INFORMATION CALENDAR FOR PREGNANT TEENAGERS by Amy Heather Anderson A project submitted in partial fulfillment of the requirements for the degree of Master of Nursing MONTANA STATE UNIVERSITY-BOZEMAN Bozeman, Montana April 2000 © COPYRIGHT by Amy Heather Anderson 2000 All Rights Reserved 11 fan 3 APPROVAL of a project submitted by Amy Heather Anderson This project has been read by each member of the project committee and has been found to be satisfactory regarding content, English usage, format, citations, bibliographic style, and consistency, and is ready for submission to the College of Graduate Studies. Lea Acord, Ph.D., R.N. Date 7 Approved for the College of Nursing Lea Acord, Ph.D., R.N. Approved for the College of Graduate Studies Bruce McLeod, Ph.D. Ill STATEMENT OF PERMISSION TO USE In presenting this paper in partial fulfillment of the requirements for a master’s degree at Montana State University - Bozeman, I agree that the Library shall make it available to borrowers under rules of the Library. If I have indicated my intention to copyright this paper by including a copyright notice page, copying is allowable only for scholarly purposes, consistent with “fair use” as prescribed in the U.S. Copyright Law. Requests for permission for extended quotation from or reproduction of this paper in whole or in parts may be granted only by the copyright holder. IV ACKNOWLEDGEMENTS I wish to express sincere appreciation to my loving parents, James Lee and Susan Kay Anderson for their support and guidance. As a professional nurse, my mother provided me with a lifelong role model that I hope I will one day live up to. My father always encouraged me to advance my career, offering assistance and advice all along the way. I could not have done this without them. I must also thank Monte Still, who has truly helped make this project and degree a reality. Thanks to Emily Fieselmann for making the whole process enjoyable. Dave Griffin went above and beyond, contributing significant technical support for this project. Thanks to Ashley, my sister and my friend, for pushing me to succeed, and for always making me laugh. Finally, Td like to thank the members of my project committee. Dr. Lea Acord, Professor Bev O’Doherty, and Dr. Gretchen McNeely, for all their help and guidance with this project. Their support and direction were priceless. They are exemplary models of professional nurses, and I am proud to have had them as my teachers. V TABLE OF CONTENTS Page ABSTRACT vii 1. INTRODUCTION 1 Purpose of the Project 1 Background and Significance of the Project 2 Identified Prenatal Resources in Gallatin County 3 Resources Developed for Adolescents 4 Resources Developed for All Ages 4 Role of Information Calendar 8 Objectives of the Project 9 Theoretical Framework 10 2. LITERATURE REVIEW.... 11 Current Trends in Adolescent Pregnancy. 11 Identified Barriers to Services 13 Role of Prenatal Education in Pregnant Adolescents 14 Theoretical Framework 15 Elkind’s Description of Adolescent Characteristics 17 Piaget’s Theory of Cognitive Development 18 Erikson’s Theory of Psychosocial Development 20 Risks and Corresponding Needs Associated with Adolescent Pregnancy... 23 Health Care 24 Nutritional.. 29 Social and Financial 35 3. METHODOLOGY 37 Project Design 37 Literature Review.. 37 Community Assessment 38 Group Interviews 38 Information Calendar 39 VI TABLE OF CONTENTS - Continued Page Introduction 40 Month One 41 Month Two 41 Month Three 42 Month Four 42 Month Five 42 Month Six 42 Month Seven 43 Month Eight 43 Month Nine 43 Congratulations/Back to School 43 Resources 44 Analysis of Data 45 Rights of Human Subjects 48 4. PROJECT OUTCOME 49 Limitations of the Calendar 50 Implications and Recommendations 50 Summary... 52 REFERENCES CITED 53 APPENDICES 58 Appendix A Consent Forms and Human Subjects Approval 59 Appendix B Information Calendar for Pregnant Teenagers 62 Vll ABSTRACT Pregnant adolescents have unique developmental characteristics which should be addressed when developing learning materials for this population. The unique risks and corresponding needs of pregnant adolescents must also be considered to most effectively meet the needs of this population. The purpose of this project was to develop an information calendar for pregnant adolescents in Gallatin County, Montana. The calendar format was based on the ability to acquire information one month at a time. The design was based on the developmental characteristics of adolescents, while the content focused on the unique risks and corresponding needs of pregnant adolescents. The focal points of the calendar were aimed at facilitating access to local resources and promoting positive behavioral change in the pregnant adolescent. The calendar provides essential information regarding important prenatal education and behavior advice that may improve the outcome of an adolescent’s pregnancy. It also includes a reference list of local resources that are available to a pregnant adolescent in Gallatin County. Finally, the information is provided on a computer disk in order to allow the calendar to be updated to reflect the changing resources within the community. The process of designing the information calendar for this project began with a general review of literature and an assessment of available resources in Gallatin County. A similar prenatal calendar directed toward adult women was utilized for the format. The theoretical framework for the project utilized the developmental theories of Elkind, Piaget and Erikson. Finally, two group interviews were conducted with pregnant and parenting adolescents in a local support group. The calendar reflects some interview themes. The project resulted in the Information Calendar for Pregnant Teenagers. The role of the information calendar is to address the unique needs and risks associated with adolescent pregnancy in a developmentally specific format. It is imperative that this population receive developmentally adapted educational materials to maximize effectiveness of the information. Finally, use of developmentally appropriate teaching materials is intended to minimize confusion and anxiety related to an overload of inappropriate information. • 1 CHAPTER 1 INTRODUCTION Purpose of the Project The purpose of this project was to develop an information calendar for pregnant teenagers in Gallatin County, Montana. The calendar provides essential information regarding important prenatal care and recommended behaviors that may positively affect the outcome of an adolescent’s pregnancy. It is directed specifically toward pregnant adolescents in Gallatin County, with an emphasis placed on those adolescents who are not enrolled in prenatal or child-birth education classes. The calendar is not intended to replace these services. It encourages pregnant adolescents to seek early prenatal care and to enroll in prenatal classes. The calendar also includes a reference list of local resources that are available to a pregnant adolescent in Gallatin County. Finally, the information is provided on a computer disk in order to allow the calendar to be updated as needed to reflect the changing resources within the community. There are currently many sources of information in Gallatin County regarding pregnancy. These sources offer an abundant supply of critical information. However, many of these resources are not specifically developed for adolescents. Because pregnancy is usually a time of crisis in the adolescent population, the adolescent is easily overwhelmed with large amounts of critical information. The developmental level of 2 adolescents further limits their ability to comprehend large amounts of information during this time of crisis. Thus, there is a need for a developmentally appropriate source of information for adolescents which relays essential prenatal information to them in a collective, concise, and comprehendible fashion. This source must also be comprehensive enough to enable the adolescent to make better use of the available resources. This paper describes the development of the information calendar which focuses on adolescent issues of prenatal education as well as the current resources available for pregnant adolescents in Gallatin County. Components of the calendar include adolescent specific information on the following seven topics: (a) nutrition and weight gain, (b) harmful substances, (c) sexually transmitted diseases, (d) preterm labor, (e) general expectations of labor and delivery, (f) contraception, and (g) infant feeding choices. A guide for finding the following resources is included with the calendar: (a) a prenatal care provider, (b) counseling resources, (c) financial resources, (d) options for obtaining a high school diploma or GED, and (e) a childbirth preparation class. The calendar is provided in Appendix B. Background and Significance of the Project The developmental characteristics of adolescents are different than those of adult women; therefore, it is necessary to adapt educational information to reflect those differences. The young adolescent understands and engages in learning differently from the 18 year old, who is different still from the 25 year old. 3 Pregnant adolescents also have unique health care, nutritional, social and financial risks that result in specific needs. When these needs are met, the outcome of adolescent pregnancy is positively affected. Many pregnancy resources in Gallatin County focus on the needs of adult women. Consequently, pregnant adolescents often do not attempt to utilize these resources. When these services and resources are utilized by the adolescent population, many of their needs remain unmet. However, when resources are tailored to meet the unique needs of pregnant adolescents, these resources are far more successful at achieving that goal. From 1993 to 1997, an average of 41 out of 1,000 adolescent females gave birth in Montana. Gallatin County’s adolescent pregnancy rate is lower than the recorded rate for the state of Montana, with a pregnancy rate of 17 out of 1,000 adolescent females for that same time period. Despite the relatively low teen-birth rate in Gallatin County, approximately 236 births to adolescents occurred from 1993 to 1997 (Montana County Health Profiles, 1999). However, there are very few resources in Gallatin County which have been developed specifically for the pregnant adolescent population. Furthermore, a lack of knowledge regarding availability and accessibility to resources are identified as significant barriers to adolescents’ use of these resources. In a time of crisis, a pregnant adolescent may not have the ability to identify personal needs and corresponding resources. Identified Prenatal Resources in Gallatin County There are many resources for pregnant women in Gallatin County. However, many of these resources have not been developed specifically for adolescents. The 4 following identified resources are divided into two sections: (a) those that are specific to adolescents; and (b) those that are available to adolescents, but that are not directed specifically toward adolescents. Resources Developed for Adolescents. Bridger Alternative High School offers a Young Parents Program. This program focuses on four basic areas: (a) positive self- concept development; (b) prenatal care, labor and delivery; (c) parenting skills and child development; and (d) economic independence. Childcare is also available through the Young Parents Program to help parenting adolescents meet their obligations as students. While this program is developmentally appropriate and very comprehensive in its scope, not all pregnant adolescents in Gallatin County are enrolled in Bridger Alternative High School. Furthermore, the prenatal content is only offered during the second quarter, thus limiting the class to those who are enrolled at that time. Prevent Child Abuse Inc. provides parent education and support for parents of all ages. However, they conduct a support group specifically for pregnant and parenting adolescents on an every other week basis. This Partnership Project is an intensive family support service, including home visits, assistance accessing community resources and ongoing parenting support. Resources Developed for All Ages. The Pregnancy Caring Center offers free pregnancy tests, a 24 hour hotline, and free brochures on pregnancy and fetal development. Birthwise is a service offered through Bozeman Deaconess Hospital. It is a series of