A health empowerment theory approach to pregnant adolescents 18 and 19 years of age in the Bahamas


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A health empowerment theory approach to pregnant adolescents 18 and 19 years of age in the Bahamas
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Curtis, Shirley
University of Miami
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Teenage pregnancy -- Bahamas   ( lcsh )


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The purpose of this study was to investigate the level of empowerment among pregnant adolescents living in The Bahamas aged 18-19 years by testing the levels of autonomy, environmental mastery, personal growth, relationship with others, purpose in life and religiosity. The findings of the study may well be used to highlight areas for future research in pregnancy prevention programs for adolescents in The Bahamas.

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University of Miami Scholarly Repository Open Access Dissertations Electronic Theses and Dissertations 2011-07-20 A Health Empowerment Theory Approach to Pregnant Adolescents 18 and 19 Years of Age in The Bahamas Shirley E. Curtis University of Miami s.curtis1@umiami.edu This Open access is brought to you for free and open access by the Electronic Theses and Dissertations at Scholarly Repository. It has been accepted for inclusion in Open Access Dissertations by an authorized administrator of Scholarly Repository. For more information, please contact jrenaud@miami.edu Recommended Citation Curtis, Shirley E., "A Health Empowerment Theory Approach to Pregnant Adolescents 18 and 19 Years of Age in The Bahamas" (2011). Open Access Dissertations. Paper 619. http://scholarlyrepository.miami.edu/oa_dissertations/619


UNIVERSITY OF MIAMI A HEALTH EMPOWERMENT THEO RY APPROACH TO PREGNANT ADOLESCENTS 18 AND 19 YEARS OF AGE IN THE BAHAMAS By Shirley E. Curtis A DISSERTATION Submitted to the Faculty of the University of Miami in partial fulfillment of the requirements for the degree of Doctor of Philosophy Coral Gables, Florida August 2011


2011 Shirley E. Curtis All Rights Reserved


UNIVERSITY OF MIAMI A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy A HEALTH EMPOWERMENT THEO RY APPROACH TO PREGNANT ADOLESCENTS 18 AND 19 YEARS OF AGE IN THE BAHAMAS Shirley E. Curtis Approved: ________________ _________________ Doris Ugarriza, Ph.D., A.R.N.P. Terri A. Scandura, Ph.D. Professor /Vice Dean of Nursing Dean of the Graduate School ________________ _________________ Joseph De Santis, Ph.D., A.R.N.P. Rosemary Hall, Ph.D., M.S.N. Assistant Professor of Nursing Associate Professor of Clinical Nursing ________________ Joyce E. Thompson, Dr.P.H., C.N.M., F.A.A.N., F.A.C.N.M. Professor Emerita of Nursing University of Pennsylvania Western Michigan University


CURTIS, SHIRLEY E. (Ph.D., Nursing) A Health Empowerment Theory Approach to (August 2011) Pregnant Adolescents 18 and 19 Years of Age in The Bahamas Abstract of a dissertation at the University of Miami. Dissertation supervised by Pr ofessor Doris N. Ugarriza. No. of pages in text. (97) In The Bahamas between the years 2,000 to 2007, the percentage of single mothers under the age of 20 years accounted for 11.3 – 12.7% of all births in the country. Mothers between the ages of 10 -14 years accounted for 0.1 – 0.4 % of all births and mothers age 15 -19 years accounted for 11.2 – 12.6% of a ll births during the same time period. Purpose: The purpose of this study was to inves tigate the level of empowerment among pregnant adolescents living in The Bahamas aged 18-19 years by testing the levels of autonomy, environmental mastery, personal grow th, relationship with others, purpose in life and religiosity. The findings of the study may well be used to highlight areas for future research in pregnancy prevention programs for adolescents in The Bahamas. Sample: The sample for this study was 105 pregnant adolescent females 18 and 19 years of age attending ante-natal clinics in The Bahamas. Measures: The selfadministered questionnaires included demographic informa tion, obstetric histor y, Ryff’s Scales of Psychological Well-Being and Santa Cl ara Strength of Religious Faith. Analyses: Data collected from the questionnaires were en tered into SPSS for an alysis. Descriptive statistics was obtained. Correlation analysis was performed to determine the significance among demographic data and levels autonom y, environmental mastery, personal growth,


relationship with others, purpose in life and religiosity. Multiple regression analysis was performed to determine the variance explaine d between the number of pregnancies and level of health empowerment. Results: The Pearson’s correlation was calculated to answer the research questions of the relationship of le vel of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance, religiosity and overall health empowerment with number of pregnancies of 18 and 19 year old pregnant females. Number of pre gnancies was negatively correlated with all dimensions of psychological well-being, religio sity and overall empowerment. Due to the small number in the sample with repeated pregnancy (19 of 105) th e correlations were not statistically significant, except personal growth. Number of pregnancies was negatively correlated but not st atistically significant with personal growth. Number of pregnancies was negatively correl ated and statistically signifi cant with current enrollment in school. Pregnancy outcome and delivery type were positively correlated and statistically significant with number of pregnancies. Overa ll health empowerment levels was negatively correlated with history of depression and positiv ely correlated with religiosity. Level of education and religiosity were positively correlated and statistically significant to the level of health empowe rment for the adolescents in this study. Conclusions: Based on the results of this study, leve l of education and religiosity are predictors of levels of health empowerment and type of delivery a nd the outcome of the pregnancy are predictors to the number of pr egnancies in pregnant adolescents 18 and 19 years old in The Bahamas.


