Running head: TEEN PREGNANCY

Teen Pregnancy: Kalkaska County Jessi Chipman, Lisa Dust, Sasha Gapczynski, Dana Knoll, Abigail OBrien, Cassie Schulte, Emily Vance & Amber Vanderstow Ferris State University

TEEN PREGNANCY Teen Pregnancy: Kalkaska County

As practicing professionals, nurses are held to a set of standards established by the American Nurses Association (ANA). These standards of nursing practice create the foundation from which all nursing practice is derived. Assessment, diagnosis, planning, implementation and evaluation (ADPIE) are just five of these standards that nurses are expected to perform in every encounter with a client. Nurses are mostly employed within hospitals, dealing with individual patients in an acute care setting, misleading people to believe that ADPIE is only applied at the individual level. As the ANA (2010) states, these standards are executed regardless of role, population or specialty (p. 310). It is this stipulation that broadens the scope of ADPIE to be implemented at local and global levels by nurses involved in public/community health. By assessing a town, county, state or even country, nurses can diagnose health problems in an effort to develop a plan to be implemented within that particular population. Once a plan has been appropriately implemented, an evaluation can occur to determine whether the plan adequately addresses the original diagnosis. In an effort to diagnose Kalkaska County our group (TCCB) first analyzed the current state of the countys health as it relates to teen pregnancy, females aged 15 - 19. With thorough analysis TCCB was able to follow through with ADPIE in an attempt to better the overall health and well-being of Kalkaska County. Assessment The Data Healthy People (HP) 2020 has set a target for teen pregnancy at 36.2 per 1,000 females, ages 15-19 (District Health Department #10 [DHD#10], 2012, p. 13). The latest data provided by the District Health Department #10 health profile chartbook reports that Michigans overall teen pregnancy rate is 48.3 per 1,000 females, with Kalkaska Countys rate being 54.4 per 1,000

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females, well above Michigans rate and the target set by HP2020 (DHD#10, 2012, p. 13). Data alone is not useful without extrapolating what the data means, and causes behind the picture that the information portrays. From the same district #10 chartbook, we saw that poverty in Kalkaska County is at 18.7%, compared to Michigans rate of 17.5%. Arguably this does not show a significant difference, although research shows that poverty has a strong correlation to rates of teenage pregnancy (Upadhya & Ellen, 2011). It is important to note that the federal poverty guideline for a single person household in 2012 was set at $11,170 (Department of Health and Human Services, 2012). Per each additional person this value is increased by approximately $4,000. So although many people may not fit the statistical definition of poverty, there are many people with an annual income that is severely inadequate for their needs. In addition to direct statistics measuring poverty, we noticed that Medicaid paid births in Kalkaska county account for 73.7% of all births occurring in the county, compared to 45.3% of all Michigan births (DHD#10, 2012). One last statistic that we considered was level of education. There is only a slight decrease in rate of high school graduates between Kalkaska County and Michigan; 86.0% and 88.4%, respectively. On the other hand, college graduates show a drastic decrease with Michigan at 25.3% and Kalkaska County at 10.4% (DHD#10, 2012, p. 3). Similar to the correlation between teen pregnancy and poverty, there is also a strong correlation between increased rates of teenage pregnancy and decreased rates of educational attainment (Upadhya & Ellen, 2011). Local Resources Agencies throughout Kalkaska County have recognized the problem of teenage pregnancy and have acted accordingly, developing resources in an effort to prevent rates from increasing. One such resource is the Teen Health Corner; a clinic first built in 2006, located

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within the Kalkaska Memorial Hospital. At this location teens have access to services such as physicals, immunizations, nutrition/exercise counseling, mental health services, and reproductive health services. Contraception is prescribed and dispensed at this clinic, although abortion counseling is not allowed as part of a stipulation set in order to receive federal grants. Teens that come into the clinic can leave with contraception that same day (R. Soles, personal communication, September 24th, 2013). Since its foundation, the clinic has expanded to a second location in the Forest Area High School. Unfortunately, because of this location being within a high school, contraception is not kept on the grounds. Instead students are given a referral for services and sent to the other Teen Health Corner location or a different provider. Although the referrals may seem like a step in the right direction, referrals, especially for the target population, is instead an inconvenience that acts as a barrier to care (R. Soles, personal communication, September 24th, 2013). A third resource within Kalkaska County is the health department. The health department offers an array of services similar to the Teen Health Corner in Kalkaska. The health department is able to counsel regarding abortion services but does not offer the procedure and again, the client interested in such a service must be referred elsewhere. Additionally, the health department is open Monday through Friday, from 8:00 am until 4:30 pm and only offers family planning clinics a few times a month (R. Soles, personal communication, September 24th, 2013). Another resource available in Kalkaska County is the Kalkaska Area Transit (KAT), a public transportation service provided for a small fee. The bus covers a large area and consequently only makes stops in larger cities, such as Traverse City, three times a day. The bus runs Monday through Friday, from 7:00 am until 6:00 pm. When you consider the schedule of your typical teenager they are in school Monday through Friday, approximately from 7:30 am