childbirth preparation classes taught by nurses who are certified birth 5 educators. The six week series covers the physical and emotional aspects of labor and delivery as well as breathing and relaxation techniques, postpartum, cesarean birth, parenting and baby care. The classes are directed toward all pregnant women in Gallatin County. Betty Kalakay, a public health nurse, finds that many adolescents find this environment intimidating; therefore, adolescents do not seek out this service (B. Kalakay, personal communication, August, 1998). However, Andrea Melvin, Birthwise coordinator, states that “Once the adolescents attend a few classes, they find they are warmly welcomed, and they do just fine” (A. Melvin, personal communication, August, 1998). Gallatin County Public Assistance provides information regarding social services, such as Medicaid, and the food-stamp program. Gallatin County Public Assistance informs the pregnant women of the qualification standards for public assistance and assists them with application requirements. Federal and state initiatives during the mid- 1980s aimed to increase access to prenatal care by expanding Medicaid eligibility and increase funding for maternal and child health block grants and other state-funded programs (Ellwood & Kenney, 1995). Women, Infants and Children (WIC) is a service offered through Gallatin County Public Health Department. WIC is a nutrition education, preventative health program for pregnant, nursing and postpartum women, and children up to the age of five. Eligibility is determined by financial status and nutritional need. Participants receive nutrition education, monthly supplemental foods, and improved access to health care via referrals to Gallatin County Public Health Department for additional services. Le Leche League 6 of Gallatin Valley provides breast feeding education and support for pregnant women and nursing mothers. Gallatin County Public Health Department sends nurses into the homes of referred pregnant women. They discuss issues regarding nutrition, fetal growth and development, common discomforts and concerns during pregnancy, and breast feeding. They also provide referrals to community resources. There is no charge for these services. There are a variety of identified counseling services available in Gallatin County. Prevent Child Abuse and The Parent Place are resources that are available on a referral basis. This service provides counseling and support to those in need. They offer a parent resource center with books and videos. Donated items such as strollers, baby clothes, and car seats are available as needed. Lutheran Social Services has pregnant adolescent counseling services which focus on adoption. Catholic Social Services provides free, confidential counseling to anyone who calls the toll-free number. They also provide comprehensive open-adoption services. Bridger Clinic of Gallatin County provides counseling on issues surrounding choices of adoption, abortion, and continuing pregnancy. They also provide reproductive health care services including birth control education and prescriptions. Fees are based on a sliding scale. MSU Human Development Training and Research Clinic offers individual, couple, and family counseling services provided by graduate students. Fees are based on a sliding scale and no one is refused service due to inability to pay. The Teen Parent Program, Human Resource Development Council (HRDC), is a program which receives referrals from the welfare program. It provides pregnant or 7 parenting adolescents with opportunities to obtain education, employment skills and meaningful on-site work experience as a means to achieve self-sufficiency. The program provides GED preparation, counseling, vocational skills training, a weekly stipend, recreational activities, and community involvement To qualify, youth must be pregnant or parenting and be under 19 years of age. Many of the previously described resources took much time and effort to identify. The resources were available in many different locations in the community and took considerable planning to compile. In a time of crisis, a pregnant adolescent may not have the ability to identify personal needs and corresponding resources. A collaborative effort is needed among health and social services to simplify, coordinate, and augment services to pregnant adolescents. An adolescent faced with the crisis of an unplanned pregnancy may view any problem, such as difficulty with the Medicaid system, as an insurmountable obstacle. Simplification... and efforts to decrease confusion may reduce barriers (Baker, 1996, p. 42). In Gallatin County, many of the resources that are available to pregnant adolescents are underutilized. This could be a result of many factors, including perceived and actual barriers. As stated previously, from 1993 to 1997, there were approximately 236 births to adolescent females in Gallatin County. The enrollment for Bridger Alternative High School’s prenatal and parenting classes for that period was 32. Gallatin County WIC, which also provides early prenatal education classes, had a maximum of five adolescent females who participated during the months of February, March and April in 1999. The number of adolescent females served by Gallatin County Public Health Department is unavailable. 8 Role of Information Calendar Only a small fraction of the approximately 236 adolescent females who gave birth in Gallatin County from 1993-1997 reported receiving prenatal education services. Therefore, there is clearly a need for an information resource for pregnant adolescents in Gallatin County. One way to achieve this need is in the form of a calendar which allows the adolescent to obtain information on a monthly basis. The calendar format eliminates the overwhelming sense of too much information all at once. It was developed at the level of the young adolescent, therefore being comprehendible for that age and older. It primarily targets adolescents who are not enrolled in Bridger Alternative High School, Birthwise, or WIC prenatal classes. However, it may be used in conjunction with the material presented in these services. Optimal distribution sites are: the Bridger Clinic, WIC office, Gallatin County Public Health Department, Moms and Kids Together Support Group, and Bridger Alternative High School. The paramount goal of the Information Calendar for Pregnant Teenagers is to provide an information resource that is specifically formulated for and directed toward the developmental level of the adolescent population. The calendar design is based on the developmental characteristics of adolescents, while the content focuses on the unique risks and corresponding needs of pregnant adolescents. The calendar is condensed and concise to parallel the adolescent attention span. It contains simple wording and definitions of pertinent medical terminology. It is colorful and contains simple graphics appealing to adolescents. Furthermore, an effort was made to avoid information that does not directly pertain to the adolescent population. 9 Another essential component of the calendar is a resource list for pregnant adolescents regarding early connections with important contacts in Gallatin County. This component of the calendar is intended to decrease some of the barriers that adolescents face during pregnancy such as perceived financial limitations, lack of perceived significance, and lack of information regarding existing services. Finally, the calendar provides information regarding continuing education by presenting a brief synopsis of the significance of finishing high school, and then listing important contacts with the Bridger Alternative High School. Objectives of the Project In Gallatin County, many services and resources exist for pregnant women. However, very few of these services are specifically developed for adolescents. The overall goal of the calendar is to increase the probability of healthy babies bom to adolescents in Gallatin County. In creating a developmentally appropriate calendar for adolescents, the following objectives are intended: 1. Increase knowledge base of pregnant adolescents regarding basic components of pregnancy, prenatal care, and available prenatal services in Gallatin County. 2. Expand use of existing services by pregnant adolescents by providing a comprehensive resource list with specific Gallatin County key contacts. 3. Provide information to pregnant adolescents regarding significance of staying in school and decrease perceived barriers by providing key contacts to Bridger Alternative High School. 10 Theoretical Framework Adolescents have unique developmental characteristics. They are no longer limited by the cognitive thinking capabilities of children, but have not yet fully developed the cognitive thinking capabilities of adults. Adolescence is a time of many developmental and social changes. These changes are important for making the transition into adulthood. Specific tasks must be completed by the adolescent in making this transition. Developmental theory was used as a theoretical framework for this project. Developmental theory assumes a predictable progression of stages throughout the lifespan. Erikson’s (1963) theory of psychosocial development, Piaget’s (1969) theory of cognitive development, and Elkind’s (1967) description of characteristics of adolescents are utilized for the basis of the calendar format. 11 CHAPTER 2 LITERATURE REVIEW Current Trends in Adolescent Pregnancy Adolescent pregnancy continues to be a national problem. Approximately one million teenagers become pregnant in the United States (US) each year. Of these, about 51% end in live births, 35% end in induced abortion, and 14% result in a miscarriage or still-birth (Felice, et al, 1999). Teenage mothers do not acquire as much education as teens who delay childbearing; therefore, they are less likely to find stable employment and more likely to rely on public assistance, thus perpetuating the cycle of poverty (Furstenburg, 1991). In 1989, the national public cost of all families started by a teen birth was $21.6 billion (Center for Population Options, 1990). A too-early pregnancy is costly to both the persons involved and to society (Rodriguez & Moore, 1995). The risk of adverse pregnancy outcomes appears to be more inherent in teenagers than in older women (Hollander, 1995). There is an increased risk of preterm delivery and low birth weight in infants bom to adolescents. Babies bom to teen mothers are at increased risk of developing physical, social, and cognitive problems and deficiencies. Low birth weight is a major public health problem in the United States, contributing substantially both to infant mortality 12 and to childhood handicaps (Paneth, 1995). In 1988, health care, education, and child care for the 3.5 to 4 million children ages 0 to 15 years bom low birth weight cost between $5.5 and $6 billion greater than if those children had been bom normal birth weight (Lewit, Schuurmann Baker, Corman, & Shiono, 1995). In 1988, the annual cost of acute care for low birth weight infants bom to teenagers was estimated to be more than $1 billion yearly (Healthy Children, 1988). Cockey (1997) states that it can cost more than $100,000 to care for a preterm infant, and, in 1990, the United States government disbursed $25 billion in Aid to Families with Dependent Children funds to teen moms. The total direct and indirect costs of adolescent pregnancy surpasses $34 billion annually. An Institute of Medicine report. Preventing Low Birth Weight, estimated that for every dollar spent on prenatal care for women at high risk, $3.38 is saved in medical care costs for low birth weight infants (Institute of Medicine, 1985). From 1993 to 1997, an average of 41 out of 1000 adolescent females gave birth in Montana. Gallatin County’s adolescent pregnancy rate is lower than that of the state of Montana, with a rate of 17 out of 1000 adolescent females for the same time period. Gallatin County currently has the fourth lowest teen-pregnancy rate in the state of Montana. Despite the relatively low teen-birth rate in Gallatin County, approximately 236 births to adolescents occurred in Gallatin County from 1993 to 1997 (Montana County Health Profiles, 1999). 