If you are administering a pre-screening tool what do you expect to see as you complete the group as far as changes in the scores.
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Targeting Unintended Teen Pregnancy in the U.S. by Hadi Danawi, PhD MPH, Zenobia Bryant, MPH, and Tala Hasbini, MS
Abstract: Teen pregnancy in the United States has become a pressing public health concern with increasing rates sur- passing other developed countries such as Canada, Japan, and Switzerland. Policies must be developed in the U.S. to lower these rates and related health issues. Factors influencing teenage pregnancy include income, education, social support networks, and environment. These fac- tors are significant and should be consid- ered when developing a successful policy. Addressing these issues among expectant mothers and in prenatal classes should include discussions of societal inequities and available resources.
Keywords: teenage pregnancies, inequities, social determinants.
Introduction Sexual behavior and the reproductive health of adoles-
cents have become major public health concerns globally and in the United States (U.S.). Female teens living in the U.S. are more likely to end up pregnant compared to teens in other developed countries. For example, U.S. teens are twice as likely to give birth compared to teens in Canada and ten times as likely as teens in Switzerland (Kearney & Levine, 2012). Teenage pregnancy rates vary greatly between different states. More specifically, an adolescent female living in Mississippi is at a greater risk for pregnancy than one liv- ing in New Hampshire (Kearney & Levine, 2012). Racial and ethnic minority groups experience higher rates of teenage pregnancy and birth rates than their counterparts in the U.S. (Shoff & Yang, 2012). In 2010, the teenage pregnancy rate
for African American teens was almost twice that of white teens. The specific pregnancy rate for African American teen girls ages 15 to 19 was 99.5 per 1,000 teens. In addition, out of every 10 African American teens, four will end up preg- nant by their 20th birthday (The National Campaign, 2014). Some of the highest teen pregnancies and birth rates in the U.S. can be found in its capital city, the District of Columbia (DC). While the teen birth rate in DC dropped from 103 per 1,000 females in 1996 (Aarons & Jenkins, 2002) to 90 per 1,000 in 2014, major racial disparities remain (Lewis, T, 2014).
Childbirth educators benefit from an awareness of these rates to educate affected specific groups on related health issues and discuss available resources to them and are of- fered on both the federal and local levels. While most teen pregnancies by state have declined in recent years, racial disparities remain. When examined on a deeper level, these rates are still much higher than other countries. The best way to create successful policies that will aid in the reduction of teenage pregnancies is to target the inequalities in society as opposed to targeting teenage pregnancy directly.
U.S. teens are twice as likely to give birth as Canada and ten times as likely as teens in Switzerland
As of 2013, the teen birth rate, across all races, was 32.1 births per 1,000 females (U.S. Department of Health and Human Services, 2015). Although there has been a decrease in the teen pregnancy rate in DC as mentioned earlier and the U.S. in general, the rates are still much higher than other developed countries. Births to teen parents cost about $9.4 billion a year. In addition, teenage pregnancies and births have a negative effect on the physical, psychological, and social wellbeing of all teen mothers and their offspring (Mar- tinez & Abma, 2015).
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Social Determinants in the United States and Unintended Pregnancies
Social determinants of health are considered the conditions where people are born, where they grow up, and where they live and work. Social determinants are shaped by communities and the distribution of money and resources (Viner et al., 2012). Four social determinants of health that may influence teenage pregnancy rates are: 1) income; 2) education; 3) social support networks; and 4) living environ- ment. Income inequalities have an impact on various areas of adolescent health as well as levels of poverty. More specifi- cally, the teenage pregnancy rates in the U.S. are related to poverty and income inequality (Viner et al., 2012). Educa- tion is another important social determinant for unintended pregnancies as the completion of higher education improves the health of adolescents as well as their health literacy. For example, adolescents that complete their secondary educa- tion tend to have better health and a higher motivation to prevent pregnancy (Viner et al., 2012). The third social deter- minant, social connections, seems to have a major impact on adolescent health as teenagers who are more connected to their family and community tend to delay sexual initiation and are less likely to end up pregnant (Viner et al., 2012). Lastly, living environment is a social determinant that is oftentimes overlooked. Adolescents who live in dilapidated neighborhoods are more likely to experience “poor educa- tional attainment, teenage pregnancy, poor mental health, and youth violence” (Viner et al., 2012).