iii Dedication This dissertation is dedicated to: 1. God, my rock and strong tower. The only constant in my life. 2. My parents, George and Vera Curtis for their support and encouragement throughout all my educational pursuits. 3. The memory of my mother Vera L. Curtis who urged me to take this last step in my educational quest. Love Shirley


iv Acknowledgments This dissertation was made possible by many pe rsons in my life. I would like to thank everyone who assisted me in anyway throughou t this educational journey. If I fail to mention you in this acknowledgement please charge it to my head and not my heart. Mrs. Endolyn Curtis-Moss & Courtney Curtis who are taking care of my bedridden father and allowed me the opportunity to undertake this th ree year journey. The administrators of the College of The Bahamas, Faculty of Pure and Applied Sciences and the School of Nursing and A llied Health Professions who supported and approved my desire for further st udy by granting full study leave. The University of Miami School of Nurs ing and Health Studies for granting the nursing PhD assistance ship to fund this period of study. Dr. Doris N. Ugarriza for your mentorship and encouragement throughout the program. Thank you for your gentle but firm supe rvision of this dissertation process. You kept me focused and on track. Dr. Rosemary Hall, Dr. Joseph De San tis and Dr. Joyce Thompson, thank you for your valuable and timely editorials, crit iques, comments and guidance during this dissertation process. I could not have done it without you. Thank you to The Ministry of Health of the Bahamas and the Public Hospitals Authority, for allowing me access to the Public Health clinics to recr uit participants and collect data. To the staff of Adolescent H ealth department and labour ward of the Princess Margaret Hospital who assisted me with acquiring statistics, thank you.


v The midwives and Community Health Nu rses in Nassau and Grand Bahama who assisted with the recruitment of participan ts and administration of questionnaires, your assistance were invaluable. Thank you to the pastor and members of Salem Union Baptist Church, Nassau Bahamas and Second Baptist Church, Richmond Heights Florida for the spiritual support and encouragement you gave during this journey. Thank you to all my family and friends who assisted my family in my absence and offered me a listening ear, words of encouragement and s upport throughout this process. Thanks once again to my parents who provi ded the platform for me to launch into this present place, Thank you to the Lord, Jesus Christ for be ing my ever present help. There is none like you. Be glorified in my life.


vi Table of Contents List of Tables ………………………………...…………………………………….……xi List of Figures …………………………………………………………………….…….xii Chapter I Introduction Statement of the Problem………………………………………………………….1 Significance of the Problem……………………………………………………….3 Purpose of the Study…………………………………………………………........6 Definition of Terms…………………………………………...……………….…..6 Adolescents………...……………………………………………………...6 Bahamian …………………………………………………………………6 Health Empowerment ………………………………………………….....7 Religiosity ………………………………………………………………...7 Research Questions………………………………………………...………….…..7 Chapter II Literature Review Effects of Pregnancy on Adolescents ………………………………………….....8 Health and Physical Effects ………………………………………………8 Psychological and Social Effects ………………………………..………12 Repeated Pregnancies in Adolescence...………………….……………………...13 Pregnancy Prevention Programs ……………….………...…………………..….16 Religiosity in Adolescents……………………………………………………….21 Health Empowerment in Adolescents …………………………………….……..24 Theoretical Framework ………..………………………………………………………...28 Shearer’s Health Empowerment Theory ……………………………………...…28 Health Empowerment Construct ………………………………………………..34


vii Chapter III Methods Purpose ………… ……………………………………………………………....35 Research Questions …………………….…...…………………………………...35 Sample Design ……………………………………………..……………………36 Sampling Procedure ……………………………….…………………………….36 Sampling Criteria …………………………………..……………………………36 Sample Size …………………………………..……………………………….…37 Measurement …………………………………………………………………….38 Demographics …………………………………..……………………….38 Health Empowerment Measure……………….…………………………39 Religiosity Measure………………………………………………..….....41 Data Collection and Analysis…………………………………………………….43 Procedure for Data Collection…………………………………………...43 Protection of Human Subjects …………………………………………..43 Missing Data ………………………………….…………………………44 Data Analysis ……………………………………………………………44


viii Chapter IV Results Overview ………………………………………………………………………..45 Research Questions ……………………………………………………………...45 Description of the Sample ……………………………………………………….45 Demographics …………………………………………………………………...46 Age……………………………………………………………………….46 Birthplace ………………………………………………………………..46 Marital Status ……………………………………………………………46 Educational Achievements ………………………………………………46 Employment Status ……………………………………………………...47 Religious Affiliations ……………………………………………………47 History of Depression …………………………………………………...47 Source of Advice ………………………………………………………..47 Pregnancy ………………………………………………………………..48 Family Planning …………………………………………………………48 Study Variables ………………………………………………………………….48 Health Empowerment…... ………………………………………………48 Religiosity ……………………………………………………………….49 Correlations ……………………………………………………………………...50 Regression Analysis ……………………………………………………………..53 Summary ………………………………………………………………………...54


ix Chapter V Discussion and Conclusions Overview……………………………………………………………………........57 Summary of Study ……………………………………………………………....57 Discussion ……………………………………………………………………….59 Research Question 1……………………………………………………..59 Research Question 2 …………………………………………………….60 Additional Findings …………………………………………………......61 Implications for Nursing ………………………………………………………...62 Implications for Education……………………………………………….62 Implications for Research ……………………………………………….63 Implications for Theory …………………………………………………64 Implications for Practice ………………………………………………...64 Study Limitations…………………………………………………………...……65 Conclusions………………………………………………………………………65 References ……………………………………………………….………………………67 Appendix Appendix A – Millennium Development Goals ………………………………...77


x Appendix B – Questionnaire ……………………………………………………79 Demographic data………………………………………………………..79 Ryff’s Scales of Psychological Well-Being …………………………….82 Santa Clara Strength of Religi ous Faith Questionnaire …………………86 Appendix C – Research Flyer ……………………………………………………87 Appendix D – Consent Form …………………………………………………….88 Appendix E – Business Card ……………………………………………..……..90 Appendix F – Application for Ethics Committee (Bahamas) …………………...91