13 Identified Barriers to Services Controversy remains as to whether prenatal services improve birth outcomes (Fiscella, 1995). However, a number of studies have demonstrated that adequate prenatal care is associated with improved pregnancy outcomes, especially among socially disadvantaged women (Kogan, Alexander, Kotelchuck, & Nagey, 1994). Unfortunately, between 35 and 53% of pregnant adolescents receive inadequate prenatal care (US Congress, 1991). The younger a woman is, the less likely she is to receive prenatal care in the first trimester (Wiemann, Berenson, Darcia-del Pino, & McCombs, 1997). The resulting problems associated with late or no prenatal care are exacerbated among adolescents who have not been educated about nutrition or who have poor health habits (US Congress, 1991). Various factors have been associated with delayed entry into prenatal care by adolescents. Emotional factors such as fear, pregnancy denial, and lack of awareness of the need for prenatal care have been identified as major factors related to inadequate prenatal care (Baker, 1996). Many adolescents enter care late as a result of efforts to conceal their pregnancy from their parents (Wiemann, et ah, 1997). Identified sociocultural factors that cause adolescents to delay initiation of prenatal care include: lack of insurance, attitude toward health care professionals, delay in suspecting pregnancy, delay in telling others about the pregnancy, initial attitudes about pregnancy, and lack of perceived importance of prenatal care (Poland, Ager & Olson, 1987). Perceived or actual financial limitations are also significant barriers for services to pregnant adolescents (Wiemann, et al., 1997). It has been suggested that 14 attending traditional prenatal education classes with adult, married, professional women is often disconcerting to adolescents. They find that this atmosphere is not conducive to learning and it limits the adolescents’ social and developmental growth as mothers (Abell & Ludwig, 1997). Furthermore, rural adolescents often have the desire to find a care provider who is not a part of their direct social group. The confidentiality factor alone may delay adolescents’ entry into prenatal care. This may be a burden in many rural communities as they are small and often the residents are very familiar with all of the other residents; thus the issues of isolation, distance, and familiarity, which are common to rural communities may impede an adolescent’s entry into prenatal care (Lee, 1998). Rural adolescents also find transportation and isolation as significant limitations to seeking prenatal care and resources (US Congress, 1991). Role of Prenatal Education in Pregnant Adolescents Data suggest that women who report receiving sufficient health behavior advice as part of their prenatal care are at lower risk of delivering a low birth weight infant (Kogan, et. al, 1994). The two most common adverse outcomes of adolescent pregnancy are prematurity and low birth weight. Inherent risk may result because the young mothers are still growing themselves; thus they may compete with the fetus for nutrients (Fraser, Brockert, & Ward, 1995). Empirical evidence documenting the importance of prenatal education in reducing rates of prematurity and low birth weight has been equivocal (Alexander & Korenbrot, 1995). Prenatal education is indicated to decrease the likelihood of preventable disturbances in fetal growth and development. It is also 15 essential for helping the pregnant adolescent understand normal and abnormal expectations of her pregnancy, thus allowing her to recognize early signs of premature labor, or other danger signs. Research suggests that specific types of prenatal education may decrease the risk of low birth weight associated with preterm birth (Libbus & Sable, 1991; Kogan, et al, 1994). It is recommended that pregnant women receive advice in the following seven areas: (a) breast feeding, (b) reducing or eliminating alcohol use, (c) reducing or eliminating smoking, (d) eliminating illegal drug use such as marijuana, cocaine, or crack, (e) eating the proper foods during pregnancy, (f) taking vitamin or mineral supplements, and (g) gaining an appropriate amount of weight during pregnancy (Kogan, et al., 1994). Women who receive all seven types of advice are less likely to deliver a low birth weight infant than those who receive none or only some of these types of advice (Kogan, et al., 1994). Several studies also suggest that the beneficial effects of prenatal education are strongest among socially disadvantaged women (Kogan, et al., 1994). Theoretical Framework Developmental theory was used as a theoretical framework for this project. Developmental theory assumes a predictable progression of stages throughout the lifespan. Each stage requires that specific tasks be completed before moving into the next stage. Elkind (1967) describes specific characteristics of adolescent development which are relevant to understanding the thinking patterns of this population. Piagef s (1969) theory of cognitive development is concerned primarily with the structure of how 16 the mind works. He described the stages of cognitive development throughout the developmental years. Erikson’s (1963) theory of psychosocial development described the development of identity of the self and the ego through successive stages that naturally unfold throughout the lifespan. Adolescents are developing biologically at an earlier age than in the past few decades (Stevens-Simon, 1993). This may be attributed to improved nutrition and health. Earlier physical development results in an asynchrony between physical and psychosocial maturation. The failure of cognitive and psychosocial development to keep pace with pubertal development over the past century makes adolescence a particularly vulnerable time. Adolescents are confronted by sexual feelings and opportunities for sexual experimentation that they are psychosocially and cognitively unprepared for (Stevens- Simon, 1993). Teen pregnancies are also occurring at an earlier age. In the US, 26% of students aged 15 and younger have had intercourse, resulting in more than 30,000 pregnancies each year (Harbin, 1995). The physical maturity that adolescents are achieving often precedes the psychosocial and cognitive maturity that is required for dealing with the consequences of an unplanned pregnancy. Adolescence is an egocentric, inwardly focused period of development. Many adolescents are not yet functioning at formal operational thought level. They may be very concrete, having difficulty with tasks requiring abstract thinking abilities, such as planning, relating cause and effect, and anticipating results. Many adolescents have limited future goals and aspirations for themselves because of developmentally immature thought processes (Flanagan, McGrath, Meyer, & Garcia Coll, 1995, p. 273). 17 Elkind’s Description of Adolescent Characteristics The adolescent is undergoing many cognitive changes. These new cognitive abilities are reflected in the teenager’s behavior in several ways. The first change is that because of their new ability to “think about their thinking,” adolescents become very introspective. By middle adolescence, this introspection is quite marked, and the teenager may assume that others are equally interested. Elkind (1967) points out that this gives rise to the teen’s “imaginary audience” The imaginary audience provides the adolescent with a means of evaluating “How do others see me?” This leads to a sense of being the focus - special, unique, and exceptional. This personal fable, which is characteristic of adolescents, is described as a complex set of beliefs of self perceiving she is special and unique (Elkind, 1967). This belief in personal uniqueness becomes a conviction that misfortune will happen to others, but not to oneself. Many young girls “become pregnant because, in part at least, their personal fable convinces them that pregnancy will happen to others but never to them and so they need not take precautions” (Elkind, 1967, p. 1032). The personal fable can also be directly related to adolescents delay in seeking prenatal care. If adolescents believe they are invincible, they may not see the significance in seeking early prenatal care, such as educating themselves regarding their pregnancy, or to actively change their behaviors, such as diet and substance use; all efforts which could possibly increase their chances of delivering a healthy, full-term infant. Being exceptional to the adolescent means being the exception, and this “fable of immunity'’ gives rise to the risk-taking behavior for which adolescents are so well known 18 (Edelman & Mandle, 1998). Risk-taking behavior is the primary cause of morbidity and mortality among the adolescent population (Bums, Barber, Brady, & Dunn, 1996). Also, risk-related behavior is reinforced by another cognitive characteristic of the adolescent called “magical thinking, ” a belief that one is magically protected from dangers that only happen to other people (Zigler & Stevenson-Finn, 1987). Adolescent pregnancy is just one consequence of risk-taking behavior. To further compound the problem, many teenagers then fail to receive adequate prenatal care, putting themselves at particularly high risk for poor pregnancy outcomes (Alexander, Patterson, & Hulsey, 1987). Due to the adolescent’s possible lack of perception of the advantages of preventative behavior, and their sometimes “magical thinking” cognitive characteristics, it becomes necessary for health care providers to use a concrete approach with adolescents to teach and encourage early prenatal care and positive behaviors. Piaget’s Theory of Cognitive Development The emergence of formal operational thought has been described by Piaget (1969) in his Theory of Cognitive Development. According to Piaget’s XhQoiy, formal operational thinking, essential for planning the future, is not yet fully developed in teens. Consequently, adolescents are less likely to perceive the advantage of preventive behaviors (Davis, 1989). This theory can explain why very young adolescents, as concrete thinkers, may not have the cognitive ability to understand the complexity or the significance of prenatal education when it is created for an adult developmental level. Piaget (1969) believes there are four major stages in the development of logical thinking. Each stage is derived from and builds upon the accomplishments of the 19 previous stage in a continuous and orderly process. The concrete operational stage and the formal operational stage are significant for the discussion of adolescent development. During the concrete operational stage (7-11 years) thought becomes increasingly logical and coherent. Children of this age do not have the capacity to deal with abstraction; they solve problems in a concrete, systematic fashion based on what they can perceive and directly observe. Reasoning is inductive. During the formal operational stage (12-15 years) adolescents begin to think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. These processes, characterized by adaptability and flexibility, are described by Piaget as formal operational thought. Piaget described the shift from childhood to adolescence as a movement from concrete to formal operational thought. Also during the formal operational thought stage, adolescents become capable of using a future time perspective rather than being tied to the here-and-now thinking of childhood. They are able to imagine possibilities, such as the sequence of future events of pregnancy and delivery. Hypothetical reasoning is aligned with thinking about possibilities. To think through hypotheses, one needs to see beyond what is directly observable and reason in terms of what might be possible. Being able to plan ahead or identify future consequences of actions are skills dependent on being able to think hypothetically. As the adolescents’ hypothetical reasoning abilities increase, their decision making skills improve. Young people develop the ability to consider hypothetical risks and benefits of possible behaviors, along with potential consequences of such behaviors; thus enabling them to make more independent decisions. Older adolescents are more 20 likely than younger adolescents to be aware of risks involved with a particular decision, consider future consequences, turn to “experts” for advice, and realize when vested interests may influence the advice of others (Lewis, 1981). Older adolescents may be able to consider some of the symbolic and long-term implications of their behaviors; thus they may respond to health promotion efforts that require a future time perspective or attention to symbolic rewards. For younger teens who primarily use concrete thinking, health promotion efforts should emphasize immediate risks or benefits of the behavior (Wong, 1995). Even with the best framework for health promotion, persons who are capable of formal operational thought and reasoned decision making do not use these processes all the time. In the face of pressure or stress, young people are more likely to abandon rational thought processes. Thoughts about unfamiliar or emotionally stimulating topics also tend to be less advanced and more vulnerable to the effects of stresses and pressures (Linn, 1983). Erikson’s Theory of Psychosocial Development The theory of psychosocial development advanced by Erikson (1963) is the most widely accepted and used theory of childhood development. It involves predictable age- related stages during which specific changes are assumed to take place. Erikson also uses the biologic concepts of critical periods and epigenesis, describing key conflicts or core problems the individual strives to master during critical periods in personality development. Successful completion or mastery of each of these core conflicts is built on the satisfactory completion or mastery of the previous core conflict. 