In the event that questions or
concerns might arise in the future, participants will be

given the name and phone number of the researcher.

Scoring

The data obtained from Part A of the instrument would
be used to describe demographic variables of the unwed
pregnant adolescents that participate in the study. This
data will be summarized and described using means.

Part B of the instrument will describe people who are
sources of support and people who are sources of
interpersonal conflict. The number of people providing
support and the number of people who are sources of
interpersonal conflict will be totaled separately then
converted to means and then to percentages.

Part B also describes satisfaction with support and
timing of support. These areas will be weighted and scored.
For example, there are 12 possible questions on adequacy.
Using a Likert scale, high adequacy is given a "4" and low
adequacy a "1". Therefore, the highest possible score for
high adequacy would be ”48". The lowest possible score for
low adequacy would be "12". Thus, it would be pessible to

get a range of scores.

88

Part C of the instrument will measure types of support,
either emotional or tangible. A 5 point Likert scale with
"l" as low support and "5" as high support will be used. A
mean score ‘will be computed for each subset, emotional
versus tangible support. The range of mean scores would
then be from 1.00 to 4.00.

Class attendance at prenatal classes will also be
recorded. Class attendance will be computed on a percentage
basis. Subjects attending 50% or more of the classes will
be classified asattenders while subjects attending less

than 50% will be classified as non-attenders.

Data Analysis

 

The initial step in data analysis of this project would
be to analyze the sociodemographic data using descriptive
statistics. Means and frequencies of distribution could be
used to identify significant correlations between
sociodemographic data and class attendance.

The amount of support, satisfaction with support,
timing of support, amount of interpersonal conflict and the
type of support (i.e. emotional. vs. tangible) to class
attendance. This is classified as correlation. Do
adolescents with higher support scores show up for more
classes? Pearson Product Moment Correlation may be used to
identify these significant correlations.

In Part A, Pearson Product Moment Correlation may be
used to identify significant correlations between

demographic variables and class attendance. In Part B

89

Pearson Product Moment Correlation may 1x3 used to identify
significant correlations between the amount of support,
satisfaction with this support, timing of support, amount of
interpersonal conflict and. class attendance. In. Part (2
Pearson Product Moment Correlation may be used to identify
significant correlation between the type of support (i.e.
emotional vs. tangible) and class attendance.

A discriminant analysis of the study variables may then
be used to interpret the data further as it would provide a
more sensitive interpretation of the data. To distinguish
between two or more groups of people (i.e. attenders vs.
nonattenders) discrimination variables that measure
characteristics on which of the groups are expected to
differ, are chosen. In this study the participants would be
divided into two groups, attenders and nonattenders. The
discriminating variables on which of these groups are
expected to differ are amount and types of support as well
as timing of support and satisfaction with support. The
advantage of this analysis is that it allows for
discrimination between groups and allows fbr prediction of
behavior if certain variables are found to occur
significantly more often in one group than the other. This
analysis then would enable the researcher to develop a
profile of "at risk" unwed pregnant adolescents.

Summary
In this chapter the development of an instrument to

identify social support factors of the unwed pregnant

9O

adolescent that may affect attendance at a prenatal learning
situation is presented. A proposed methodology for
implementation is also included. A summary of the project
and implications for nursing practice, research and

education follow in Chapter V.

CHAPTER V

SUMMARY AND CONCLUSIONS

Introduction

 

In Chapter V a brief summary of the project is
presented. Recommendations for further study as well as
implications for nursing practice, education and research

are also discussed.

Summary

Teenage pregnancy is a topic that has been studied over
a number of years. Adolescent pregnancy remains a national
health issue of major proportions. According to the
Guttmacher' report (1981) there are more than a million
pregnancies among adolescents each year and more than six
hundred thousand youths delivering infants.

Delivery of an infant during adolescence has immediate
as well as long range effects on the individuals involved.
Physical, social, educational and economic aspects of life
are affected. The physical effects for the mother include
anemia, poor weight gain and delivery complications although
data are equivocal. The effects on the infant are more
definite. Often, the infant is Of low birth weight, subject
to the risks inherent to that condition. Infants born to

adolescent mothers lead to poorer performance patterns in

91

92

school and lower intelligence quotients. (Guttmacher, 1981)
However, improved prenatal care can positively affect many
of these outcomes. Childbirth education classes or
expectant parent classes have emerged as a part of this
prenatal care. Unfortunately, as stated previously, it has
been noted that few adolescents attend these prenatal
classes. The goal of this study is to examine one area that
may affect the attendance of the unwed pregnant adolescent
at these classes.