xi List of Tables Table 1 – Descriptive Statistic s of the Subscales of the Scales of Psychological WellBeing and Overall Health Empowerment for Pregnant Adolescents …………………50 Table 2 – Correlations Among Total H ealth Empowerment, Religiosity and Demographics Variables of Pregnant Adolescents…..………………………………..51 Table 3 Correlations Between Empowermen t, Religious Faith and Dimensions of Psychological Well-Being Scale of Pregnant Adolescents……………………………52 Table 4 Correlation and Effect Size of Numb er of Pregnancies with Dimensions of Psychological Well-Being and Religios ity of Pregnant Adolescents……………...….53


xii List of Figure Health Empowerment Construct………………………………………………………34


1 CHAPTER I Introduction Statement of the problem Adolescent pregnancy is a seri ous public health concern that is associated with maternal high school dropout rates and rece ipt of late or no pr enatal care, infant prematurity, low birth weight, and child abus e and neglect (US Department of Health & Human Services (USDHHS), 2000). This public h ealth issue is worldw ide with close to 16 million adolescents becoming pregnant each year accounting for 11% of all births globally (Watt, 2001; WHO, 2008). Complications from pregnancy and childbirth are the leading causes of death in young women 15-19 y ears of age in developing countries. An estimated 70,000 adolescent mothers under 20 ye ars of age die each year because they have children before they are physically ready for child bearing and parenthood (Mayor, 2004). Published articles vary in the defi nition of adolescence depending on the psychosocial, biological, pers onal or environmental factor s under review. In the WHO report on young people (1986), adolescence was de fined as 10 -19 years, youth as 15-24 years and young people as 10 -24 years. Studies will also vary according to cultural and legislative factors in the country. For the purpose of this study the researcher will investigate pregnant females in late adolescence, 18 – 19 years of age. Fifty percent of all adolescent births o ccur in seven countries: Bangladesh, Brazil, the Democratic Republic of the Congo, Ethiopi a, India, Nigeria a nd the United States, (WHO, 2008). The teenage pregnancy rate in the United States is the highest among industrialized countries (Singh & Darroch, 2003). The rates of births for teenagers 15 -17 years and 18-19 years in the United States are 22 and 73 per 1000 females, respectively.


2 The rates of births for 18-19 year old teen s, who are already parenting, is 55.4 per 1,000 for second births and 14.8 per 1,000 for third bi rths (USDHHS, 2009). Schelar, Franzetta, and Manlove, (2007) reported th at non-Hispanic Black and Hi spanic adolescents are at increased risk for repeated pregnancies and th e birth rate for Black adolescents is more than double the rates for non-Hi spanic White teenagers. In 2006, young people between the ages of 10-19 years in Latin America and the Caribbean (LAC) comprised 20% of the to tal population, (Pan American Health Organization, [PAHO], 2007). Twen ty-five percent of females became mothers before 20 years of age (Economic Commission for La tin America and the Caribbean, 2008). In English-speaking Caribbean countries, adoles cents 10-19 years comprise 11-24% of the population (PAHO, 2007). Half of the countries in the Americas have adolescent fertility rates > 72 per 1,000 live births. In The Bahamas, the total populati on in 2007 was 334,000. Adolescents 15-19 years accounted for 11.3% of the population. Th e percentage of single mothers under the age of 20 years accounted for 11.3-12.7% of all births in the country between the years 2000 to 2007. Mothers between the ages of 1014 years accounted for 0.1 – 0.4 % of all births and mothers aged 15 -19 years accounted for 11.2 – 12.6% of all births during the same time period. Births among teenagers 15-19 years were 45.5 per 1,000 live births (Health Information & Research Unit, 2008), which almost doubled the rate (23 per 1,000 females) reported in 2003 for the same age group (PAHO, 2007). Blum, Halcon, Beuhring, Pate, Campbe ll-Forrester, and Venema (2003) and Halcon and colleagues (2003) conducted a su rvey in 9 of the 19 English speaking Caribbean countries to inves tigate the health of adolescents 10-19 years of age. The


3 Bahamas was included in the sample populat ion. Halcon and colleagues, (2003) reported that 65.9% (n = 15,695) of the adol escents stated that they ne ver had sexual intercourse. One quarter of the female adolescents who were sexually active stated that the age of first intercourse was 10 years or younger. One quarter of the adolescents (males & females) always used some form of birth control and 10% of the adolescents had a history of being pregnant. Blum and colleagues, (2003) also reported that connectedness to parents (OR = 0.76, p < .01) was strongly protective against pre gnancy among teenagers younger than 16 years. Teenagers older than 13 years, attending religious services (OR = 0.90, p < .01) was associated with a lower rate of ever having had intercourse. Re sults showed a strong association between early in itiation of sexual activity a nd skipping school (OR = 1.47 to 1.59, p < .01 for all age groups). Blum and colleagues used a random sample of adolescents attending school in the 9 Cari bbean countries; theref ore the results are representative of adolescents who attend school and not t hose who may have dropped out of school. The questionnaire was revised af ter it was reviewed by maternal and child health directors in the various countries and pilot tested be fore the survey was conducted. The questionnaire was self-administered and collected by educational officers, which may have affected the adolescents’ responses. Significance of the problem Adolescent pregnancy can result in ec onomic, psycho-social and health problems for the adolescent and her child. Women who begin childbearing in adolescence face numerous problems during pregnancy and la ter in life (Klerman, 2004). These mothers are less likely to complete high school, whic h may result in poverty and dependence on government assistance. Infants born to adoles cent mothers are at risk for low-birth