21 Erikson describes eight stages of psychosocial development within the course of an individual’s lifetime. According to Erikson, two of the most important tasks of adolescence include establishing autonomy and developing a sense of identity. The achievement of these tasks is a gradual processes which takes place concurrently with the physical and cognitive changes that are significantly influencing the adolescents’ perceptions of themselves and of others (Abell & Ludwig, 1997). Establishing autonomy is a fundamental psychosocial task of adolescence. It requires developing one’s abilities to make responsible and independent decisions. Autonomy includes cognitive, emotional, and behavioral components. Cognitive development was discussed above as described by Piaget. Individuals generally begin developing emotional autonomy during early adolescence. This refers to the ability to \ differentiate between the needs of the self and the needs of others (Abell & Ludwig, 1997). “Behavioral autonomy in adolescence refers to the ability to make decisions independently and to follow through with those decisions. A behaviorally mature adolescent is able to understand the consequences of decisions and actions and acts in accordance with that understanding” (Abell & Ludwig, 1997, p. 42). Developing a sense of identity is another central task of adolescence. It begins to occur between 12 and 18 years of age, and is described by Erikson as the identity versus role confusion stage. The task of identity formation is to develop a stable, coherent picture of oneself that includes integrating one’s past and present experiences with a sense of where one is headed in the future (Abell & Ludwig, 1997). The development of identity is characterized by rapid and marked physical changes. Children become overly preoccupied with the way they appear in the eyes of others as compared with their own 22 self-concept. They are attempting to integrate their concepts and values with those of society. They are also feeling the need to come to a decision regarding an occupation. The central processes of the task of identity formation are peer pressure and role experimentation; the key socializing agent is the society of peers. Inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity (Erikson, 1963). Erikson’s stage of identity versus role confusion can explain the increased risk of an unhealthy pregnancy at this age (Holt & Johnson, 1991). Adolescents are faced with role confusion as they approach the adult world of responsibility while experiencing intense internal changes of adolescence and pregnancy. The tasks of understanding their role as an adolescent are incomplete, thus complicating the task of understanding their role as a mother. The intimacy versus isolation stage doesn’t occur until early adulthood. A sense of intimacy is established on a sense of identity. Intimacy is the capacity to develop a close relationship with another and interpersonal relationships with friends, partners, and other significant persons. Without intimacy, the individual feels isolated and alone (Erikson, 1963). “Identity, role definition, and establishing independence from family are tasks of adolescence that may conflict with maternal role attainment...motherhood does not confer adulthood, nor does motherhood necessarily hasten developmental progression” (Flanagan, et al., 1995, p. 274). The developmental tasks of adolescence have been known to be difficult in and of themselves. When these tasks are coupled with an unintended pregnancy, an overwhelming situation is presented to the adolescent. 23 Therefore, it is necessary to take into account the development of the adolescent, her role of mother, as well as that of the developing fetus when planning educational materials for this population. The unique developmental characteristics of adolescents makes it necessary to create developmentally specific learning tools for this population. When adolescents face pregnancy, they are in a position where they need to learn a large amount of important information in a short amount of time. In addition to being limited by their developmental stages, adolescents are often facing a crisis situation; thus further requiring succinct developmentally appropriate information. Risks and Corresponding Needs Associated with Adolescent Pregnancy There are many risks that are increased with adolescent pregnancy when compared to adult pregnancy. These risks further define needs that pregnant adolescents have that pregnant adult women may not have. These can be categorized under the broad topics of health care, nutritional, and social/financial needs. Behavioral risk factors are particularly important for this project because they are modifiable. Intended pregnancy is associated with behaviors that may positively influence the course of pregnancy and birth outcomes, while conversely, unintended pregnancy has been associated with behaviors such as smoking and drinking alcohol during pregnancy (Hellerstedt, et al., 1998). Eight out of every 10 teenage pregnancies is unplanned (Alan Guttmacher Institute, 1994). This factor alone clearly presents an increased risk for poor pregnancy outcomes. 24 Health Care Pregnant adolescents are at high risk for health problems during pregnancy which result in unique health-care needs. Pregnant adolescents younger than 17 years of age have a higher incidence of medical complications involving mother and child than do adult women (Felice, et al.,1999). Pregnant adolescents are more at risk for pregnancy complications such as anemia, high blood pressure and placental problems (March of Dimes, 1992). However, the two most frequently reported serious neonatal complications associated with adolescent childbearing are prematurity and low birth weight (Institute of Medicine, 1985). Prematurity or preterm delivery (birth at less than 37 weeks gestation) occurs in approximately 14% of births to adolescents 17 years old or younger, versus 6% for women between 25 and 29 years old (Davidson & Felice, 1992). Scholl, Hediger, and Belsky (1994) found an increased risk of preterm delivery was associated with young maternal age in both developed and developing countries. Preterm delivery has been associated with a maternal weight gain that is inadequate for gestation. Among adolescents, poor weight gain after mid-pregnancy is associated with at least a two-fold increase in preterm delivery (Hediger, et al., 1990). Preterm delivery is an important underlying cause of the increased risk of low birth weight infants of adolescents. Women often ignore early warning signs of preterm labor (Mackey & Tiller, 1997). Approximately 70-80% disregard signs of preterm labor until membranes rupture, bloody show is present, or pelvic pressure increases, which leads to cervical dilation and precludes effective treatment. Pregnant adolescents also ignore or misinterpret early 25 signs of preterm labor (Mackey & Tiller, 1997). If these signs are identified early, medical treatment may prolong gestation. One study by Mackey & Tiller (1997) discovered that participating pregnant adolescents were completely unaware of the health consequences that occur to infants who are bom prematurely. They did not appreciate the importance of carrying their pregnancies to full-term. “Grace wanted her baby to be bom 1 month early so that she could go on a school band trip” (Mackey & Tiller, 1997, p. 415). Cognitive and age-appropriate teaching strategies need to be developed that focus on recognizing the signs of preterm labor and understanding the positive consequences of following health care regimes as well as the negative consequences of preterm labor and birth (Mackey & Tiller, 1997). In addition to discussing warning signs of preterm labor, a simple discussion of normal labor and delivery is often beneficial to both pregnant adolescents and adults. Because pregnant adolescents are at increased risk of preterm labor, it may be beneficial to include a simple discussion of the expectations of a normal labor and delivery. Maternal expectations of labor and delivery based on prenatal experience and knowledge are predictive of postpartum maternal-infant attachment. The primary goal of childbirth education classes is to reduce the fear-pain-tension cycle and make the childbirth experience a positive one... (Youngkin & Davis, 1998, p.465). The incidence of low birth weight (infants weighing less than 2500 grams at birth) in teen mothers is more than double the rate for adults (Centers for Disease Control, 1994). Young adolescent mothers (14 years and younger) are more likely than other age groups to give birth to under-weight infants (March of Dimes, 1997). Low birth weight increases the likelihood for a variety of adverse conditions, including infant death, blindness, deafness, chronic respiratory problems, mental retardation, mental illness, and 26 cerebral palsy (Maynard, 1996). Known risk factors for low birth weight are numerous and have been well documented. Some behavioral risk factors for low birth weight include inadequate diet and nutrition, inadequate weight gain, cigarette smoking, alcohol use, use of illegal drugs, and inadequate prenatal care (Sable & Herman, 1997). There is increasing evidence to indicate that various sexually transmitted diseases (STDs) are associated with low birth weight and preterm delivery (Chomitz, Cheung, & Lieberman, 1995). Pregnant and non-pregnant adolescents are at great risk for acquiring STDs (McAnamey, 1987). The risks for acquiring STDs are similar for both adolescent pregnancy and low birth weight, namely, multiple sexual partners, early sexual activity, low socioeconomic status, and unmarried status (McAnamey, 1987). The possible relationship between prenatal genital infections and low birth weight is important because infections are treatable (McAnamey, 1987). Contraceptive and family planning education are other health care needs of pregnant adolescents. A recent study of unmarried first-time adolescent mothers indicated that 93% were sexually active and most did not use contraceptives regularly. One in six pregnant adolescents will get pregnant again within one year (Cockey, 1997). Studies show that an adolescent who has previously been pregnant has a much greater chance of becoming pregnant again than she did of becoming pregnant the first time. The likelihood of repeated pregnancy is further increased if the first pregnancy is carried to term. Single adolescent mothers who have repeated pregnancies are likely to find that parenthood is a very heavy burden (Mapanga, 1997). Adolescents are at risk for abusing substances. This is no different for the pregnant adolescent. There are many potential substances of abuse among pregnant 27 adolescents. Cigarette smoking and alcohol ingestion are among the most common. Other commonly abused substances include, but are not limited to caffeine and over-the- counter drugs. The most obvious way to decrease rates of low birth weight and preterm birth is to stop cigarette smoking during pregnancy. Cigarette smoking is the single most important known cause oflow birth weight. Up to 20% of low birth weight deliveries could be prevented if all