Nuismer (1981) identified certain aspects of social
support that indicated whether a pregnant adolescent was
more likely to attend these classes. In gaining a greater
understanding of why unwed pregnant adolescents do not
attend prenatal classes, strategies can be developed that
would improve attendance and therefore enable the nurse
clinician to improve the quality of care to this client
population. Nuismer's study (1981) is also important in
increasing our understanding of social support's potential
role in the adjustment to stressful life events. Not only
is adolescent pregnancy a stressful event, but also an event
whose impact on the individual's well-being could reasonably
be influenced by the presence or absence of social support.

Health care is changing rapidly in this country.
Health care costs are soaring and there is a major effort on
many fronts to keep health care costs down. Earlier
hospital releases, alternative birthing choices and the

affects of proper diet and exercise on pregnancy are all

93

factors that have implications for the necessity of prenatal
education classes as an important component of prenatal
care. In order for these classes to be effective, however,
adolescents must attend. Therefore, ,attendance is an
important concept that needs to be studied. Factors that
affect attendance need to be examined, thus enabling the
nurse clinician to identify strategies that can increase
attendance. Further study of this topic will contribute to
an increase in the knowledge base and improved quality of
care. A study in this area can impact society in general by
decreasing pregnancy complications, thus improving pregnancy
outcome and thereby decreasing health care costs.

A tool was developed based on literature and previously
developed tools to assess social support of the unwed
pregnant adolescent. The instrument obtained demographic
data, persons the adolescent felt were supportive,
satisfaction with support received, and types of support,
emotional vs. tangible, that were received. Data collection
is now needed to fully determine the usefulness of this
tool. However, this project can increase the nurse's
understanding of a potential need of the unwed pregnant
adolescent that may enhance or interfere with attendance at
prenatal classes thereby increasing the client's self—care
potential or ability.

Limitations of the study as well as implications for
nursing practice, nursing education and future nursing

research will be presented in the following sections.

94

Limitations of the Study

Anticipated limitations of the study may include the

following:

1.

Since the questionnaire will be completed by the
pregnant adolescent during a scheduled office or
clinical visit, other variables may affect the
adolescent's responses to the questionnaire.

Since data collection can occur at any point after
the 12th week of pregnancy, the adolescent may
already be attending prenatal classes. This may
affect some of the responses.

Factors other than social support are not measured
by ‘the instrument and. may influence class
attendance. For example the teen may feel she had
no choice about attending.

The instrument wording may be unclear or misleading
to adolescents.

The stage of the pregnancy may affect the
adolescent's responses.

The length of the tool may affect how the
adolescent responds.

The adolescent may receive help in filling out the
questionnaire, especially if someone accompanies
her to the doctor or clinic visit.

The concept of time as operationalized in this
study is too global. Future research may include

frequency.

95

Implications for Nursing Practice

The implications for nursing practice will be discussed
within the context of the nursing process adapted from Orem
(1980). According to Orem the nurse's goal is to increase
the client's ability to perform self-care. Self-care is
defined as "the practice of activities that individuals
initiate and perform on their own behalf in maintaining
life, health, and well-being" (Orem, 1980, p. 35).

When working with the pregnant, unwed adolescent, the
goal of the nurse in expanded practice is to increase the
teen's self-care abilities. Therefore, the pregnant
adolescent is able to achieve her maximum health potential
and is able to adequately care for her infant. One way this
goal may be accomplished is by successfully promoting
attendance by the teen at expectant parent classes. By
attending prenatal classes, the pregnant teen is able to
learn behaviors that contribute to a healthy pregnancy as
well as to a healthy baby. The nursing challenge is to
identify ways to increase attendance at expectant parent
classes by this specific population. The nurse in an
advanced practice role is in a key position to identify from
the client persons who provide social support factors that
may have a bearing on class attendance and assist the client
to mobilize these "supports" so that successful class
attendance is accomplished. The nurse in primary care
provides accessible, continuous, coordinated care to this

adolescent. The Family Clinical Nurse Specialist (FCNS) may

96

already have a data base useful in identifying social
factors because of previous contact with the adolescent as
well as other family members. Because the FCNS develops a
continuous relationship over time, the FCNS has the
potential to impact the adolescent's relationship with her
infant. Social support information previously assessed may
be updated and applied to the development of strategies that
enhance the mother/infant relationship. In addition, the
nurse in primary care is in an ideal position to assess
social support with all adolescents, not just the unwed
pregnant adolescent.