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until 2:30 3:00 pm. It would be incredibly difficult for a teen to leave from school and make it to the bus with enough time to make it to an appointment and then catch the bus back home. Whether the available resources are adequate to solving this problem is a much more complicated question than at first glance. Arguably, the Teen Health Corner provides all of the necessary services and education at an affordable cost that should be more than sufficient in preventing teenage pregnancy. Yet, Kalkaska County still has a very high rate of teenage pregnancy, six years after the Teen Health Corner has opened. Unfortunately there are many more factors that contribute to the actual consumption of these resources by the target population. For example, the public transportation that is available (KAT) does not provide a level of service that is convenient for a teenage population to utilize. Beyond the obvious inadequacies of particular services, there are also psychosocial factors that are best viewed through a theoretical lens. Health Belief Model The Health Belief Model (HBM) is a psychological theory developed by Hochbaum, Rosenstock and Kegels to explain and/or predict health-related behaviors by focusing on individuals beliefs and attitudes (Becker, 1974). Engaging in a health-related behavior depends upon perceptions of susceptibility to a health threat (in this case teenage pregnancy), the severity of the threat, the benefits gained by action and the barriers to action. These perceptions are swayed by cues to action and self-efficacy. Perceived susceptibility. Perceived susceptibility considers whether teens believe they are at risk for becoming a pregnant teen. Many teens, especially those who have not had comprehensive sexual education, may not consider the risk they are taking when engaging in sexual intercourse without the use of contraception.

TEEN PREGNANCY Perceived severity. Perceived severity is the perception of how serious the

consequences of a particular health threat seem to be. Considering Kalkaska County has such a high rate of teenage pregnancy, teenagers may see their friends or older siblings, etc., going through teenage pregnancy thus desensitizing them to the implications of such a situation. If many friends, family members and members of the community experience teenage pregnancy then it may become a norm within this particular population. Perceived benefits. Teenagers will consider how the use of contraception will benefit their life. For example, is condom use seen as more of a benefit or a burden? If we consider the teenagers without comprehensive sexual education they may not appreciate the efficacy of correct condom usage or other forms of birth control. Perceived barriers. Although the most important barriers may be those related to access and resources, one must consider the social environment in which teenagers are navigating on a daily basis. Teens who practice abstinence or contraception use may become labeled as unpopular, inexperienced or otherwise assigned any variety of socially damaging stigmas. Cues to action. Cues to action are external strategies used to promote the particular health behavior or activate readiness in the particular individual/population. Are there reminders that teens see on a regular basis promoting abstinence or contraception? This could include media (posters, television commercials, etc.) as well as education, such as sexual education within school. It is important to consider where these teens are receiving messages regarding pregnancy prevention, if they are receiving them at all. Self-efficacy. This is the internal confidence of the individual in their ability to take action and perform the health behavior. Teens may not have the confidence that they can

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successfully prevent pregnancy. They may lack the knowledge of methods of contraception, where to access these methods or even how to use them. Strengths & Barriers Strengths. The main strength of Kalkaska County is the existence of the Teen Health Corners. The fact that not only one, but two locations are now open and serving the county shows that generally speaking, the county is aware of the need for these services. The Teen Health Corner has considered that the county in which they serve is highly impoverished and accordingly, no one is turned away due to inability to pay for services. Unfortunately, the strengths of Kalkaska County begin and end with the Teen Health Corner locations. Barriers. As previously mentioned, barriers are not merely a lack of resources. For instance, while the lack of adequate transportation provided by the KAT may hinder a teen from gaining access to resources, the socioeconomic and psychosocial trends of the county may act as much more powerful obstacles. Kalkaska County is primarily a conservative county and the state of sexual education in its public schools reflects as such (R. Soles, personal communication, September 24th, 2013). Currently, Kalkaska County schools have abstinence only sexual education and this topic has not been revisited since it was first established. In relation to this lack of comprehensive sexual education, teens within the county have a skewed perception of their personal risk of becoming pregnant. Teens that have a perception of low risk or perception of low severity are less likely to engage in health behaviors to prevent pregnancy (Wang, Charron-Prochownik, Sereika, Siminerio & Kim, 2006). Lastly, some research focuses not on the lack of sexual education obtained, but instead the lack of motivation for educational attainment as a risk factor for teenage pregnancy (Kearney & Levine, 2012). Teens who come from impoverished and otherwise disadvantaged backgrounds are often faced with the reality