4 weight, neglect, abuse and frequent emerge ncy room visits (Cor coran & Pillai, 2007). The issues surrounding adolescent pre gnancy and childbearing have serious repercussions for the adolescent family and society. Second and subsequent births may make it almost impossible to break the cycle of poverty (Klerman, 2004). Delaying subsequent childbearing may be an important factor promotin g success in an adolescent mother’s later life (Koni ak-Griffin et al., 2002). Over the past 20 years, dramatic social political and economic shifts, together with medical and public health interventions, have radical ly altered th e landscape of adolescent health globally (Blum & Nelson-Mmari, 2004). The importance of empowerment strategies for adolescent s was recognized by the United Nations Population Fund’s (UNFPA) in the State of the World Population Report (2003). Authors of the report acknowledged that investing in adolescent in formation and services will empower adolescents to make responsible and healthy choices that wi ll yield benefits for generations to come. To ensure continued im provement of the plight of the underserved and at risk members of the population, the United Nations Assembly adopted eight Millennium Development Goals following ag reement of the Millennium Declaration (UN, 2000). These goals were adopted by worl d leaders in 2000 and are set for final evaluation in 2015 (Appendix A). The empowerm ent needs of women were addressed in MDG 3 and MDG 5. Gender equality and empo werment of women are promoted in MDG 3, and in MDG 5 the improvement of matern al health in the nations of the world is promoted. The target of MDG 3 is to elimin ate gender disparity in primary and secondary education worldwide; this is a strategy that relates to the empowerment of female adolescents. The target of MDG 5 is to reduce the maternal mortality rate by three-


5 quarters, by 2015 (UN Millennium Project, 2005). To meet MDG 5, women require social support and acceptance during and after pregnancy, acce ss to education and information, and skills on how to pr event further pregnancies (MDG, 2005). The 2007 State of World Population re port (UNFPA, 2007) reads that the empowerment and well-being of women are the pillars of sustainable cities. Better access to education and health care, and the power of voice through social and governmental involvement were cited as means to impr ove the empowerment of women. The report goes on to support the involvement of young peopl e in the decision making process of the community. Use of the natura lly resourceful, creative na ture of young people toward community improvement was encouraged. The Centers for Disease Control and Prevention (CDC) went a step further and sponsored a Youth Empow erment Strategies (YES!) project (Wilson, Minkler, Dasho, Wa llerstein, & Martin, 2008) designed for elementary and middle school youth to promot e problem-solving skills, social action and civic participation to decrease the use of drugs alcohol and ot her risky behaviors such as unprotected sex. Researchers have not adequately addresse d health empowerment levels of female adolescents to delay adolescent births and s ubsequent births, which could improve their economic, social, and health status (Arnol d, Smith, Harrison, & Springer, 2000: Cabezon, Vigil, Rojasc, & Leivad, 2005; & Martyn, Darling-Fisher, Smirtka, Fernandez, & Martyn, 2006). Pregnancy prevention programs have had mixed results. Programs that contain a focus on enhancing life skills and increasing life options have shown the most promise (Harris & Allgood, 2009). There are no published studies addressing adolescent pregnancy or the level of health empowerm ent of adolescents in The Bahamas. The


6 literature reviewed presented in this study highlights the si gnificance of the problem in other populations and adds to the knowledge gained from The Bahamian sample. Purpose of the study The purpose of this study was to examine the characteristics of pregnant adolescents and an identification of the level of personal re sources for health empowerment. Health empowerment was m easured using Ryff’s (1989) Scales of Psychological Well-Being that tests levels of autonomy, environmental mastery, personal growth, relationship with othe rs, and purpose in life. Religiosity was measured using the Santa Clara Strength of Religious Faith – short form (Plante, Vallaeys, Sherman, & Wallston, 2002). The findings of the study hopefully can be used to guide future research on health empowerment with pregnant adolescents in The Bahamas. Definitions of terms Adolescents Conceptual definition: Adolescents10-19 year s old, early adolescence 10-14 years old and late adolescence 15-19 years old (WHO, 1986) Operational definition: Pregnant female adolescents 18-19 years old. Bahamian Conceptual definition: Females born in The Bahamas who possess a valid birth certificate or papers of naturalization. Operational definition: Females born in The Bahamas or who have lived in The Bahamas within the last 10 years.


7 Health Empowerment Conceptual definition: Purposefully part icipating in the process of changing ones behaviors and one’s environment, recognizing patterns and engaging inner resources for well-being (Shearer & Reed, 2004). Operational definition: The sum of scores on the Ryff’s Scale of Psychological WellBeing (Ryff, 1989). Religiosity Conceptual definition: The degree to which individuals exhibit the characteristic of believing in and worshiping a superhuman controlling power (The New Oxford American Dictionary, 2005). Operational definition: The sum of scores on the Santa Clara Strength of Religious Faith Questionnaire – Short Form (SCSRFQ-SF), (Plante et al., 2002). Research Questions The research questions for this study were: 1. What is the relationship among the levels of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance and religiosity and the number of pregnancie s of 18 and 19 year old adolescents in The Bahamas? 2. What is the relationship between the level of Health Empowerment and the number of pregnancies of 18 and 19 year old pregnant adolescent females in The Bahamas?