In utilizing the nursing process, the nurse must assess
sociodemographic variables as well as support available to
the teen. The adequacy of this support and the kind of
support available may enable the nurse to identify "at risk"
individuals. The assessment tool developed in this project
could be used for this purpose. The nurse must help the
client identify lack of social support that may interfere
with successful class attendance. However, the tool
developed for this project is long. Due to time
limitations, use as a quick assessment tool in the clinical
setting would be unrealistic. Two important areas of the
tool that may be quickly assessed include adequacy and
sources of support. The nurse may assess adequacy by asking
the teen how much she felt she needed to discuss feelings or
needed some physical assistance, if she would have liked

more and if she received too much support. Sources of

97

support. can. be assessed. by asking the teen to identify
individuals who serve supportive functions such as
listening, loaning money or giving information. The nurse
must form his/her own perceptions of adequacy or lack of
support and share these with the pregnant teen. Thus, the
two would form a therapeutic relationship and base the goals
or outcomes of the relationship on mutually defined problems
(Orem, 1980). During this assessment phase it is possible
the client may not perceive a lack of social support or may
perceive support that is not actually available. Here the
nurse may use anticipatory guidance to assist the individual
in identifying real or potential problems. By assisting the
client to identify potential problems a nursing diagnosis
can then be developed and used to guide nursing
interventions.

In addition to the area of support members, one area
rarely assessed, is sources of interpersonal conflict. The
nurse in an expanded role must acknowledge this area and
include it in a complete assessment. Thus, the therapeutic
regimen will be based on the individual's perceptions and
individualized to the client. At the initial visit, the
FCNS may begin assessment of potential conflicting
relationships by identifying some sociodemographic
information such as who the teen lives with. In addition,
observations of who accompanies the adolescent to the clinic

and the interaction between these people can be accomplished

98

at the first visit. If the pregnant teen comes to the
clinic alone, it is important for the nurse to find out why.
Questions that directly elicit sources of interpersonal
conflict may not be appropriate for the first visit.
Because of involvement in the primary care, the FCNS is in
an ideal position to develop a rapport with this client over
time. Thus, continued assessment of sources of
interpersonal conflict can be accomplished. It is important
that the nurse in advance practice be aware that the nurse's
perceptions of support and supportive persons may differ
greatly from the client's view of support. It is vital that
a tool based on the client's perceptions be used so that
nursing intervention is based on the patient's perceptions.
Thus, it is important for the nurse to recognize that not
all supportive relationships are positive. When assessing
support, it is important for the FCNS to determine whether
the client perceives this support as positive or negative.
Teens at risk for not attending need to be identified
and alternative nursing intervention must be developed. On
the first visit, the FCNS may again obtain information on
areas that might affect attendance such as transportation
and problems with school attendance. If the teen has no
transportation (n: unreliable transportation, attendance at
prenatal classes may be affected. In addition, a history of
minimal or erratic attendance at school could have a bearing

on prenatal class attendance.

99

On the first visit as well as at subsequent visits
parts of this tool could be used to elicit sources of
support, thus, identifying teens with decreased or minimal
support. For example the FCNS might ask who the teen goes
to when she needs someone to talk to or who would loan her
money if she needed it.

In the planning and implementation phase the nurse and
patient must design a system of nursing assistance together
that will facilitate a supportive relationship. This
project has several implications for efforts to develop and
implement interventions directed at aiding pregnant
adolescents as well as other groups facing critical life
transitions. Strategies to assist adolescents in expanding
the number of their significant relationships that provide
support may be a potential value. Even those relationships
that are supportive, however, might be ineffective in
facilitating adjustment if they are also sources of
interpersonal conflict. Interventions designed to eliminate
conflict in otherwise supportive relationships would
seemingly strengthen the role of social networks aiding the
adjustment of people undergoing major life changes.
Satisfaction should be a primary target of interventions.
Changing the adolescent's sense of satisfaction with the
support they receive is the goal.

It is evident that nursing is in a unique position to
assist the patient in the goal of self-care. Nursing can

provide anticipatory guidance early in the prenatal period

100

so as to increase attendance at prenatal classes and help to
improve pregnancy outcome. The nurse can provide ongoing
assessment and problem solving during and throughout the
entire pregnancy and postpartum period. The nurse in
primary care is in an ideal position to look at other areas
of self-care in addition to attendance at prenatal classes.
Does the adolescent return for the postpartum exam? Does
the teen participate in monthly self breast examinations?
The FCNS may assess satisfaction with the process of health
care delivery itself. Can the adolescent verbalize that she
"feels good" about the care she received? Because of the
family focus, the FSNS can assess health care for the baby.
Does the teen bring the infant for immunizations? Does the
teen have and use a car seat?

Other health care providers may be utilized in
assisting the pregnant adolescent to attend prenatal
classes. Social workers, teachers, dieticians, public
health nurses as well as other nurses may all provide unique
support that may benefit the client at different times. The
clinical nurse specialist is in an ideal position to help
coordinate these other disciplines so an effective goal is
realized.