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that even if they graduate from high school, they have lower chances of attending college and/or finding a job that provides adequate monetary compensation and/or benefits. In lieu of this dismal future, motherhood may provide an alternative route to adulthood (SmithBattle, 2005). After looking at Kalkaska Countys statistics regarding high school and baccalaureate graduation rates, especially compared to Michigans rates, it becomes clear that a gap exists in post-high school educational attainment. A Problem For Community Nursing Teen pregnancy is an issue that affects many people, from health care providers and teachers to parents/grandparents and the community at large. Teen pregnancy is not an individual problem, but a community problem and should be addressed accordingly. According to Ferguson (1997), Nurses are in a unique position to interact with adolescents because of their work in the community, at clinics, hospitals and in schools (p. 186). This increased level of contact between the nurse and the community builds communication between other health professionals and adolescents and/or families in need. Beyond the medical community, educators (teachers, principals, guidance counselors) as well as parent associations (such as Parent Teacher Alliance) should be involved to address the problem affecting the youth of the community. The health department and the Teen Health Centers are agencies on the forefront of this issue and are invaluable resources to Kalkaska County and could provide the essential expertise needed to further address teen pregnancy. Diagnosis The next step to ADPIE is the diagnosis. As is evident, the assessment of a community can yield an enormous amount of data to consider, making the process seem overwhelming. Yet, it is imperative that a diagnosis is determined based upon the assessment data so that the next

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steps of the nursing process (planning, implementation and evaluation) are clear and focused. As Muecke (1984) states, The diagnosis sets the groundwork for community health nursings goals of reducing health risks by identifying them and the factors that appear to sustain them (p. 32). Based upon Mueckes format for a community health diagnosis and the assessment data, we determined a risk of teen pregnancy among Kalkaska females aged 15 19-years-old related to poverty, lack of sexual education as demonstrated by current rates of teenage pregnancy (54.4 per 1,000 females aged 15 19). Conclusion Although Kalkaska Countys teen pregnancy rates are on the decline, the current rate is much higher when compared to the whole of Michigan. Factors contributing to this higher rate are simple and complex, problems such as availability of resources, abstinence-only sexual education, as well as a conservative geopolitical climate and psychosocial issues prevalent within the community. Our groups application of the first two steps of the nursing process to Kalkaska County revealed a range of dynamics best examined through the scope of the Health Belief Model, taking the target populations perspective into account. After such an overload of correlational factors, a diagnosis allowed the group to refocus the assessment in an attempt to proceed to the next step of the nursing process, the planning. Application of the nursing process to a community serves the same purpose as it does when applied to an individual; it functions to solve a problem. The very foundation of all nursing practice, regardless of specialty, lies within the problem solving techniques of the nursing process.

TEEN PREGNANCY References

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American Nurses Association. (2010). Nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org Becker, M.H. (1974). The health belief model and personal health behavior. Health Education Monographs, (2)4. Department of Health and Human Services. (2012). Federal Register, (77)17, 4034-4035. District Health Department #10 [DHD#10]. (2012). Health profile chartbook 2012: Kalkaska county, 1-17. http://dhd10.org/images/Kalkaska_Chartbook_2012_April_2_2013.pdf Ferguson, S. (1997). Nurses role in the prevention of teen pregnancy. Journal of Pediatric Nursing, (12)3, 186-187. Kearney, M. & Levine, P. (2012). Why is the teen birth rate in the united states so high and why does it matter?. Journal of Economic Perspectives, 26(2), 141-166. Muecke, M. (1984). Community health diagnosis in nursing. Public Health Nursing, (1)1, 23-35. SmithBattle, L. (2005). Examining assumptions about teen mothers. The American Journal of Nursing, (105)4. Retrieved on 9/22/2013 from http://www.jstor.org/stable/29745683 Upadhya, K. & Ellen, J. (2011). Social disadvantages as a risk for first pregnancy among adolescent females in the united states. Journal of Adolescent Health, 49, 538-541. Wang, S., Charron-Prochownik, D., Sereika, S., Siminerio, L., & Kim, Y. (2006). Comparing three theories in predicting reproductive health behavioral intention in adolescent women with diabetes. Pediatric Diabetes, 7, 108-115.