pregnant women stopped smoking cigarettes (Chomitz, et al., 1995). Smoking during pregnancy is a major preventable risk factor for low birth weight and has been linked to 20 to 30% oflow birth weight deliveries and 10% of fetal and infant deaths (Chomitz, et al., 1995). The goal should be for all health care providers to encourage and assist their pregnant patients in smoking cessation (Sable & Herman, 1997). Unintended pregnancy has been associated with smoking cigarettes and drinking alcohol during pregnancy; conversely, women who reported a wanted pregnancy were more likely to quit smoking (Hellerstedt, et al., 1998). Alcohol use during pregnancy is related to a series of congenital malformations described as fetal alcohol syndrome (Chomitz, et al., 1995). Fetal alcohol syndrome is characterized by a pattern of severe birth defects related to alcohol use during pregnancy which include prenatal and postnatal growth retardation, central nervous system disorders, and distinct abnormal craniofacial features (Chomitz, et al., 1995). Heavy alcohol consumption has been cited as the leading preventable cause of mental retardation worldwide (Abel & Sokol, 1987). Marijuana use has been associated with the birth of smaller infants to both adult and adolescent mothers (McAnamey, 1987). Children exposed to marijuana in utero may be smaller than nonexposed infants. Some reports suggest that pregnant women who 28 smoke marijuana are at higher risk of preterm labor, miscarriage, and stillbirth (McAnamey, 1987). Finally, it is an identified health care need of pregnant adolescents to receive education comparing breast feeding and bottle feeding (Kogan, et al., 1994). A study by Weimann, DuBois, and Berenson (1998) found that the most important obstacles to breast feeding were perceived barriers such as breast feeding during school or work, rather than lack of information. This study compared adolescents who chose to bottle feed their infants with adolescents who chose to breast feed their infants. They also found that adolescents who chose to bottle feed were making their decision later in pregnancy and had fewer breast-feeding role models than those who chose to breast feed. Therefore, they suggest that breast-feeding role modeling and facilitation may be key components of interventions within this group of adolescent mothers to help overcome perceived barriers to breast-feeding. In most circumstances, human milk provides the precise nutrients that infants need to grow and develop at an appropriate rate for the first four to six months of life. Human milk helps protect children against diarrheal illnesses, allergies, ear infections, and gastrointestinal, respiratory, bacterial, viral, and fungal infections. The prolonged intimate physical contact between mother and infant during breast feeding helps in the bonding process (Rodriguez-Garcia & Schaefer, 1990). Breast milk is free of monetary cost and amply available, while formula and the necessary supplies can cost several hundred dollars per year. Furthermore, the hassle of mixing formula and cleaning bottles and rubber nipples is eliminated with breastfeeding. However, it should be noted that breast feeding an infant does take time, effort, patience, and skill to accomplish. 29 Maternal nutrient and fluid requirements are also higher among breast feeding women. Many women find it too painful and time-consuming to continue. This should be factored into the decision of whether to breast or bottle feed. Nutritional Pregnant adolescents have unique nutritional needs resulting from their increased risk for nutritional deficiencies related to poor dietary intake and rapid growth. The nutritional demands for the proper development of the fetus and the nutritional demands for the continual development of the adolescent mother must both be met. Adolescents have higher baseline nutritional requirements than do older women (Heald & Jacobson, 1980). Diet and nutritional status are particularly notable issues in that they are “modifiable,” and attention to them before and during pregnancy may reduce the risk of unfavorable pregnancy outcomes (Story & Alton, 1995). However, eating patterns typical of this age group may not be conducive to a healthy diet. The nutritional needs of younger pregnant adolescents demand particular attention. Maternal weight gain is an independent predictor of infant birth weight (McAnamey, 1987). There is a strong relationship between inadequate maternal weight gain and low birth weight in both adults and adolescents. One study by Scholl et al., (1994) found that growing teenagers had significantly smaller infants when compared with same-age peers who did not grow while pregnant. This suggests that larger weight gains are necessary for young adolescents during pregnancy. In general, the less weight the mother gains, the smaller the infant. 30 Pregnancy places adolescent females, who are already at risk for nutrition problems, at even greater risk because of the increased energy and nutrient demands of pregnancy. Although data on nutrient requirements of pregnant adolescents are limited, in general, the greater the amount of uncompleted growth at conception, the greater the energy and nutrient needs above those normally required during pregnancy (Story & Alton, 1995, p. 147). Potential causes of inadequate weight gain include substance abuse, heavy cigarette smoking, psychosocial stress or depression, eating disorders, intentional restrictive eating, high levels of physical activity, pregnancy-related nausea, or limited food availability (Story & Alton, 1995). “Because adolescence is often accompanied by intense concern over body size and shape, pregnant adolescents may potentially resist gestational weight gain” (Story & Alton, 1995). In focus groups with 60 pregnant adolescents and teenage mothers. Story and Alton (1995) found that there was a notable feeling of confusion as to why an adequate amount of weight gain was important. A popular statement was, “ Why should you gain 30 pounds when the baby only comes out about seven or eight pounds?” (Story & Alton, 1995, p.147). Discussing the components of weight gain and using charts depicting where the weight is distributed is helpful to pregnant teenagers (Story & Alton, 1995). Eating patterns of adolescents are important to take into consideration when discussing gestational nutrition. Pregnant teenagers have food preferences and eating behaviors similar to those of nonpregnant teenagers. Common issues that relate to teenagers also apply to pregnant teenagers. These include concern about weight gain, meal skipping and being too busy to eat, frequent snacking on foods high in fat and sugar and low in nutritional value, as well as reliance on convenient and fast foods. This 31 displays the need for viewing adolescent eating patterns and behaviors within a developmental and psychosocial context (Story & Alton, 1995). It is also important to note that, because pregnant adolescents are disproportionately poor, they may lack sufficient or adequate food. For these reasons, it is important that they participate in federally funded food assistance programs such as food stamps or Women, Infants, and Children (WIC) (Story & Alton, 1995). Some of the key nutrients include energy, protein, iron, calcium, and folate (Story & Alton, 1995). Further recommendations regarding multiple vitamin-mineral supplements and recommend food intakes follows. Sufficient energy in the form of calories is a primary dietary requirement of pregnancy. If energy needs are not met, available protein, vitamins, and minerals cannot be used effectively for various metabolic functions. Also, energy intake is probably the most important dietary factor associated with birth weight. Current recommendations are that pregnant women increase their average energy intake by 300 calories per day during the second and third trimesters of pregnancy (Institute of Medicine, 1990). Adequate energy, which is dependent on growth status, activity level, body size, and state of pregnancy is best indicated by an appropriate weight gain. Adolescents who begin pregnancy underweight, are still growing, or who are physically active may need additional energy intake during pregnancy. Grains are the body’s main source of energy. The March of Dimes Birth Defects Foundation (1999) recommends 6 to 11 servings of whole grain or fortified products be consumed each day. Additional protein is required during pregnancy for maternal, placental, and fetal needs. The Recommended Daily Allowance (RDA) for protein for adolescent females is 32 approximately 45 grams per day. An additional 10 grams per day is recommended throughout pregnancy. Three to four servings of protein should be consumed per day (March of Dimes, 1999). Pregnant adolescents are at particularly high risk for iron deficiency anemia associated with poor nutritional intake (March of Dimes, 1997). Both pregnancy and adolescent growth are associated with increased iron requirements because of lean tissue increments and red cell mass expansion (Scholl, Hediger, Fisher, & Shearer, 1992). According to the United States birth certificate data, teenagers under age 20 had elevated rates of gestational anemia compared with women 20 to 24 years of age. Iron deficiency anemia in early gestation has been associated with a two to three fold increased risk for prematurity and low birth weight infants (Scholl, et al., 1992). The pregnancy RDA for iron is 30 mg/day. Most women cannot get enough iron from their diets to meet their pregnancy needs; therefore, to meet the iron requirements of pregnancy, iron supplementation with 30 mg of elemental iron per day during the second and third trimesters of pregnancy is recommended (March of Dimes, 1999). Low-dose iron can be given alone or as part of a multivitamin and mineral supplement of appropriate composition for pregnancy. Regular consumption of heme sources of iron (meat, fish, poultry), which are well absorbed, and ascorbic acid sources, which enhance absorption of non-heme sources of iron, should also be encouraged to promote adequate iron intake (Story & Alton, 1995). Low calcium intakes are well documented in adolescent females (Scholl, et al., 1992). Calcium is required during pregnancy for building fetal bones and teeth as well as maintaining maternal bone mass (March of Dimes, 1999). Adequate calcium intake is 33 especially important for pregnant adolescents who are still increasing their own bone mass. The current RDA for pregnancy is 1,200 mg of calcium per day for women of all ages. The March of Dimes Birth Defects Foundation (1999) recommends at least four to five servings of dairy products per day to obtain adequate calcium intake. Supplemental calcium is indicated when adolescents are unable or unwilling to achieve the recommended dietary calcium intake from food sources. The Institute of Medicine (1990) recommends a supplement providing 600 mg of elemental calcium. Folate is essential for nucleic acid synthesis. It is required in greater amounts during pregnancy as a result of maternal and fetal tissue growth and red blood cell formation. Folate deficiency during pregnancy may result in intrauterine growth retardation, congenital anomalies such as neural tube defects, or spontaneous abortion (Institute of Medicine, 1998). Dietary sources of folate include fortified breakfast cereals, orange juice, dried beans, and spinach. The March of Dimes, the CDC (1991) and the Institute of Medicine recommend that women who could become pregnant consume 400 micrograms of synthetic folic acid per day (March of Dimes, 1999). Most women only get about 200 micrograms of folic acid from their diets daily (March of Dimes, 1999). The Institute of Medicine (1998) further recommends that women should increase their intake of synthetic folic acid to 600 micrograms a day once their pregnancy is confirmed. Supplementation with folate during early gestation has been related to a 50% protective effect against first occurrence and a 70% protective effect against recurrent neural tube defects such as spina bifida, anencephaly, and encephalocele (March of Dimes, 1999). 