8 Chapter II Literature Review Effects of pregnancy on adolescents Health / physical effects Adolescent pregnancy is a se rious public hea lth concern, given its association with receipt of late or no pr enatal care, infant prematurit y, low birth weight, child abuse and neglect (US Department of Health and Human Services, 2000). Between 14 and 15 million adolescent girls 15 -19 years of age give birth each year, accounting for more than 10% of births worldwide. Adolescent gi rls account for 15% of the global burden of disease for maternal conditions and 13% of all maternal deaths (WHO, 2000). Safe Motherhood Inter-Agency Group (2002) reporte d for every young mother who dies in childbirth, 30-50 others are left with an injury, infection or disease. Child and infant mortality are highest among children of adol escent mothers. Young mothers are more likely to have low birth-weight babies and infants at risk of malnourishment, delayed development, or death (WHO, 2006). Blum & Nelson-Mmari (2004) examined the chief causes and influences of morbidity and mortality among young people (10 -24 years) throughout the world by conducting a literature search fr om numerous sources to compile the data for this report. The sources included published and unpublis hed reports from WHO, UNICEF, UNFPA, United Nations and Population Reference Bur eau. The sample included adolescents (10 19 years) and youth (15 -24 years) and the te rms were used interchangeably throughout the report. There were times when it was unclear the exact age gr oups being referred to in the report. The report does gi ve an indication to the seri ousness of the problem from a


9 global prospective. Given thes e limitations the authors found, a higher risk of maternal death exists among teenage girls compared with women aged 20-34 years. Young women who have not reached full physical and physio logical maturity were three times more likely to die from complications in childbirth as older women. Complications from pregnancy and childbirth are the leading cause of death in women 15 -19 years of age in developing countries (Blum & Nelson-Mmari, 2004). Mayor (2004), in a nalyzing of the most recent da ta available at the time from government statistics for different countries or from international surveys reported that an estimated 70,000 adolescent mothers died each year because they had children before they were physically ready for delivery and child birth. The complications from pregnancy and childbirth were the leading cause of death for girls 15 19 years of age in poorer countries and girls in this age group we re twice as likely as older women to die from causes related to pregnancy and childbirt h. These findings were similar to those of Blum and Nelson-Mmari (2004). The babies of adolescents were 50% more likely to die than children born to women in their 20s. The youngest mothers, those 14 years of age and under, faced the greatest risks. Obstruct ed labor was found to be common in teenage girls, resulting in increased ri sk of infant death and of mate rnal death or disability. Mayor (2004) also found that young mothers and their ba bies were at greater risk of contracting HIV. Partington, Steer, Blair, a nd Cisler (2009) conducted a 10year retrospective review of records for all adolescent pr egnancies in Milwaukee from 1993-2002 to determine if the risk of low-birth-weight babies was due to maternal age or other identifying predictors. The researchers found 22,660 births were among 18,050 teenagers.


10 Adolescents with one birth only accounted for 14,451, second births accounted for 3,782 births, 602 were third births a nd 62 were fourth or fifth birt hs. The analysis of the data revealed that second births were more likely to be preterm than first birth (15% vs. 12%), and the prevalence of low-birth weight was the same for firs t and second births (12%). After controlling for pregnancy behavioral ch aracteristics of the mothers, the odds of having a low-birth-weight infant or a preterm infant in the second pregnancy increased if the mother (a) smoked during pregnancy ( OR = 2.2 and 1.9; p < .001), (b) had inadequate prenatal weight gain ( OR = 1.8 and 1.4; p <.01), (c) had an inter-pregnancy interval of less than 18 months ( OR = 1.6 and 2.3, p< .001 ), (d) was Black ( OR = 2.7 and 1.7; p <.001), or (e) younger than 16 years ( OR = 2.7 and 2.05; p < .01). The researchers concluded that the predictors of poor bi rth outcomes in teenage mothers included modifiable behaviors that could be addressed by health care workers in prenatal interventions. Partington a nd colleagues (2009) used birth certificate data to identify repeat births. The actual data could possibly be higher than reported when you take into consideration errors in data en try and adolescents who might ha ve had their first infant in another State. The data collected were congr uent with the national average of repeated pregnancies in adolescents (19%) and the re searchers were able to demonstrate the significance of the low birth we ight infants among adolescent s with repeated pregnancies. Ickovics, Niccolai, Lewis, Kershaw, and Ethier (2003) in a longitudinal study of pregnant and non-pregnant teen age girls ages 14 – 19 years reported that the pregnant teens (n = 203) were twice as likely to ha ve an STI compared to nulliparous sexually active peers (n = 203). After a 6 month followup there was higher risk taking behaviors in parenting female adolescents (95% CI [0.97 – 3.89], p = 0.06).


11 Mead and Ickovics (2004) conducted a system atic review of 51 studies to identify and document the rates of sexually transmitted infection (STI), repeat pregnancy, condom use, and other contraceptive use among adolescent mothers in the United States. The authors did not indicate the region of the country where the study was conducted. Across samples of 19 studies, 10 -51% of the pregna nt or mothering teens reported a history of STIs (weighted mean of 28%; 95% CI [21.6%, 26.0%]). Authors from 16 studies documented 12-44 % repeat pregnanc ies within 12 months (weighted M =19.0%, 95% CI [17.6%, 20.4%]), 28-63% within 18 months (weighted M = 39.2%; 95% CI [36.5%, 41.9%]). Four authors in the review reported 20-37% repeat adoles cent birth within 24 months (weighted M = 24.8%, 95% CI [23.5%, 26.1%]). Me ad and Ickovics (2004) noted that studies and interventions are required that address the needs and risk factors for mothering teens with the purpose of unders tanding what type of program works for specific problems faced by adolescents. This systematic review by Mead and Ickovics had very clear and stringent inclusion criteria which included the age of the participants, the minimum sample size, the variables that were to be addressed in the study and the percentage of retention in longitudinal studies. Although statistics exis t related to deleterious outc omes of adolescent pregnancy, age may not be the primary factor associat ed with the health risks experienced by pregnant adolescents. Matern al mortality in developed and developing countries is associated with low rates of prenatal and obs tetric care, lower soci al and economic status, and low levels of education. These characte ristics are 4-6 times higher in rural areas (WHO, 2006). Research noted above conducte d within the United States supports the fact that there are adverse health effects, such as low birth we ight in babies of adolescent


