Introduction
In comparison to other developed nations, the U.S. currently has the highest rate of adolescent pregnancy and childbirth, where adolescent pregnancy is defined as the pregnancy of girls at age 19 or younger” (MedlinePlus, 2007). This phenomenon is attributed to various factors such as emotional immaturity despite sexual maturity, peer pressure, media influences and the lack of education regarding responsible sex.
Adolescent pregnancy carries with it serious health and social consequences for both mother and child. Different nursing interventions have been formulated to address these problems and with varying outcomes. This paper describes and then critiques a study designed to evaluate the effects of one such intervention program. Conducted in 2000 by nurses, the study is entitled “A Public Health Nursing Early Intervention Program for Adolescent Mothers: Outcomes from Pregnancy Through 6 Weeks Post Partum”.
Problem and Purpose
Among the identified health risks associated with adolescent pregnancy is the increased incidence of low birth weight or premature infants. This occurs due to the lack of pre-natal care, inadequate nutrition of the adolescent mother, engaging in unprotected sexual intercourse which increases the risk to sexually transmitted diseases and unhealthy habits such as smoking, drinking or use of illicit drugs (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
Another health risk is the increased rates of hospitalization of infants or children because of unintended injury or illness. The difficulty of young girls to take on their role as mother or parent, underlying identity problems, the absence of social and financial support systems, emotional immaturity or insufficient knowledge are deemed to lead to such conditions which often require emergency treatments (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
Adolescent mothers also have a high tendency to drop out of school and their limited educational attainments curtail their chances of obtaining employment and earn adequate income to support themselves and their children. Current welfare systems further require beneficiaries to be employed for a few years following the receipt of welfare services, a requisite that most young girls may not be able to comply with. As such, adolescent mothers and their children often live in poverty.
The Early Intervention Program (EIP), designed using a public health nursing framework, is intended to reduce the health, economic and social costs of adolescent pregnancy in recognition of its significant impact on the over-all health and welfare of the nation. The program is geared towards providing a broad range of continuing, community-based interventions by nursing professionals.
Consequently, the aim of the study is to assess the effectiveness of this program by ascertaining its impacts on the following aspects: 1. the health and social behavior of adolescent mothers and their children, 2. the quality of care giving and 3. the interaction between the mother and her child (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
The EIP involves pre-natal home visits to increase the use of health care, prepare the adolescent mother for childbirth and impart self-care education while post partum visits focus on family planning, caring for infants and well-baby health care (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000). Counseling sessions were also provided by nurses to respond to arising emotional or mental health problems of participants.
Review of Literature and Definitions
Based on available literature, the authors recognized that there is a dearth in the formulation and implementation of community-based nursing intervention programs for adolescents which are founded on public health nursing models. Moreover, existing programs that promote adolescent health are mainly confined to particular aspects such as substance abuse or sexual behavior.
When programs do focus on adolescent pregnancy or motherhood, interventions are limited in scope to focus only on pre and post-natal care. Further, there are few studies providing longitudinal assessments of existing nursing intervention programs created for the adolescent population and employing precise criteria in evaluating outcomes (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
The authors then cited only four studies related to their research. The most notable work cited focused on the effects of home visitations by nurses on the maternal health of pregnant adolescents, the rate of child abuse or neglect in the sample chosen for the study, the number of children sustaining injuries related to accidents, the rate of succeeding unwanted pregnancies and the economic status of adolescent mothers. The assessment was conducted over a period of 20 years.
The other three studies dealt with a set of outcomes which were less comprehensive as the study mentioned above although two of these employed interventions that combined home visitations with other methods namely, telephone calls and regular clinic visits by the mothers and their children. Despite varying program components, goals, implementers and sample population, all studies pointed to the positive impacts of home visitations performed by public health nurses, a common element of all the intervention programs reviewed.
Hypotheses and/or Research Questions
Based on the positive effects of home visits as obtained from literature, a more intensive program with home visitation at its core is expected to result in decreasing the negative consequences related to adolescent pregnancy. Is a public health nursing model-based intervention program which utilizes home visitations as a primary component effective then in improving the specified health and social outcomes of pregnancy in the adolescent population, particularly those belonging to disadvantaged groups?
Sample
The research participants were 144 pregnant adolescents aged 14 to 19 years who have not given birth to live infants previously and were 26 weeks or less into their pregnancy, were not engaged in substance abuse, had no plans of aborting their pregnancies and had no critical medical conditions which may adversely affect their pregnancies. All adolescents selected for the study were residents of a county in Southern California.
Through referrals, they came in contact with public health nursing care providers at the local health department’s Community Health Services office. Majority of the participating adolescents were not married, had minority ethnic backgrounds – mainly Latinas and African Americans, and came from families that experienced economic disadvantage. Physical and sexual abuse was a common experience among the participants while some had attempted suicide a year prior to the study.
Research Design
The study employed a longitudinal quantitative research, specifically a quasi-experimental design to assess the effects of the EIP by comparing it with the Traditional Public Health Nursing (TPHN) care. The EIP group or experimental group received a total of 17 pre and post-natal home visitations, with the number of visits determined using evidence-based recommendations. Aside from this, they attended Preparation for Motherhood classes.
The control group or TPHN group received the typical services provided by health departments whose constrained budgets prevent the planning and implementation of programs specifically for pregnant adolescents. The number of visits for this group ranged from 1-3. Comparative statistical measures were employed to determine significant differences in the scores of the two groups as compared to baseline data.
Internal Validity
History: No important social events which could impact participant behavior at the time of the study are known and mention of such changes was not made in the study. However, this poses a potential threat because of the longitudinal nature of the study.