34 A low-dose vitamin-mineral supplement is often recommended for pregnant adolescents. Many young and disadvantaged adolescents have chronically poor dietary habits and may enter their pregnancies in less than optimal nutritional condition (Story & Alton, 1995). Since very young pregnant adolescents are most likely to be undernourished before pregnancy, nutritional supplementation may have the greatest effect in this group. A significant increase in average birth weight was recorded for infants of adolescents less than 16 years old who received supplementation compared with those who did not receive supplements (McAnamey, 1987). An adequate intake of calories, protein, minerals, and vitamins during pregnancy is important to ensure a healthy outcome for the pregnant adolescent and her developing fetus. Nutrient intakes to meet these increased needs can be achieved (with the exception of iron and synthetic folic acid) by selecting foods consistent with the US Dietary Guidelines and the Food Guide Pyramid. Recommended daily servings appropriate for pregnant adolescents are two to four fruits/juices (including a vitamin C source), three to five vegetables (including a dark green/deep orange vegetable), four to five low-fat dairy products, three to four servings of meat or meat alternatives, and 6 to 11 whole/enriched grain products (March of Dimes, 1999). Effective teaching strategies include: use of concrete, visual teaching approaches; eating pattern messages that are simple and positive, with focus on foods rather than nutrients; and positive reinforcements for healthy behaviors. Most adolescents want more “how to” information and less “why” information (Story & Alton, 1995). For eating-behavior change, information should be behaviorally oriented, focusing on the following: What to eat, how much and how often to eat. (Story & Alton, 1995). 35 Social and Financial Adolescent pregnancy is associated with many social and financial risks and corresponding needs. Most adolescents are either at school or training for a career. This is essential both for the economic development of the adolescent and for a more secure adulthood for the individual. Many adolescent mothers withdraw from school. This is frequently coupled with low economic status, chronic unemployment, and dependence on social services. Many unmarried first-time mothers rely financially on public assistance (Felice, et al., 1999). Adolescent mothers are not only less able to take care of their own needs, but in consequence, are also less able to care for the needs of others. “Many social factors have been associated with poor birth outcomes, including poverty, unmarried status, low educational levels, drug use, and inadequate prenatal care. A combination of biological and social factors may contribute to poor outcomes in adolescents” (Felice, et al, 1999, p. 518). Improved social and financial outcomes have been shown to occur with adolescents who continue their high school education or obtain their GED (Zill, 1996). Nearly one in every four children in the United States is bom to a mother who has not finished high school, and more than one in eight is reared by such a mother during the critical preschool period. Some studies have shown that the health and welfare of children are linked to the education level of their parents, with parental education often being a stronger predictor of child well-being than family income, single parenthood, or family size. Higher parent education levels make it more likely that children will receive adequate medical care and that their daily environments will be protective and 36 responsive to their needs. Of the various aspects of child development and well-being, parental education is associated most closely with cognitive development and academic achievement. Parental education is linked to children’s economic well-being, social development and emotional well-being, in addition to their physical health (Zill, 1996). According to reports from the March of Dimes (1992), the most critical elements in helping teenagers have healthy babies include: • Getting early and regular prenatal care from a primary health care provider or clinic, • Eating a nutritious and balanced diet, • Consuming 0.4 mg of folic acid daily to reduce the risk of a serious birth defects of the brain and spine, • Avoiding smoking and alcoholic beverages, and • Avoiding all drugs, unless recommended by a health care provider who is aware of the pregnancy (March of Dimes, 1992). 37 CHAPTERS METHODOLOGY Project Design The process of designing the information calendar for this project began with a general review of literature and an assessment of available resources for pregnant women in Gallatin County. Relevant brochures were gathered from community resources and referred to for calendar content. A similar prenatal calendar directed toward adult women was also utilized for the design idea (Great Beginnings, 1991). Finally, two group interviews were conducted with pregnant and parenting adolescents in a local support group. The information calendar was designed to be utilized by pregnant adolescents throughout their pregnancies. The calendar format was based on the opportunity to present information one month at a time. The actual calendar was formatted and designed simultaneously with the above steps. Literature Review Development of the information calendar began with an extensive review of literature regarding issues surrounding adolescent pregnancy. Particular attention was paid to developmental aspects of adolescents and risks of adolescent pregnancy. More 38 specific topics identified for literature review included health care, nutritional, financial, and social needs and corresponding risks of pregnant adolescents. These topics are reflected in the components of the calendar. Community Assessment An assessment of community resources occurred early in the process of designing the calendar. This assessment included phone calls and visits to the Gallatin County Public Health Department, Bridger Alternative High School, Prevent Child Abuse Program, Bridger Clinic, and many of the other identified resources listed in Chapter 1. Brochures were gathered at sites that offered them. These brochures were utilized as guides for calendar content. The community assessment reflected a need for developmentally specific prenatal information for pregnant adolescents because of a lack of resources and services that have been designed for that population. Group Interviews Group interviews were conducted with pregnant and mothering teens who participate in a local support group. Discussion topics included perceived barriers to prenatal information and resources in Gallatin County, infant feeding choices, labor and delivery experiences, and calendar format. These interviews were conducted later in the process of developing the calendar. This allowed the researcher to present the nearly complete calendar to the participating adolescents. The teens who agreed to participate were given multiple examples of possible text fonts and colors of the calendar pages and 39 selected their favorites. Their input was used to determine the most effective format of the calendar. The interviews were recorded. However, there were times when the participating adolescent would request that the recorder be shut off so she could discuss an issue that may have been too sensitive to record. These requests were honored by the researcher. Information Calendar The calendar is divided into nine months with a congratulations page, a back to school page, and a resource list at the end. It is intended that the calendar will be given to the adolescent at the time she has a positive pregnancy test, ideally shortly after her first missed period. However, recognizing that many adolescents do not seek health care early in their pregnancies, the introduction to the calendar encourages adolescents to read all months previous to the current month of pregnancy. Each month contains developmentally appropriate information specific to adolescent pregnancy. The developmental characteristics of adolescents make it necessary to create specific learning tools for this population. This project resulted in a developmentally appropriate information calendar for pregnant teenagers. Young adolescents are in Piaget’s (1969) concrete operational thinking stage. Therefore, the calendar is very concrete, simple, and in the “here-and-now” offering information in monthly increments. Providing information in monthly intervals allows the adolescent to focus on one issue at a time, becoming less overwhelmed or over- stimulated by too much information all at once. This is the basis of the calendar design. An effort was made to avoid information that is not pertinent to the adolescent at a given 40 time. The calendar also provides definitions of necessary medical terminology, and unnecessary medical terminology is avoided. Critical information is sometimes repeated in the calendar so the adolescent will have more than one opportunity to discover the information. Adolescents in Piaget’s (1969) concrete operational thinking stage also have limited abilities to plan ahead or identify future consequences of actions. Therefore, it is an important component of the calendar to state the ‘why’ in simple and relevant terms when relating advice about prenatal health actions. Elkind’s (1967) description of the adolescent’s ‘personal fable \ or fable of immunity" relates to the necessity of describing concrete consequences to adolescents. Their personal fable convinces them that consequences will happen to others, but never to them. Therefore, without a simple, concrete description of the ‘why’ part of health advice, many adolescents may dismiss the information as irrelevant to them. The calendar refers to the adolescent in the “YOU” terminology in order to make a greater impact about the adolescent’s perceived significance of the information. Pregnant adolescents have unique health-care, nutritional, social, and financial needs and risks which are addressed in the monthly breakdown of the calendar. Each month is colorful and contains simple graphics to obtain the attention of the adolescent. The words are simple and the topics are brief. Introduction. The cover of the calendar serves as a welcoming introduction to the calendar. It briefly addresses finding a prenatal care provider, substance use, and nutrition components. The adolescent will be encouraged to read all months up to the 41 current month of pregnancy, as important information is included early in the calendar and should not be missed. The pregnant and parenting teen support group is discussed, \ and a phone number and names are provided. Month One. Because adolescents tend to delay seeking prenatal care into their second or third trimester, the first month provides information to the adolescent about the importance of finding a prenatal care provider early in pregnancy. This information was put into the first month because of the chief importance of relaying this information to the adolescent early in pregnancy. A list of prenatal care providers is presented to assist the adolescent in finding a prenatal care provider. An access number to Medicaid is also provided. Month Two. The two most frequently reported serious neonatal complications associated with adolescent childbearing are prematurity and low birth weight (Institute of Medicine, 1985). The calendar addresses these complications by designating a month of discussion on several of the risk factors associated with prematurity and low birth weight. These include inadequate maternal weight gain, nutritional deficits, substance use and abuse, STDs, and preterm labor. The nutritional needs of pregnant adolescents are addressed in month two of the calendar. Foods are highlighted over nutrients. A simple list of foods assists the adolescent in identifying the number of recommended servings and food choices. A list of nutrition resources is also included to allow the adolescent easy access to these community services. A multivitamin supplement with folic acid is encouraged. 