When support persons are identified, the clinical nurse
specialist can help facilitate these relationships so the
teen receives the maximum benefit. Some strategies to
accomplish this may include encouraging attendance of a

particular support person at clinic appointments and

101
including this support person in clinic activities with the
client. Providing separate discussion groups for support
persons, to increase their understanding of what the
pregnant teen is experiencing may be, another strategy.
Because of the continuous, ongoing relationship with this
adolescent client, the nurse in primary care is in an ideal
position to be a support person herself. At regular clinic
visits, the FCNS can show interest and give positive
reinforcement to the adolescent client attending prenatal
classes. The FCNS can also assess how the adolescent likes
these classes. At a regular clinic visit, during the time
the adolescent is attending prenatal classes, the FCNS might
ask questions such as what were some factors that made you
attend classes? Do you find the classes of value to you?
Strategies may then be implicated to help the adolescent
view the classes as valuable.

The nurse must be aware of other factors in addition to
social support that may affect whether or not the teen
attends prenatal classes. One obvious area is the method of
instruction. Group learning may not be suited to everyone's
learning needs. The FCNS should make some assessment at the
first or second clinic visit regarding previous group'
participation. For example, does the teen participate in
any group functions during or after school such as band,
student council or sports. Is the teen involved in a church
group? If the FCNS identifies no previous group experience,

then the adolescent may be at risk for not attending

102

prenatal classes. Individualized education strategies could
then be employed with these individuals who do not benefit
from a group learning situation. Contracting may be an
alternative. Allowing the pregnant teen to contract as to
the number of classes and which classes she may attend may
be a strategy used by the clinical nurse specialist.

Finally, the nurse in advanced practice in
collaboration with other disciplines in the community
especially schools and school administrators may plan and
develop special' programs. These programs designed
specifically to provide information about the physical,
social, economic and psychological implications of teenage
pregnancy could be aimed at peers, parents and others
affected by adolescent pregnancy.

In the evaluation phase of the nursing process,
progress toward goals and change in the system is assessed.
Progress would be based on a behavioral outcome of class
attendance. This may be affected by changes in support
persons, changes in feelings of adequacy of support and
changes in type of support needed at a specific time.
Constant evaluation and modification of the plan are
required through a joint relationship between nurse
clinician and client.

Due to the increased costs of health care today, there
is a movement to change the direction of health care from
treating the sick to preventing problems. Emphasis on the

recoqnition of a person's ability to care for his/herself

103

and identification of ways to overcome self-care limitations
would lead to more efficient use of health care services.
If people are helped to recognize and improve their own
self—care abilities and to use the health care system only
when an actual or potential limitation is identified,
inappropriate use of services would decrease. Emphasis on
self-care would also decrease the length of time an
individual may require health care services. It is
therefore timely for the nursing profession to address
itself to self-care issues. Nurses in advanced practice
must. develop innovative strategies to increase the
effectiveness of already established programs such as
prenatal education classes. One strategy would be to
conduct prenatal classes to include only the unwed pregnant
adolescents. Another strategy would be to have the classes
or parts of the classes taught by an unwed teen who has
already gone through the experience of pregnancy, birth and
parenting.

Political awareness and activity is essential in
supporting policy changes that recognize financial
reimbursement for nurses. These alternative strategies then
become viable options to assist individuals in successfully
performing self-care, therefore, helping in the fight to
decrease health care costs.

In summary, the clinical nurse specialist can assist
the unwed pregnant adolescent in performing self-care by

assessing social support factors that may enhance attendance

104

at these classes. Identification of adolescents "at risk"
for nonattendance may encourage development of alternative
strategies to increase class attendance in this group.
Support and development of community health promotion
programs aimed at decreasing teenage pregnancies is also an

important function of the clinical nurse specialist.

Implications for Nursing Education

This project can increase understanding of the
potential role of social support in adjustment to a
stressful life event, namely, pregnancy and thus, can be
valuable in recommendations for nursing education.

Nursing education programs should include the view of
the family as the basis unit from ‘which the pregnant
adolescent comes. Recognizing the pregnant adolescent as a
unique person coming from some type of family unit,
experiencing pregnancy and childbirth within the context of
this unit is important for all levels of nursing. However,
the adolescent and/or the family may not be the
stereotypical, ideal family. Therefore, it. is important
that nursing education programs address the controversial
nature of teenage pregnancy and motherhood with its
physical, social, economic and psychological implications.
The unwed pregnant adolescent is an area that is often
viewed very subjectiveLy and can illicit highly moralistic
feelings. It is an area many people feel strongly about.
All levels of nursing education programs should address this

issue beginning at the undergraduate level, into graduate

105

education and more importantly in the area of continuing
education and staff development. Continued discussion and
emphasis of these feelings and how they impact care should
be an important aspect of staff development.

It. is important that. educational programs integrate
social support and its effects into the nursing cirriculum.
The instrument developed in this project could add to the
nursing knowledge base. Since little research is available
on the effects of social support in teen pregnancies, the
use of this social support questionnaire could provide some
beginning documentation of the relationship between social
support and attendance at prenatal classes. Research
results added to the nursing knowledge base could be
utilized in the nursing cirricula for advanced nursing
practice in primary care programs, as well as family focused
programs. These research results could also be used in
updating staff development programs. Continuing education
and staff development programs must legitimize social
support as a component of comprehensive patient care in the
development and implementation of inservice education for
practicing nurses in community and health care agencies.