Education and Unintended Teenage Pregnancy in the U.S.
Another social determinant of health is education. Those with low levels of formal education are more likely to experience teenage pregnancies. Teens who live in a poor environment may feel that due to limited educational op- portunities, there is no use in delaying child birth (Shoff & Yang, 2012). In addition, the educational level of the parents is inversely associated with the risk of teenage pregnancy among adolescents (Penman-Aguilar, Carter, Snead, & Kourtis, 2013). On the other hand, those who are more committed to attending college and university may be more committed to delaying pregnancy (Kearney & Levine, 2012). It is reported that the educational life span of a teen mother is about two years shorter than that of teens who decide to delay childbirth. In addition, teen mothers are less likely to attend college (Basch, 2011).
Social Support Networks and Unintended Teenage Pregnancy in the U.S.
Social support networks are important for the health of adolescents. One important part of social networks for ado- lescents is parental involvement. Adolescents whose parents are more involved tend to choose to delay sexual initiation and are at a lower risk for unintended pregnancy (Hoskins & Simons, 2015; Viner et al., 2012). In addition to parental involvement, the peers that teens spend time with also have an impact on pregnancy rates. Females who have friends that engage in risky sexual behavior are more likely to engage in the same behaviors and are more likely to experience unin- tended pregnancy (Hoskins & Simons, 2015).
Living Environment and Unintended Teenage Pregnancy in the U.S.
The last important social determinant of teenage pregnancy is the living environment. Teenagers who live in overcrowded areas with poor public infrastructure and high levels of violence are at a greater risk for experiencing severe outcomes such as unintended pregnancies (Viner et al., 2012). The presence of graffiti, litter, and physical disorder in the neighborhood is associated with higher rates of teen pregnancies. In addition, lower neighborhood socioeconomic status is also associated with higher rates of teen pregnan- cies (Penman-Aguilar, Carter, Snead, & Kourtis, 2013). The daughter of a teen mother is at a higher risk for experiencing unintended pregnancy as a teen (Penman-Aguilar, Carter, Snead, & Kourtis, 2013).
Cultural Awareness and Unintended Teenage Pregnancy
Cultural awareness affects a person’s views on the world and is based on learned behavior that is passed from genera- tion to generation (Ingram, 2011). Among different ethnic and racial groups, teenage pregnancy can be common and many adolescents may be exposed to teenage motherhood through their families and environments (Akella & Jordan, 2011). In addition, some cultures believe that early mother- hood will secure their relationships with their boyfriends (Akella & Jordan, 2011). The rate of acculturation and language used at home were positively associated with teen- age childbearing. Latinas who have emigrated to the U.S. from their native countries tend to have much higher rates of unintended teenage pregnancies (Dehlendorf, Marchi, Vit- tinghoff, & Braveman, 2010).
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Life Expectancy and Unintended Teenage Pregnancy
As of 2014, the life expectancy at birth for the U.S. was 79.56 years and ranked number 42 worldwide, which is much lower then other developed nations (Central Intel- ligence Agency, n.d.). There are many factors that contribute to the life expectancy ranking of the U.S. such as high levels of tobacco use, obesity, and physical inactivity. In addition, sexual practice and high levels of violence also contribute to the life expectancy ranking (Avendano & Kawachi, 2014). One major contribution to the life expectancy ranking could be the rate of teenage mothers as they seem to have poorer health status and higher mortality. In addition, teen moth- ers are at increased risk for heart disease and cervical cancer, which are among the top ten causes of death (Olausson, Ha- glund, Weitoft, & Cnattingius, 2004). Lastly, teenage preg- nancies place these adolescent mothers at a greater risk for living in poverty and in a lower socioeconomic level (Meade & Ickovics, 2005). When there is a large gap between socio- economic status and poverty gradients, the nation as a whole tends to have a lower life expectancy at birth (Wilkinson & Pickett, 2010).