12 mothers, but they are due to modifiable beha viors not the age of the mother. The authors stop short of giving us the solution to the problem. Psychological and social effects The psychological and soci al problems of adolescent pregnancy are well documented in literature. Carter and Spear (2002), conducted a cross-sectional pilot study of 52 ninth-grade students 14 16 years of age (boys and girl s) in a rural community in the southern United States, to examine know ledge, attitudes and behavior related to pregnancy in the teenage population. The researchers found 28.9% of the students ( n = 15) had at least one teenage friend with a baby, and 17% ( n = 9) had three or more friends with a baby. Eighty-four pe rcent of these students ( n = 44) stated that mostly peers influence their sexual behavior. Thirty-one percent ( n = 16) of the students were sexually active, 14 of these were girls. Ten (67%) of the girls had their first intercourse between 13 and 14 years of age. Two girls reported having intercourse at 10 years or younger. Three boys and two girls reported having at least one child. The researchers concluded that although the sample size wa s inadequate to conduct further analysis, there is need for further research to address the unique issues of adolescent pregnancy in each community. The sample size for this study was small (52) and represented only 21% of the accessible students at the school. Eligibility to participate in the study depended on parental consent and assent from the students. Seventy-one pa rents consented but only 52 of the students assented to participate in the study. There ma y be sampling bias because the students and parents who were willing to participate in th e study may not have b een representative of the other 14 and 16 year olds in the school.


13 Using data from the United States Nati onal Longitudinal Surv ey of the Labor Market Experience of Youth ( n = 4,480) and the Panel Study of Income Dynamics ( n = 8,500 families), Hofferth and Reid (2002) comp ared the children of older women with the children of women who had their first birth during their te en years. Findings indicated that teenage childbearing was a ba rrier to educational attainment of the mothers as well as their children. Children of women who becam e mothers as teenagers scored lower on achievement tests and higher on behavioral problems. Hofferth, Reid, and Mott (2001) using the same data set, reported that adol escent mothers completed 1.9 -2.2 fewer years of high school than older mothers. The re searchers cautioned to take time trends, for example economic and educational trends, of all scores into consideration when interpreting the effects of ear ly motherhood on th eir children. The literature gives supports that adoles cent pregnancy does have direct social effects on the adolescent and her family. Ther e is lowered academic achievement of the mother and her child which can potentially a ffect the earning power of the household for years to come. The psychological effect ma y not directly relate to the adolescent pregnancy. Problems such as intimate pa rtner violence may be a product of the environment. Here again the authors have not addressed factors internal to the adolescent that are also predictors of their behavior. Repeated pregnancies in adolescence Adolescence is the second decade of life, a period of great physical and psychological changes. This peri od of development brings cha nges in social interactions and relationships. This stage of developmen t provides an opportunity for a healthy and productive adulthood and the redu ction of the risk of health problems in the years to


14 come (WHO, 2010). In this transitional pe riod from childhood to adulthood, adolescents might consider themselves grown up and matu re enough to engage in sexual intercourse (Nyanzi, Pool, & Kinsman, 2001). However, th e adolescent often lacks knowledge about consequences of unprotected sex, such as unwanted pregnancy and sexually transmitted infections including HIV infection (Lema, Mpanga, & Makanani, 2002). 1n 2001, approximately 900,000 teenagers became pregnant in the United States (Kirby, 2001), and more than 4 in 10 adolescent girls were pregnant at least once before 20 years of age (Klein, 2005). In 2003, of the 421241 pre-adolescent and adolescent births in the United States, 84,570 were sec ond or higher order births (Martin et al., 2005). Adolescent pregnancy affects minority gr oups 2-3 times more than their White counter-parts. African Americans account fo r 32% of adolescent births, followed by 24% among Hispanics and 11% among NonHispan ic Whites (Martin et al., 2009). One quarter of the teenagers giving birth will be ar another child within 2 years (Schelar, Franzetta, & Manlove, 2007). In a longitudinal study at a Medical Cent er in the United States, Coard, Nitz and Felice (2000) examined socio-demographic, fam ily and health factor s related to repeat pregnancy of predominantly African American (92.5%) adolescent mothers 13 – 17 years of age at 12 and 24 months postpartum ( n =80). At 12 months ( n = 80), contraceptive method used was asso ciated with repeat pregnancy ( x2 = 12.66, p < .05) and at 24 months ( n =66) contraceptive method used, ( x2 = 7.79, p < .05) frequency of contraceptive use ( x2 = 7.81, p < .05), age ( r = .26, p < 05 ) and history of miscarriages were associated with repeat pregnancy ( r = .26, p < .05). Family fact ors and educational levels were not associated with repeat pregnancy ( p > .05). The researchers concluded


15 that further research be conducted to exam ine how the social context influences the adolescents perception of thei r adult roles and how these f actors are associated with repeat pregnancy. In this study, the repeat pregnancy was determined by medical records and the adolescents were not re-interviewed to determine if there was a change in family factors, educational status, contraceptive us e or method. The socio-demographic, family and health factors are based on information obt ained from the first interview, which could have changed. Raneri and Wiemann, (2007), authors of the social-ecological pred ictors of repeat pregnancy, assessed Black, Mexican American and White mothers ages 12-18 years at a Medical Center in Texas, 48 mont hs after the first pregnancy ( n = 581). The findings revealed 42% (n=245) adolescent mothers ex perienced a repeat pregnancy within 24 months. Predictors identified were: (a ) not using long-term contraceptives ( OR = 2.8, 95% CI [1.61-3.52], p < .001), (b) not being in relationshi p with the father of the first child ( OR = 2.04, 95% CI [1.34-3.05], p < .001), (c) being more than three years younger than the first child’s father ( OR = 1.60, 95% CI [1.10-2.35]), (d) experiencing intimate partner violence ( OR = 1.85, 95% CI [1.18-2.88], p < .01), (e) not returning to school after the postpartum period,( OR = 1.75, 95% CI [1.20-2.55], p < .01) and (f) having many friends who were adolescent parents ( OR = 1.52, 95% CI [1.03-2.26], p <.05). Raneri and Wiemann recommended future research and interventions to address the multifaceted aspects of adolescent mothers to prevent rep eat pregnancy. The sample for this study included White, Black and adolescent mothers but the data were collected from the labor unit of one hospital in Texas. The socioecological predictors identified could be reflecting the population of persons that utilize that partic ular facility.