Nurses involved in teaching prenatal classes should be
educated to factors that affect attendance at these classes.
One factor may be social support. Nurses must also be
educated to the many nursing interventions that can be used
to increase an individual's social support, thereby

increasing class attendance. The pregnancy study helps

106

provide data that social support alone may not be the only
factor to consider. Therefore, it is important to educate
the nurse to the fact that perceived satisfaction with
support is also important. The individual's perception of
social support must be taken into consideration when
developing a nurse management plan. Nurses must know that
each. individual. will have Iher own perception of social
support and that the nursing management plan must be unique
and individualized based on the perceived adequacy of social
support.

Nursing education programs must also include the
concept of self-care, especially in the changing arena of
health care today with it's increased focus on promotion and
maintenance of health. Normal pregnancy and childbirth are
not illness status and Orem's self—care approach may be
helpful in utilizing self-care with this client population
to increase social support and enhance self-care
capabilities. This emphasis can be promoted outside the
profession as well, particularly from this cost
effectiveness perspective. Further studies can demonstrate
the role of prenatal education and its effect on reduced
length of hospital stay or better parenting as examples.
Nursing cirricula should incorporate the findings from such
studies in the continued development of the clinician role.

The nursing process is an important aspect of nursing
education and must be included. This project addresses the

assessment of social support and utilization of the nursing

107

process in identifying social support, helping the client
mobilize supports and evaluating the effectiveness of this
support.

Nursing education programs should also include the
effects of sociodemographic variables and adolescent
pregnancy. Since previous studies have identified many of
the measures studied are confounded by variables moderately
to highly correlated with teenage pregnancy such as race and
social class. It is difficult to separate effects due to
age along from other factors. It is also valuable to be
aware of an individual's ethnicity, living arrangements,
financial status and education background when developing
nursing management plans.

Since attendance at prenatal classes may be a function
of the type of class offered the nurse must know the
different educative strategies such as individualized versus
group instruction. When working with the unwed pregnant
adolescent to attend classes, nurses must also be taught to
provide anticipatory guidance to the pregnant teen in terms
of the effect this pregnancy can have on her life. If the
nurse can provide anticipatory guidance and discuss
potential benefits of classes and how they can assist in
adjustment to this pregnancy, attendance may increase.

Nurses must be made aware of the importance of prenatal
classes to this client population. Prenatal classes can
have an impact on this client group. Nursing education must

encourage nurses to take this information and apply it to

108

other innovative education programs stressing self-care
strategies that may benefit this client population.
Parenting classes may be one good example. Attendance is
also important here and some of the same social support
factors may impact attendance at these classes.

Finally, nursing education programs should include the
importance of using nursing diagnoses when developing
nursing management plans. A nursing diagnosis describing
the social support an individual has and perceives she has
would be invaluable when developing strategies to increase
self-care abilities in prenatal class attendance as well as
other aspects of care. In undergraduate education, nurses
need clinical experience with the unwed pregnant adolescent.
Part of this experience may include observation of prenatal
classes attended by unwed pregnant teens. Care of unwed
pregnant teens during labor, delivery and postpartum period
may be useful in identifying differences between teens who
attended classes and those who did not attend.

In graduate education, the FCNS also needs clinical
experience with the adolescent. Involvement in continued
care of this age group to enhance maturational development
and help the teen develop good life long self-care habits is
important in identifying which anticipatory guidance is
needed. Other preventive self-care practices can be
stressed for example, dental care, breast self exam, car
safety and normal infant growth and development to name a

few.

109

In summary then, recommendations for nursing education
in undergraduate, graduate and continuing education and

staff development can be made.

Implications for Future Nursing Research
The tOpic of teenage pregnancy has been studied over a
number of years and the social climate seems to indicate
that current attention given this topic will continue.
Social support is also a tOpic that has been extensively
studied. However, the effect of social support on
attendance of the unwed pregnant adolescent at prenatal
classes has not been examined in previous research. Thus,
it is recommended that the instrument developed in this
project be administered at some point in time to address the
following research questions.
'1) What is the effect of social support on attendance
at prenatal classes.

2) Is there a difference in attendance at EPC between
high satisfaction with support and low satisfaction
with support.

3) Is there a difference in the kind of support
available and attendance at prenatal classes.

4) Are there specific sociodemographic variables that
affect attendance at prenatal classes.

Findings from a study utilizing this instrument would be
valuable in refining and improving the instrument as well as

the study design.