Current Effort in the U.S. to Reduce Unintended Teenage Pregnancies
The unintended pregnancy rate in DC is much higher than the rate nationwide. In addition, the adolescents in DC are more likely to have their sexual debut prior to 13 years old (Koo et al., 2011). In order to reduce the high preg- nancy rate in DC and reduce health inequities interventions must begin early. One such intervention, Building Futures for Youth (BFY), was created for the fifth and sixth grade classroom (Koo et al., 2011). The curriculum consisted of 10 sessions for fifth graders and 13 sessions for sixth grad- ers. The content of the sessions consisted of information on abstaining from sexual intercourse, information on effective communication and decision making skills, and strategies to avoid early sexual behavior (Koo et al., 2011). The sixth grade classes also contained information on the influences of the media, sexually transmitted diseases, and contraceptive methods. This intervention resulted in a reduction of sexual initiation among intervention attendees. No reduction of sexual initiation was seen for the control group (Koo et al., 2011).
Development of Health Policy in the U.S. When developing health policies, it may not be ben-
eficial to target unintended teenage pregnancy prevention directly. For example, policies that directly target sex educa- tion, access to contraception, and abstinence are not likely to improve teen pregnancy rates and teen births among disad- vantaged populations (Kearney & Levine, 2012). The way to cause or affect a positive social change relating to a decline in teen pregnancy rates is to create policies that reduce pov- erty and that create a more equal society. In order to create a more equal society, inequalities such as income difference and the gap between various socioeconomic levels must be targeted (Kearney & Levine, 2012). In addition, to decrease teenage pregnancies, policies should be culturally sensitive so as not to alienate different racial and ethnic groups as well as target upstream issues. For example, since adolescents who live in high poverty areas are more likely to experience unex- pected teenage pregnancies, policies should be created that will assist different cultural and racial groups with integrating nutritious food into their diet without having to change their intake of their specific cultural foods (Battle, 2012). Child- birth educators armed with an understanding of the nation’s teen pregnancy problem and observing the demographics of their clients to assess and identify vulnerable groups in order to convey additional resources which may be available at the state level will make a difference. Creating positive social change and engaging affected communities in intervention programs aimed at reducing teen pregnancies in the U.S. must constitute a priority action item. Being proactive is a social responsibility in which every citizen should partake.
References Aarons, S. J., & Jenkins, R. R. (2002). Sex, pregnancy, and contra- ception-related motivators and barriers among Latino and African- American youth in Washington, DC. Sex Education, 2(1), 1-30. Doi: 10.1080/1468181022013359 6
Akella, D., & Jordan, M. (2011). Impact of social and cultural factors on teen pregnancy. Journal of Health Disparities Research and Practice, 8(1), 41-62. Retrieved from http://digitalscholarship.unlv.edu/jhdrp
Avendano, M., & Kawachi, I. (2014). Why do Americans have shorter life expectancy and worse health than do people in other high-income coun- tries? Annual Review of Public Health, 35, 307-325. Doi: 10.1146/annurev- pubhealth-032013-182411
Basch, C. E. (2011). Teen pregnancy and the achievement gap among urban minority youth. Journal of School Health, 81(10), 614-618.
Battle, L.S . (2012). Moving policies upstream to mitigate the social deter- minants of early childbearing. Public Health Nursing, 29(5), 444-454. Doi: 10.1111/j.1525-1446.2012.01017.x
Bennett, I. M., Frasso, R., Bellamy, S., Wortham, S., & Gross, K. (2013). Pre-teen literacy and subsequent teenage childbearing in a US population. Contraception, 87(4), 459-464. Doi: 10.1016/j.contraception.2012.08.020
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Boonstra, H. D. (2011). Teen pregnancy among young women in foster care: A primer. Policy Review, 14(2), 8-19.