42 Month Three. The third month focuses on information regarding maternal weight gain guidelines. Adequate weight gain is critical during adolescent pregnancy to decrease the likelihood of preterm labor and low birth weight. A table showing weight gain distribution is provided. It is recommended that adolescents gain a minimum of 30 pounds. Healthy snack recommendations are further highlighted. Month Four. Harmful substance issues are the focus of month four. Adolescents are in a high risk category for substance use and abuse. Therefore, pregnant adolescents require information about the importance of avoiding these substances. An effort to strictly discourage use of harmful substances is made. Warnings about the use of prescription and over-the-counter drugs are included. Referrals to services in Gallatin County for drug and alcohol problems are offered. Month Five. The fifth month addresses sexually transmitted diseases (STDs). Risks associated with becoming pregnant are much the same as the risks of contracting STDs. Early treatment of STDs may decrease the likelihood of preterm labor and low birth weight. The information provided this month encourages any pregnant adolescent who is experiencing symptoms, or who has not been tested, to see a primary care provider as soon as possible. Abstinence is encouraged, and condom use is highlighted for those adolescents who are sexually active. Furthermore, the adolescent is encouraged to enroll in a child birth education class at this time. Month Six. Because adolescent pregnancy is associated with a higher incidence of preterm labor, month six focuses on signs of preterm labor. Early identification and 43 treatment of preterm labor may allow the fetal lungs enough time to develop. A definition of preterm labor is included. The adolescent is encouraged to seek immediate medical attention if she experiences any of the warning signs. Month Seven. Infant feeding choices are the focus of the seventh month. This section promotes breast feeding, but highlights some advantages of bottle feeding as well. Connections to Le Leche League and WIC are provided. Month Eight. The eighth month focuses on very general signs of how to know when true labor is starting. The adolescent is encouraged to seek out people who will be available to help her after the baby is bom. Month Nine. One in six teens who get pregnant will get pregnant again within one year (Cockey, 1997). Studies show that the adolescent who has previously been pregnant has a much greater chance of becoming pregnant again than she did of becoming pregnant the first time. The likelihood of repeated pregnancy is further increased if the first pregnancy is carried to term. Therefore, month nine focuses on contraception and the importance of using reliable contraceptive methods is emphasized. Though abstinence is encouraged, contraceptive options and resources are presented. Congratulations/Back to School. This page is not in a calendar format. The congratulations page facilitates a personal closure within the calendar. The bottom of this section addresses the importance of finishing high school. A resource for Bridger Alternative School is provided. Erikson’s (1963) developmental theory illustrates the 44 enormous tasks that adolescents are faced with attempting to complete. Pregnant adolescents are adolescents first. Becoming pregnant does not hasten the progression of developmental tasks (Flanagan, et al., 1995). According to Erikson (1963), identity formation is the central task of adolescence. The central processes of the task are peer pressure and role experimentation; the key socializing agent is the society of peers. Because most adolescents are trying to develop a sense of their identity and autonomy, it is essential that learning materials address the adolescent as unique and important, but not alone. Therefore, the emphasis of staying in school is critical in the social development of adolescents in addition to being important for their future financial stability. Furthermore, connections and information about a local support group with other pregnant and parenting adolescents are significant components lending to the social development of the adolescent. This component has the capacity to help the adolescent overcome the threat of isolation during Erikson’s stage of identity formation. Resources. The last section of the calendar provides a comprehensive list of resources in Gallatin County. In addition to being limited by their developmental stages, adolescents are often facing a crisis when they become pregnant. This situation further limits their ability to use advanced thinking skills such as identifying or planning necessary steps in finding and following prenatal care information. The calendar addresses this crisis by offering a comprehensive packet with many pertinent topics of prenatal information. Also, the calendar provides a comprehensive resource list for adolescents regarding early connections with important contacts in Gallatin County. This 45 component of the calendar is intended to decrease some of the barriers that adolescents may face during pregnancy. Adolescent pregnancy is associated with many social and financial needs and risks. This aspect of adolescent pregnancy is also addressed by the resource guide within the calendar. Because pregnancy in adolescence is often a time of crisis, the resource guide may assist the adolescent in finding critical support during her pregnancy. Analysis of Data Four adolescents were interviewed during a regularly scheduled pregnant and parenting adolescent support group session. All four adolescents were currently mothers, and of those, one was in her second pregnancy. Their ages ranged from 17 to 21 years of age. After a brief introduction, interested participants signed consent forms. They were first presented with a copy of the calendar to preview. Then they were given a paper that included: several different fonts, bold versus plain text, and italicized versus non- italicized text. They were also provided with two identical pages, one was black and white, while the other had color. They were given time to choose their preferences in all situations. The introduction of material as simple as text choices was used to gain trust and build rapport with the participating adolescents. Finally, a recorded discussion of open-ended questions revealed additional ideas for the calendar. The general impression from all participants was that the calendar was something that would be useful to pregnant adolescents. They overwhelming approved of pages with color in the art and text over black-and-white pages. They preferred italicized text 46 over non-italicized text, and bold over plain text. Further, only two of the ten different fonts were not chosen in any girl’s top five ranked favorites. During the interviews, the adolescents were asked to discuss ideas of what they liked and didn’t like about the calendar. They all especially liked the resource lists, and felt that these would have been nice to have had during their pregnancies. A common theme was that of feeling isolated. Two of the four girls stated they had just moved to Bozeman, and didn’t know anyone here; thus the resource list would have helped them to identify necessary resources. All girls noted that they needed to access Medicaid early in their pregnancy, and had difficulty initiating this. Two of four said their first contact for information was with WIC. They felt that once they were involved with WIC, they had access to all the necessary resources. Another positive response involved the weight gain chart, which depicts the distribution of weight gained during pregnancy. All felt that the chart was very helpful. The discussion about infant feeding choices revealed some interesting themes. All four teens stated that they decided to breast feed very early in their pregnancy. They all stated that they chose breast feeding because information they received indicated breast feeding was more healthy for their babies. However, three of the four teens discontinued breast feeding after only one week. The fourth teen breast fed for one month. Reasons breastfeeding was stopped included mastitis, “baby not getting enough,” uncomfortable breast feeding in public, mom got Strep throat, and “difficult to feed when in the car.” Two of the girls stated that their choice to discontinue breastfeeding led them to feel like they failed, but only for a short time. One teen mother stated that she didn’t want to bottle feed, but when she did, she was so happy just to see her baby eating that 47 she didn’t care. The teens felt that the calendar was fair to breast and bottle feeding. Finally, one teen stated that she would have tried harder to continue breastfeeding if she had known that it would help her get “back into shape” quicker. A discussion about labor and delivery prompted responses from everyone. All girls stated that their labor was different than they had expected. One young mother said she was in labor for only one hour, which was shorter than she expected. Another stated she was in labor for 12 hours, longer than she had expected. One young woman said that her labor was far more painful than she had expected despite some pain reliever in her I. V. She suggested a section in the calendar that states, “Labor and delivery really is painful, but it is worth it when it is over.” One mom said that she went into preterm labor twice, but was able to stop it both times because she recognized it early and went to the hospital. She suggested the month on preterm labor was very important. Two of the teens would have liked to see more information about what is happening in mom’s or baby’s body. They felt that even one or two points throughout the calendar would be helpful to know what is happening and what to expect. Another suggested content area was for child-proofing the home near the end of the calendar. One teen suggested a section that recommends lining up support systems before the baby is bom. She suggested that because new moms are so tired they really need to have support people in mind before the baby comes. Another interesting point brought up by one new mom, 19 years old, was that of what she calls herself. She felt that the terms ‘young woman’ or ‘teen’ were most accurate above terms such as ‘woman’, ‘girl’, or ‘adolescent.’ 48 The calendar reflects many of the adolescent’s suggestions. It refers to the pregnant adolescent as a young woman or a teenager rather than a woman, girl, or adolescent. It has a section encouraging teens to find support people before the infant is bom. The calendar contains colorful text and graphics, and is in the preferred fonts, bold and italicized. The discussion of labor and delivery in month eight includes a statement about labor pain and the common feeling that “it is worth it.” Rights of Human Subjects The group interviews were approved by the Human Subjects Review Committee at Montana State University - Bozeman, College of Nursing. Copies of the Human Subjects Approval and the consent forms can be found in Appendix A. 49 CHAPTER 4 PROJECT OUTCOME In order to provide effective, comprehensive health care, nurse practitioners (NPs) should provide developmentally appropriate learning tools for their clients. Pregnant adolescents are no exception. This population requires developmentally specific educational material. Pregnant adolescents are faced with an enormous amount of information that is critical to the outcome of their pregnancies. An effort should be made to simplify the presentation of this information in order to maximize effectiveness. The purpose of this project was to design an information calendar for pregnant adolescents in Gallatin County. Developmentally specific information directed toward the pregnant adolescent was the basis of the project. The focal points of the calendar were aimed at facilitating access to local resources and promoting positive behavioral change in the pregnant adolescent. The theoretical framework for the project utilized the developmental theories of Elkind, Piaget and Erikson. 