110

Recommendations for future research would include use
of different types of sample populations such as adolescents
receiving care from a private physician versus pregnant
teens receiving care in a clinic setting. The sample might
also include younger as well as older adolescents to examine
differences in social support and attendance between age
groups. Adolescents from different ethnic groups or
cultural backgrounds could be studied as well as adolescents
from broken homes versus intact homes to identify
differences among these groups.

The area of timing may be operationalized differently
in future research. Frequency may be a better measure. How
does support differ in type, amount and satisfaction in each
trimester?

A longitudinal study examining how social support might
change over time would be an interesting focus. One example
would be to assess social support at the beginning of the
class series and at the end of the classes. Another
recommendation would be to use this tool to assess sources,
satisfaction and types of support at the different
trimesters of pregnancy to identify differences in this
area.

A study could be done comparing adolescents who
completed classes with those who did not complete classes to
determine common sociodemographic characteristics. From
this research it may be possible to identify "at risk"

parameters.

 

111

Another useful study would be to examine attitudes of
the unwed pregnant adolescent towards prenatal classes.
Questions addressing why the teen attended or did not
attend, appropriateness of class content, expectations from
classes and whether or not the teen actually utilized
information that she learned in the classes might be
included. Answers to these questions would help in future
program development.

To add to previous research, the influence class
attendance has on pregnancy outcome for this specific
population could be examined. Comparing or contrasting
attenders versus nonattenders to determine statistical
differences in the outcome measures of weight gain of
mother, birth weight of the baby and type of delivery, would
add to the knowledge base of studies already addressing
effectiveness of prenatal education. Another interesting
perspective would be to compare attenders versus
nonattenders and other self—care practices such as when
prenatal care was started, number of prenatal visits, taking
vitamins and nutrition.

Since satisfaction with support is one area of support
addressed in this tool, future research could be focused on
what factors contribute to the development of satisfying
support. How do we go about changing the adolescent's sense
of satisfaction with the support they receive is an

important question to answer.

 

112

Peers are an important source of sexual education for
adolescents and as adolescence progresses, peer influence
tends to become increasingly important. An interesting area
for future research could be the involvement of adolescent
peer counselors in prenatal education for unwed pregnant
adolescents. Assessment of the affect and effectiveness of
these peer educators/counselors on social support and
attendance at prenatal classes would be an interesting
study.

In addition to nursing practice, this project has
implications for future research for other disciplines as
well. School officials, juvenile authorities, counselors
and psychologists should also be aware of the effects of
social support on the adolescent. There is a need for
future research that addresses social support factors that
may affect attendance at other programs aimed. at
adolescents, school completion courses, drug/alcohol
programs, and parenting classes to name a few.

Thus, recommendations for future research would
include:

1) Assess the effect of social support on class

attendance with different pOpulations.

2) Assess the effect of social support on class

attendance over time.

3) Assess the effect of attitudes on attendance at

prenatal classes.

4) Assess the effectiveness of prenatal education on

113

pregnancy outcome.

5) Assess factors that contribute to the development
of satisfying support.

6) Assess the implications of adolescent peer
involvement in the area of social support and
prenatal class attendance.

7) Assess the effect of social support on other
self-care practices.

8) Assess the effect of social support on attendance
at other programs aimed specifically at the
adolescent population.

In Chapter II a conceptual model is presented

illustrating the relationship between social support, the
unwed pregnant adolescent and attendance at a prenatal

learning situation with nursing intervention based on the

self-care concepts described by Orem (1980).
Recommendations for future research would include
development of a different conceptual model. Future

research could utilize Norbeck's framework for incorporating
social support into clinical practice (1981). This model
appears more global and contains eliments and relationships
that must be studied to incorporate social support into
nursing practice. In addition to other components it
incorporates the eliments of assessment, planning,
intervention and evaluation of the nursing process (Norbeck,

1981). It would be more advantageous to build on Norbeck's

 

114

model (1981) since it appears more comprehensive and has a

specific nursing focus.

Summary

In summary, then, this project has provided a
conceptual framework, review of literature and development
of a tool designed specifically to assess social support
factors in the unwed pregnant adolescent. Data collections
is needed to fully determine the usefulness of the tool
developed, but a foundation has been established for further
study. This chapter also included recommendations and
implications for nursing practice, nursing education, and

further nursing research.

APPENDICES

 

APPENDIX A

QUESTIONNAIRE

QUESTIONNAIRE
PART A
BACKGROUND INFORMATION
The following questions describe general things about you.

Please answer all the questions to the best of your ability.
Remember all information will remain confidential.

 

 

1. When were you born? T
/ / ._
(month) _Yday) (year) i
2. What was the last grade in school you completed? ,
(check one)
8th grade
9th grade
10th grade
11th grade

high school diploma
some post high school classes
some college

3. What kind of school do you attend?
(check one)

regular high school
vocational or technical school
alternative high school

adult high school

college

other (write in)

do not attend schoOl

 

4. What is your ethnic background?
(check one)

Black

White (Caucasian)
Mexican American
Native American
Asian American
Other

115

5.