16 This section establishes the prevalence of repeated pregnancies in adolescents. The use of long term contraceptives is the only factor that ha s been significantly associated with repeated pregnancies. More emphasis needs to be put on the adolescent themselves to make responsib le choices for their lives. Pregnancy prevention programs Because of the psychosocial and health factors associated with adolescent pregnancy, millions of dollars a year have been spent on programs in the United States to prevent initial pregnancy and delay init iation of sexual activity (Stephens, 2006). Franklin and Corcoran (2000) reviewed prim ary prevention programs and practices in the United States aimed at preventing adolescent pregnancies. They reported that programs offering a comprehensive approach of cont raception knowledge, sex education, and skills training were successful in reduci ng sexual risk taki ng behaviors. Carrera and The Children's Aid Societ y (1984) developed a holistic program model in the United States aimed to empowe r youth and prevent adolescent pregnancy. The Carrera Adolescent Pregnancy Prevention Program (CAPP) is an "above the waist approach to primary pregnancy prevention" The focus of the program is success in school, meaningful employment, access to quality health services, and interaction with adult role models. This program has been in tegrated into many in-c lass and after school programs throughout the United States. In the United Kingdom, Carter (2008) evaluated a Teen and Toddlers primary prevention program. Vulnerable teenagers in th e program were given the responsibility to be positive role models to toddlers. Th e focus of the intervention was neither contraception nor abstinence, instead the te ens were encouraged to think through the


17 implications of unprotected sex and make their own decisions. The result of a retrospective study (McDowell, 2004) on graduates from the program ( n = 83; 62 females & 21 males) showed a pregnancy rate belo w the national average and no pregnancies under the age of 16 years. There were five ma jor findings from the survey; (a) 87% of the participants said the right time to become a parent is over 20 years old; (b) 88% agreed that the program taught them about sexual hea lth issues; (c) 92% sa id that the program helped them understand the impor tance of financial stability before having a child, (d) 90% thought the program was necessary to help young people make good decisions and (e) 79% said the program ma de them feel more confident about themselves. The limitations of this study is 203 surveys were di stributed and 83 (40%) were returned. The results may reflect those who had a positive response from the program. The focus of prevention of secondary pregnancies has been providing support services for pregnant and parenting adoles cents (Franklin & Corc oran, 2000). In a study of the efficacy of secondary adolescent pr egnancy prevention programs Key, O’Rourke, Judy, and McKinnon, (2005) found a decrease in repeat teen births during the intervention period with a rebound after the intervention was discontinued. There is a lack of information in the literature c oncerning the reason for this rebound after the program ends. Boardman, Allsworth, Phipps, and Lapane (2006), using the Na tional Survey of Family Growth ( n = 1117), found adolescents who inte nded to have the first pregnancy ( AOR = 3.27, 95% CI [1.87 – 5.70]), those with prior poor obstetrical outcome ( AOR = 2.36, 95% CI: 1.10-2.62) and those with pa rtners who wanted a pregnancy ( AOR = 2.46, 95% CI [1.45-4.18]) were more likely to have a rapid repeat pregnancy within two years.


18 The authors concluded that knowing if the pr egnancy was intended or not could help to generate effective programs a ppropriate to meet the need s of the adolescents. The researchers in this study collected data fr om women 20 – 30 years of aged who had a history of adolescent pregnancy. The research ers relied on the memory of the woman for data input. The women are more mature a nd might give answers that are socially acceptable. Sangalang, Barth, and Painter (2006) conduc ted a retrospective study to examine a case management intervention for first-time pregnant and parenting mothers in the Adolescent Parenting Program (APP) in Nort h Carolina. The researchers compared 1,260 adolescent mothers who participated in an Adolescent Parenting Program to 1,260 adolescent mothers who did not. The findings indicated that the odds of the intervention group giving birth to a normal weight infant were 1.67 times that of the non-intervention group ( OR = 1.67; CI: 1.29-2.16; p < .001). Maternal age ( p < .05) and smoking were also significantly associated with low birth weight (p < .01). The adolescents age 12-16 years in the intervention group ( n = 875) delayed second births significantly longer than the non-intervention group ( n = 719, p = .006). The researchers concluded that a combination of case management and direct services provided by a multidisciplinary team helped the adolescent mothers postpone subsequent births in adolescence. A limitation of this study was that the partic ipation in the APP program was voluntary, indicating the participan ts probably had some level of se lf motivation before entering the program.