Central Intelligence Agency. (2015). The world fact book. Retrieved August 21, 2015, from https://www.cia.gov/library/publications/the-world-factbook/ index.html
Dehlendorf, C., Marchi, K., Vittinghoff, E., & Braveman, P. (2010). Socio- cultural determinants of teenage childbearing among Latinas in California. Maternal and Child Health Journal, 14(2), 194-201. Doi: 10.1007/s10995- 009-0443-8
Hoskins, D. H., & Simons, L. G. (2015). Predicting the risk of pregnancy among African American youth: Testing a social contextual model. Journal of Child and Family Studies, 24, 1163-1174. Doi: 10.1007/s10826-014-9925-4
Ingram, R. R. (2011). Using Campinha-Bacote’s process of cultural com- petence model to examine the relationship between health literacy and cultural competence. Journal of Advanced Nursing, 68(3), 695-704. Doi: 10.1111/j.1365-2648.2011.05822.x
Kearney, M. S., & Levine, P. B. (2012). Why is the teen birth rate in the United States so high and why does it matter? Journal of Economic Perspec- tives, 26(2), 141-166. Doi=10.10.1257/jep.26.2.141
Koo, H. P., Rose, A., El-Khorazaty, M. N., Yao, Q., Jenkins, R. R., Anderson, K. M…& Walker, L. R. (2011). Evaluation of a randomized intervention to delay sexual initiation among fifth-grader followed though the sixth grade. Sex Education, 11(1), 27-46. Doi: 10.1080/14681811.2011.538146
Lewis, T (2014). Teen pregnancy rates by state. Live Science. Retrieved from http://www.livescience.com/45355-teen-pregnancy-rates-by-state.html
Martinex, G. M., & Abma, J. C. (2015). Sexual activity, contraceptive use, and childbearing of teenagers aged 15-19 in the United States. NCHS Data Brief, 209, 1-8.
Meade, C. S., & Ickovics, J. R. (2005). Systematic review of sexual risk among pregnant and mothering teens in the USA: Pregnancy as an oppor- tunity for integrated prevention of STD and repeat pregnancy. Social Science and Medicine, 60, 661-678. Doi: 10.1016/j.socscimed.2004.06.015
Almader-Douglas, D. (2013). Culture in the Context of Health Literacy Update. National Network of Libraries of Medicine. Retrieved from http:// nnlm.gov/outreach/consumer/hlthlit.html
Olausson, P. O., Haglund, B., Weitoft, G. R., & Cnattingius, S. (2004). Premature death among teenage mothers. BJOG: an International Journal of Obstetrics and Gynaecology, 111, 793-799. Doi: 10.1111/j.1471- 0528.2004.00248.x
Penman-Aguilar, A., Carter, M., Snead, M. C., & Kourtis, A. P. (2013). Socioeconomic disadvantage as a social determinant of teen childbearing in the U.S. Public Health Reports, 128, 5-22.
Shoff, C., & Yang, T. (2012). Spatially varying predictors of teenage birth rates among counties in the United States. Demographic Research, 27(14), 377-418. Doi: 10.4054/DemRes.2012.27.14
Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. Lancet, 379, 1641-1652. Doi: 10.1016/s0140-6736(12)60149-4
The National Campaign. (2014). Teen pregnancy in the United States. Retrieved from http://thenationalcampaign.org/resource/fast-facts-teen- pregnancy-united-states
The National Campaign. (2015). Teen pregnancy and childbearing among non-Hispanic black teens. Retrieved from http://thenationalcampaign.org/ resource/fast-facts-teen-pregnancy-and-childbearing-among-non-hispanic- black-teens
US Department of Health and Human Services. (2015). District of Columbia adolescent reproductive health facts. Retrieved from http://www.hhs.gov/ ash/oah/adolescent-health-topics/reproductive-health/fact-sheets/state. html?s=district_of_columbia
Wilkinson, R., & Pickett, K. (2010). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury Press.
Dr. Danawi is trained in Public Health with a PhD in Epidemi- ology from the University of Texas at Houston. He has an inter- national exposure to various Public Health issues in the U.S., Middle East and Africa and is passionate about creating positive social change and advocate for maternal and child’s health. Dr. Danawi currently serves as a full time faculty at Walden Univer- sity, College of Health Sciences teaching and mentoring doctoral dissertations. Ms. Bryant is originally from Atlanta, Ga but currently resides in Gaithersburg, MD. She is currently pursuing her PhD in Public Health with a concentration in Epidemiology from Walden University. She has a passion for adolescents with future plans to work in the field of adolescent sexual and reproductive health. Ms. Hasbini is trained in nursing studies and practice with a Master’s degree in Public Health from the American University of Beirut, Lebanon. Ms. Hasbini is passionate about bringing help and education to mothers and children alike as well as highlight- ing the awareness of Nursing and Public Health in the region.
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