6.

116

Before you became pregnant, which of the following
diseases did you have?

(check only those that apply)

heart disease
cancer
epilepsy (convulsive disorder)
—allergies
—diabetes

'_—_——kidney disease
—respiratory disease
any other not listed (write in)
none of the above

 

To the best of your knowledge, has any member of your
immediate family ever had the following (this includes
parents, brothers, sisters and grandparents)?

diabetes

high blood pressure
heart disease
stroke

cancer

multiple births
birth defects
genetic diseases

What is your childhood religious background?

no religious upbringing
Catholic

Protestant

Jewish

Other (write in)

 

Do you consider yourself a religious person? That is,
are your personal religious views a source of comfort to
you?

yes ;_____no

Are you working now at a job outside the home?
(check one)

working full time
working part time
unemployed

laid off

disabled

do not work

117

10. If earning money, what is your yearly income?

(check one)

do not earn money
below $2,000
$2,001 - $4,000
$4,001 - $6,000
$6,001 - $10,000
$10,001 - $15,000
$15,001 or over

11. Do you receive any financial help such as general
assistance, social security, WIC, medicaid or
foodstamps?

yes no

 

 

12. With whom are you now living?
(check all that apply)

parent or parents

other family member (brother, sister, aunt,
uncle)

boyfriend

friend or friends

No one, I live alone

any other person not listed
(write in)

 

13. Do you smoke?

have never smoked
used to smoke but quit

currently smoke - if so, how much
(write in)

 

14. How much beer, wine or alcohol do you drink?
(check one)

never drink
used to drink but quit

currently drink — if so, how much
(write in)

 

 

118

15. Do you use drugs?
(check one)

have never used drugs
used to use drugs but quit

currently use drugs - if so, what kind

 

(wri—te inT
and how much

 

(write in)

16. What was the first day of your last normal menstrual

period?

(write in)

 

/ /
(fibnth) (day) (year)

17. When is your estimated due date?
(write in)

/ /
(month) (day) (year?

END You have completed this questionnaire.
answering the next questionnaire.

Please begin

 

 

PART B

*
SOURCE AND SATISFACTION

In this section I would like you to identify the people who
are important to you in a number of different ways.
Descriptions of ways that people are often important to us
are given. After you read each description write down first
names, initials, or nicknames of the people who fit the
description. These people might be friends, family members,
teachers, ministers, doctors, nurses or other people you
might know. You do not have to fill all the blanks or you
may add spaces if not enough are given.

I will only want you to give me the names of people you
actually know and that you have actually talked to during
the last six months. It's possible, then, that you won't
get a chance to name some important people if for one reason
or another you haven't had any contact with them in the last
six months.

Remember all information will remain confidential. There
are no right or wrong answers. Answer all questions to the
best of your ability..

A. PRIVATE FEELINGS

1. If you wanted to talk to someone about things that
are very personal and private, who would you talk to?
Give me the first names, initials, or nicknames of the
people that you would talk to about things that are
very personal and private.

 

 

 

 

 

 

 

 

 

 

 

 

*Adapted from. Barrera, M,, Jr.: Social Support in the
Adjustment of Pregnant Adolescents. In Gottlieb, B. H. ed.:
Social Networks and Social Support. Beverly Hills,
California. Sage Publications, 1981.

119

120

2. During the last six months which of these people
did you actually talk to about the things that were
personal and private?

 

 

 

 

 

 

 

 

 

 

 

 

3. During the last six months, would you have
liked: (circle the best response)

1 = a lot more opportunities to talk to people
about your personal and private feelings
2 = a few more opportunities

3 = or was this about right?

.5
II

or was this too much?

4. During the last six months, how much do you
think you needed people to talk about things
that were very personal and private?

1 = quite a bit
2 = a little bit
3 = not at all

5 . During the past six months , how often did you
actually talk to these people? (circle the
best response)

1 = more than one time

2 one time only

3

not at all

MATERIAL AID

1. Who are the people you know that would lend or give
you $25 or more if you needed it, or would lend or give
you something (a physical object) that was valuable?
You can name some of the same people that you named

 

121

before if they fit this description, too, or you can
name some other people.

 

 

 

 

 

 

 

 

 

 

 

 

2. During the past six months, which of these people
actually loaned or gave you some money or gave or
loaned you some valuable object that you needed?

 

 

 

 

 

 

 

 

 

 

 

 

3. During the past six months, would you have liked
people to have loaned you or have given you: (circle
best response) ‘

1 = a lot more

2 = a little more

3 = or was it about right?
4 = or was this too much?