Maturation: Again, because the study spans more than a year, many developmental changes could have occurred in the participants which were measured but may not be a direct result of the interventions provided.
Testing: Although the instruments utilized in the study were peer-reviewed, no mention was made regarding pre or post testing.
Instrumentation: Four evaluators, who had no knowledge of the actual interventions conducted by the nurses, administered the instrument packets at the beginning and end of the intervention program and interpreted the data. This does not pose any threat because they were not involved directly in providing nursing care and eliminates experimenter effects. The same instrument packet is administered for both baseline and post-intervention data.
Mortality: Of the 144 total participants at the start of the study, only 121 remained at its commencement. Two of those dropped from the study changed residence and could not be located. The information from the 23 who did not continue may have effects on the results as there are more participants in the EIP group than in the TPHN group.
Selection Bias: All pregnant adolescents who were referred to the local health department and who satisfied the sample criteria were invited to participate. Those who responded positively joined the study and hence did so at their own volition. No incentives were provided prior to enrollment in the study.
External Validity
Selective Effects: The conclusions of the study were generalized to the whole pregnant adolescent population, whereas the sample is limited to a certain socioeconomic status and ethnic backgrounds. Participants are considered volunteers as they became part of the study by responding to invitations. Random selection only occurred in determining which of the participants will belong to either of two the groups.
Reactive Effects: The length of contact (maximum of one and a half years) between the nursing care providers/researchers and their assigned participants is sufficient to establish rapport and a routine which may eliminate reactive effects, a condition that may be very evident at the start of the study.
Measurement Effects: Baseline data collected at the beginning of the study were compared to the results of another round of data collection at the end of the study.
Research Methodology
Methods
Participants joined the research through invitation by public health nurses not directly involved in their care and were randomly divided using a computer program into the two Early Intervention Program and Traditional Public Health Nursing (TPHN) care. Because they were minors, their informed consent was obtained. After being subjected to base-line, standardized nursing interviews and answering written questionnaires, the participants were given $15 in exchange for their time.
The research team, contracted through a university grant, was composed of 15 nurses, 6 providing care for the EIP group and 5 for the TPHN group while the other 4 serve as evaluators who conduct the nursing interviews and administer questionnaires prior to the start of the study and again at 6 weeks after the adolescents give birth. Interview questions were peer-reviewed and questionnaires incorporated widely accepted measurement scales.
The researchers were BSN degree-holders and certified public health nurses with a minimum 5-year experience in public health nursing. Each researcher was tasked to provide care to a specified number of participants using the case-management approach. Evaluators have no knowledge about the actual treatments provided. Other sources of data include medical records and videotaped sessions. Three BSN students were recruited as research assistants to extract raw data from the medical records of participants and their infants and into a standardized coding sheet.
Reliability & Validity
The actual number of visits received by members of the EIP group was varied and attributed to the participant’s lack of commitment in adhering to scheduled visits or unavailability. It is probable that the monetary compensation the participants received at the commencement of the study provided an incentive for initially continuing with the research but its absence during the subsequent months dampened their enthusiasm in fully participating.
Analysis of Data
No principal statistical differences in pre-natal health, type of delivery or birth weights of infants were noted between the control and experimental group based on t-test results and analysis of hospital records. About half of the participants had pregnancies without complications and majority experienced normal delivery with full-term, healthy babies (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
On the other, significant statistical difference point to members of the EIP group as having less number of days that their infants stayed in the hospital for conditions such as fever or respiratory illness, suggesting that they had better abilities of recognizing the onset of illness and properly responding by seeking medical care before the condition becomes acute (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000).
Participants of this group were also more likely to continue their studies, finish high school and attend junior college compared to the TPHN group. No significance was observed in measures for substance abuse during the span of the research, in mother-child interaction and in social competence as well (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000). Both groups registered increasing scores over time in social competence measures.
Conclusions, Implications and Recommendations
Although the EIP was not proven to be more effective than TPHN care in many of the outcomes specified by the study, its impact in lowering school drop out rates and improving infant care is commendable and corroborates the results of previous research. The information generated also underscores that typical public health nursing interventions as well as more intensive ones are effective in improving the health of pregnant adolescents as evidenced by their superior pre-natal health and birth outcomes.
It also means that despite a difference in the frameworks of both interventions, nursing care provided by the implementers basically had similar goals that were fully achieved (Koniak-Griffin, Anderson, Verzemnieks and Brecht, 2000). An unexpected finding is the incidence of a minority of the participants resuming their smoking, alcohol and marijuana use – some during pregnancy and the others after giving birth. This poses a major and continuing issue that public health nurses need to address effectively. The researchers recommend that improvements based on the results of this study be made on the EIP to further increase its effectiveness.
Applications to Nursing Practice
Pregnant adolescents require more intensive nursing care because of the circumstances surrounding their pregnancy – their emotional immaturity, their incapacity to attain financial independence and their lack of preparedness for the responsibilities of parenthood. Special focus should be further provided to those belonging to disadvantaged families, a factor that increases their risk to the negative outcomes of their pregnancy. The varied factors that determine adolescent pregnancy outcomes compel nurses to adopt and further enhance intervention programs based on public health principles.
List of References
Koniak-Griffin, D., Anderson, N., Verzemnieks, I. and Brecht, M. (2000, May). A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks post partum. Nursing Research, 49(3): pp. 130-138.
MedLine Plus (2007, November). Adolescent Pregnancy. Retrieved November 8, 2008 from http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001516.htm.