50 Limitations of the Calendar One limitation of the calendar is the cost of reproduction. Because color is an important aspect of the calendar, the print cost is increased. Therefore, it is beyond the scope of this project to mass produce the calendar for distribution. Another potential limitation of the calendar is that it may be perceived as yet another source of information among the many other brochures and booklets already available to pregnant adolescents. Rather than being used to replace and simplify some of the existing information, it may overload the learning process if used in addition to the plethora of existing information. The community assessment was also viewed by some as a limitation of this project. Most of the identified resources for Gallatin County are in Bozeman, Montana. However, it should be recognized that there are other small towns in Gallatin County that may have resources that were not identified for this project. A final limitation of the calendar relates to the use of the disks. The disks are intended to minimize difficulty in keeping the calendar current with updated information. However, if the disks are difficult to use, the calendar will become outdated quickly. Use of the disks was not evaluated for this project. Implications and Recommendations The calendar created as part of this project is a valuable resource for nurse practitioners (NPs) providing health care to pregnant adolescents. Integrating 51 developmentally appropriate learning materials into the provision of care allows the NP to offer more comprehensive and effective teaching to the clients. It is hoped that the calendar will be available for use in the future. The Montana State University - Bozeman, College of Nursing will ideally hold the disks and keep them current based on changing community resources. Persons responsible for the disks may contact potential community sources to identify interest. It may be possible for a grant to be obtained to cover the cost of printing the calendars. It is recommended that the calendar be distributed throughout various locations in the community. The Bridger Clinic, Gallatin County Public Health Department, WIC office. The Pregnancy Caring Center, Bridger Alternative High School Young Parent’s Program, and the Moms and Kids Together support group are a few recommended sites for distribution. Finally it is strongly recommended that the calendar be reviewed and evaluated by a larger sample of pregnant adolescents. These adolescents should be surveyed regarding aspects of the calendar such as content, writing style, clarity, and presentation of information. Outcome measurements of adolescent behaviors during pregnancy could also be obtained to determine effectiveness of the calendar. While the literature is saturated with studies examining risks associated with adolescent pregnancy, very few studies actually focus on ideal health-related learning materials for this population. Further research is recommended to clarify the effectiveness of various teaching strategies in written materials. 52 Summary The purpose of this project was to develop an information calendar for pregnant teenagers in Gallatin County. The calendar provides essential information regarding important prenatal care and behavior that may improve the outcome of an adolescent’s pregnancy. Developmental theories provided a theoretical framework to guide the design of the calendar. Many pregnancy resources exist in Gallatin County. However, very few of those resources have been developed specifically for the adolescent. The developmental characteristics of adolescents is different from the developmental level of adults. Therefore, it is necessary to adapt educational information to reflect those differences. Furthermore, pregnant adolescents have unique health-care, nutritional, social, and financial needs and risks that are necessary to address when developing educational material for this population. The role of the prenatal information calendar is to address the unique needs and risks associated with adolescent pregnancy in a developmentally specific format. It is imperative that this population receive developmentally adapted educational materials to maximize effectiveness of the information. 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Young maternal age and adverse neonatal outcome. American Journal of Diseases in Children. 141.1053-1059. Montana County Health Profiles. (1999). Montana Department of Public Health and Human Services. Helena, MT. Morrison, G. (1990). The world of child development: Conception to adolescence. Huntington Beach, CA: Del Mar. National Center for Health Statistics. (1987). Monthly Vital Statistics Report, Vol. 36, No. 4, supplement, July 17. Office of Technology Assessment. (1988). Healthy Children: Investing in the future. Washington, DC: Congress of the United States. Piaget, J. (1969). The theory of stages in cognitive development. New York: McGraw-Hill. Poland, M., Ager, J. & Olson, J. (1987). Barriers to receiving adequate prenatal care. American Journal of Obstetrics and Gynecology. 157.297-303. Rodriguez, C. & Moore, N. (1995). Perceptions of pregnant/parenting teens: Reframing issues for an integrated approach to pregnancy problems. Adolescence. 30(119), 685-707. 57 Rodriguez-Garcia, R. & Schaefer, L. (1990). Breastfeeding promotion for child survival and child spacing. A suitable area for nursing intervention and leadership. In Lactation education for health professionals (pp. 121-151). Washington, DC: Pan American Health Organization. Sable, M. & Herman, A. (1997). The relationship between prenatal health behavior advice and low birth weight. Public Health Reports. 112(4L 332-340. Scholl, T, Hediger, M, & Belsky, D. (1994). Prenatal care and maternal health during adolescent pregnancy: A review and metaanalysis. Journal of Adolescent Health. 15, 444-56. Scholl, T., Hediger, M., Fisher, R. & Shearer, J. (1992). Anemia vs. iron deficiency: Increased risk of preterm delivery in a prospective study. American Journal of Clinical Nutrition. 55, 985-8. Stevens-Simon, C. (1993). Clinical applications of adolescent female sexual development. The Nurse Practitioner. 18. 18-27. Story, M. & Alton, I. (1995). 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Public Health Reports. 111(1). 34-43. 58 APPENDICES 59 APPENDIX A CONSENT FORMS and HUMAN SUBJECTS APPROVAL 60 Subject Consent Form for Participation in Human Research Montana State University Dear Pregnant or Parenting Teen: You are being asked to give your opinions for the benefit of a graduate project. The results of this study will be used to develop an informational calendar for pregnant teenagers. If you agree to participate, you will be involved in a group discussion within your regularly scheduled support group. These sessions are expected to last approximately one hour during one to three sessions. These sessions will be tape recorded. Your name will never be used in conjunction with the material on the tapes. There will be no other expectations of you in the future. You are free to ask questions now and during the time you are involved in the discussions. You may withdraw at any time. If you agree to participate, there are no physical risks involved. There will be no financial or other compensation in payment. This study is of no direct benefit to you. Your participation is strictly voluntary. If you choose not to participate, or choose to withdraw from the discussion, your care or participation in your regularly scheduled support group will not be jeopardized in any way. Complete confidentiality will be maintained. The data and consent forms obtained will be stored in a locked file. The researcher will be the only one with access to this data. As mentioned above, your name will never be used in conjunction with the material on the tapes. This study was approved by the Human Subjects Review Committee at Montana State University College of Nursing - Bozeman Campus. Further questions or information may be obtained by calling Amy Anderson at (406)522- 9215. You may also contact my committee chair person. Dr. Lea Acord at 994-3784, Thank you. Authorization: I have read the above and understand the reason for this discussion and what is expected of me. I agree to participate in this discussion. I understand that I may withdraw from the discussion at any time. I have received a copy of this consent form for my own records. Amy Anderson, BSN, RN Graduate Student MSU College of Nursing Signed: Date: Witness: 61 Date: January 31, 2000 To: Meg Segal, Family Support Worker Prevent Child Abuse, Inc P.O. Box 4325 Bozeman, MT 59772 From: Amy H. Anderson, BSN, RN, FNP student at MSU, Bozeman As part of my graduate work, I am developing an information calendar for pregnant adolescents. The calendar will contain information that is intended to help adolescents have a healthy pregnancy. The information is developmentally specific. It addresses issues that are pertinent to pregnant adolescents in a format that is easily understood by this age-group. I am requesting permission to utilize the support group for pregnant and parenting teenagers to access potential participants for my graduate project research. Access to this support group is needed to gain insight from the perspective of the pregnant and parenting adolescent. I am expecting it will be necessary to take approximately 45 minutes to one hour of time from the support group during 1-3 sessions. However, this time frame is highly negotiable. I intend to have a rough draft of the calendar to use at the meetings. An open discussion will be the format used to obtain the information. Topics addressed will be: ♦ What were/are some barriers to information that you have found during your pregnancy? ♦ What information did/do you see as important for having a healthy pregnancy? ♦ How do you learn from written information best? ♦ What could be added to the calendar to make it more usable? ♦ What could be taken out of the calendar to make it more usable? ♦ What font do you prefer to read? Do you prefer color in the text? ♦ What were some issues that you found important with making a decision to breast or bottle feed your baby? The potential participants will be asked if they are interested in participating in a group discussion regarding the above information. They will be assured that their participation in the support group as well as their care from the Gallatin County Health Department will not be jeopardized in any way by choosing not to participate. If they agree, they will sign a consent form. These discussions will be openly tape recorded. They will be assured that they may withdraw at any time, without coercion. It is understood that participation is strictly voluntary. Confidentiality will be maintained throughout the study. This study has been approved by the Human Subjects Review Committee at Montana State University, College of Nursing - Bozeman Campus. If you have any questions, you may contact me at 522-9215. You may also contact my committee chair person. Dr. Lea Acord at 994-3784. Your agreement to support this project by allowing access to adolescents is deeply appreciated. Thank you, Amy H. Anderson, BSN, RN Graduate student Consent of Program: Authorized Signature Date Great Falls Campus Missoula Campus 2800 11th Ave. South 32 Campus Drive Suite 4 Missoula, MI 59812-8238 Great Falls, MI 59405 Phone (406) 243-6515 Phone (406) 455-5610 •> Fax (406) 243-5745 Fax (406) 454-2526 Amy Anderson, BSN, RN 211 West Koch Bozeman, MT 59715 Dear Amy, , Per our discussion on November 3, 1999 regarding your Human Subjects Review Committee proposal and your recent re-submission of the proposal with the changes we discussed, I am pleased to inform you that you may begin the data collection process for your master’s project. The committee’s recommended changes which you have made were as follows: ► Informed consent statement includes: a clear statement of the purpose of the study and the potential risks and benefits for subjects; explication of duration of subject participation; freedom to refuse to participate or withdraw at any time with no loss of care or support group participation; /. confidentiality of data and storage of signed informed consent forms (eg locked file for 5 years per policy); and plan for referral if needed. Please feel free to contact my office at (406) 995-3783 if you have any further questions regarding this process. Sincerely, ' rA. Gretchen McNeely, DNSc, RNC Associate Dean cc: Lea Acord, PhD, RN, Committee Chair CON file of Human Subjects Review Committee approvals ► ► ► ► ► College of Nursing Main Campus Sherrick Hall P.O. Box 173560 Bozeman, MT 59717-3560 Phone (406) 994-3783 Fax (406) 994-6020 Billings Campus Campus Box 574 MSU • Billings Billings, MT 59101 Phone (406) 657-2912 Fax (406) 657-1715 November 16, 1999 62 APPENDIX B INFORMATION CALENDAR FOR PREGNANT TEENAGERS DOOOOOaOOOOOODOOOOOOOOOOOOOODOOOOOOOOOOOOOOOaO f% o o o o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 V) x. <0 CO c Q) t- o X. x. 05 JU CO U JC o 4^ CO £ .b? c Qi O C _ _Q. o 03 .. £ V/> Q3 £ 05 *§“ O -c. 45 o ^ ? 1 4: <0 'S ° . ^>-h? <0 tO -rr £ -Ct U , X. "O 5 o to 3 => w i- JCL. +— to "rr C "O ^ •C -C- £ J5 O +- to +“ .5 O “U o c xu .§ sz to 05 ? -O. ^ § _05 £ 05 •3} ^ T= * f - ^5 _ u 05 o> to c 05 05 O' o 05 c 05 “n “=• o ^ to 4__ _ ^ t o tO j ^ 1 15 -H 3 ^ 35 to ^a-45 2 ^ g, s. 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