4. During the past six months, how much to you think
you needed people who could give or lend you things
that you needed? (circle the best response)

1 = quite a bit

2 a little bit

3 = not at all

5. During the past six months how often did someone
actually lend or' give something that. was ‘valuable?
(circle the best response)

1 = more than one time
2 = one time only
3 = not at all

122

ADVICE

1. Who would you go to if a situation came up when you
needed some advice? Remember, you can name some of the
same people that you mentioned before, or you can name
some new people.

 

 

 

 

 

 

 

 

 

 

 

 

2. During the past six months, which of these people
actually gave you some important advice?

 

 

 

 

 

 

 

 

 

 

 

 

3. During the past six months, would you have liked:
(circle the best response)

1 = a lot more advice

2 = a little more advice
3 = or was it about right?
4 = or was this too much?

4. During the past six months, how much do you think
you needed to get advice? (circle the best response)

1 = quite a bit
2 = a little bit
3 = not at all

5. During the past six months, how often did someone
actually give you advice? (circle the best response)

1 = over a period of times
2 = one time only
3 = not at all

123

POSITIVE FEEDBACK

1. Who are the peOple that you could expect to let you
know when they like your ideas or the things that you
do? These might be people you mentioned before or new
people.

 

 

 

 

 

 

 

 

 

 

 

 

2. During the past six months, which of these people
actually let you know that they liked your ideas or
liked the things that you did?

 

 

 

 

 

 

 

 

 

 

 

 

3. During the past six months, would you have liked
people to tell you that they liked your ideas or things
that you did? (circle the best response)

1 = a lot more often

2 = a little more
3 = or was it about right?
4 = or was this too much?

4. During the past six months, how mmch do you think
you needed to have people let you know when they liked
your ideas or things that you did? (circle the best
response)

1 = quite a bit

2 a little bit

or
II

not at all

124

5. During the past six months how often did people
actually tell you they liked your ideas or liked the
things you did?

1 = over a period of times
2 = one time only
3 = not at all

PHYSICAL ASSISTANCE

1. Who are the people that you could call on to give
up some of their time and energy to help you take care
of something that you needed to do - things like
driving you someplace you needed to go, helping you do
some work around the house, going to the store for you,
and things like that? Remember, you might have listed
these people before, or they could be new names.

 

 

 

 

 

 

 

 

 

 

 

 

2. During the past six months, which of these people
actually pitched in to help you do things that you
needed some help with?

 

 

 

 

 

 

 

 

 

 

 

 

3. During the past six months, would you have liked:
(circle the best response)

1 = a lot more help with things that you needed to

do
2 = a little more help
3 = or was this about right?

4 = or was this too much?

125

4. During the past six months, how much do you feel
you needed people who would pitch in to help you do
things? (circle the best response)

1 = quite a bit
2 = a little bit
3 = not at all

5. During the past six months, how often did someone
actually help you do something you needed help with?
(circle the best response)

1 = over a period of times
2 = one time only
3 = not at all

SOCIAL PARTICIPATION

1. Who are the people that you get toqether with to
have fun or relax? These could be new names or ones
you listed before.

 

 

 

 

 

 

 

 

 

 

 

 

2. During the past six months, which of these people
did you actually get together with to have fun or
relax?

 

 

 

 

 

 

 

 

 

 

 

 

126

3. During the past six months, would you have liked:
(circle the best response)

1 = a lot more Opportunities to get together with
people for fun and relaxation

2 = a few more
3 = or was it about right?
4 = or was this too much?
4. How much do you think that you needed to get

together with other people for fun and relaxation
during the past six months? (circle the best response)

1 = quite a bit
2 = a little bit
3 = not at all

5. During the past six months, how often have you
gotten together' with. people to have fun or relax?
(circle the best response)

1 = over a period of times
2 = one time only
3 = not at all

NEGATIVE INTERACTIONS

1. Who are the people that you can expect to have some
unpleasant disagreements with or peOple that you can
expect to make you angry and upset? These could be new
names or names you listed before.

 

 

 

 

 

 

 

 

 

 

 

 

127

2. During the past six months, which of these people
have you. actually' had some unpleasant disagreements
with or have actually made you angry and upset?

 

 

 

 

 

 

 

 

 

 

 

 

H. Are any of the people you listed the father of your
baby? (initials)

Indicate which person

 

END: You have completed this questionnaire. Please begin
answering the next questionnaire.

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LIST OF REFERENCES

LIST OF REFERENCES

 

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Barrera, M., Jr. (1981). Social support in the adjustment
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Block, R. W., Saltzman, S., & Block, S. A. (1981). Teenage
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Copeland, D. 2. (1979). Unwed adolescent primigravidas
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131

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Fisher, S. M., & Scharf, K. R. (1980). Teenage pregnancy:
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.h

 

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