19 Black and colleagues (2006) conducted a randomized controlled trial of homebased mentoring intervention programs in prev enting second births within 2 years of the adolescent mother’s firs t delivery. The sample ( n = 181) consisted of African American adolescents < 18 years of age from low – income homes in Baltimore. Eighty-seven adolescents were assigned to the interv ention group and 94 to the control group. All participants received information on the resources available to young mothers in the community at the beginning of the study. The intervention group received additional home visits every other week until the infant’s first birthday. Both groups were evaluated when their infants were 6, 13, and 24 months old. At the 2-year evaluation, 27 (18%) had given birth to a second child. Mothers in th e control group were 2.5 times more likely to have given birth to a second child than moth ers in the intervention group (24% vs. 11%; OR = 2.45; CI [1.003-6.03], p = .05). The researchers recommended future pregnancy prevention interventions for African Ameri can adolescent mothers include mentoring programs with components of in terpersonal nego tiation skills. Schaffer, Jost, Pederson, and Lair, (2 008), evaluated a school-based Pregnancy Free Club (PFC), implemented by public hea lth nurses to prevent repeat adolescent pregnancy in Minnesota. The strategies incl uded daily presence of the public health nurses in the school, health counseling, referral, health education cla sses and day-care for participants. Over a 9-year period, 20 pre gnancies occurred among the 276 participants, an overall repeat pregnancy rate of 7.2%. The pa rticipants agreed that the presence of the Public Health Nurse, along with the avai lability of birth c ontrol and supportive nonjudgmental environment assisted in th eir choice to remain pregnancy-free.


20 Barnet and colleagues (2009) conducted a randomized trial of three groups to determine the effectiveness of a computer-a ssisted motivational intervention (CAMI) in the prevention of rapid subsequent birth in adolescent mothers ages 12-18 years in a lowincome, predominately African Amer ican community in Maryland, ( n = 235). Of the three groups, one group received CAMI only ( n = 87), another group received CAMI plus home-visits ( n = 80) and the control group received the standard usual follow-up care ( n = 60). Forty-three (18%) participants expe rienced repeat pregnancies by 24 months postpartum. Compared to the control group, pa rticipants in the CAMI plus home visits group showed a trend toward lower repeat birth rates (25.0% vs. 13.8%; p = .08); those in the CAMI only group did not (25.0% vs. 17.2%; p = .32). After controlling for group differences, the findings indicated the hazard ra tio (HR) for repeat birth was significantly lower for the CAMI plus home visits gr oup (HR = 0.45; 95% CI [0.21-0.98]). Time of repeat birth did not differ among the groups ove rall. The mean time to subsequent birth ranged from 22.6 – 23.0 months ( p = .10). The researchers reco mmended that behavior change technologies with tailored feedbacks be integrated into clinic and community based pregnancy prevention programs for pre gnant adolescents. One limitation of the study was that the researchers could not control the delivery of the interven tions in the community setting. There were standardized instruments but the home environment was unpredictable and could have affected the quality and delivery of the intervention. Programs evaluated in the literature where one-on-one in tervention or group sessions geared to the adolescent having a f eeling of belonging, were successful in preventing repeated adolescent pregnancy. Th ere were no programs that incorporated family members or persons familiar with partic ipants who can continue to act as support


21 persons when the interventions are discon tinued. This family/ support person inclusion might address the problem of reboun d pregnancies (Key et al., 2005). The literature supports the harmful psychosocial and biological sequelae that can occur as a result of adolescen t pregnancy. Programs that rende r social support have been proven to be most successful. The pr ograms stopped short of addressing the characteristics of the adolescent which will be needed to sustain the effects of the program once it is discontinued. Religiosity in adolescents The link between spirituality and health is not well understo od, but researchers have documented the positive influence that spirituality has on the health of women, and in particular African American women (Dai ley & Stewart, 2007; Dessio et al., 2004; & Musgrave, Allen & Allen, 2002). Religion and spirituality are also important to adolescents and are considered protective fa ctors against deleterious health outcomes ( Ball, Armistead, and Austin, 2003; Cotton, Zebracki, Rosenthal, Tsevat, & Drotar, 2006; & Holder et al., 2000). Interest in the effects of religious /spiritual involvement with adolescents has increased in rece nt years (Harris et al., 2008). Holder and colleagues (2000) used a conve nience sample of 141 youth (46 male & 95 female) ages 11 -25years, from an urban adolescent primary health care practice to examine the relationship between dimensions of spirituality and voluntary sexual activity. The findings revealed that spiritual interconnectedness with friends ( OR = 0.92, 95% CI [0.85, 0.99]) and age ( OR = 1.75, 95% CI [1.34, 2.28]) were independent predictors of voluntary sexual activity. The researcher s concluded that younger age and higher spirituality are associated with a lowe r likelihood of voluntary sexual activity. The


22 researchers admitted that the age of the participants and the sensitivity of the questions could have led to under re porting of sexual activity. Th e convenience sampling method may also introduce a level of bias. McCree, Wingood, DiClemente, Davies, a nd Harrington (2003) examined the relationship between religiosity and risky be havior in African American adolescents ( n = 522) ages 14 – 18 years. The participants were given a survey to examine religiosity and a structured interview to collect informati on regarding sexual beha vior. The researchers found that adolescents who had higher religiosity scores were more likely to have higher self-efficacy in communicating with new, or steady male partners about sex, STIs and pregnancy prevention ( p = .001). Some adolescents were also more likely to initiate sex at a later age ( p = .01), use condoms in the past six months ( p = .04), and possess more positive attitudes toward condom use ( p = .01). Researchers concl uded there is a positive relationship between religiosity and ability to negotiate safer sex. As in the study by Holder and colleagues (2000), the data obtaine d from this study were self-reported and may have been under or over reported. Inte rviewing adolescents on sexual behavior may have also affected the responses. Nonnemaker, McNeely & Blum (2003) conducted a study using secondary data from the United States National Long itudinal Study on Adolescent Health ( n = 16,306) to examine the public (frequency of attendance in religious services and frequency in participation in religious yout h group activities) and privat e (frequency of prayer and importance of religion) domains of religiosity and adolescent health risk behaviors of 7 – 12 grade students. Higher levels of public a nd private religiosity were protective against cigarette smoking ( p < .001), alcohol use ( p < .05) and marijuana use ( p < .001) and


23 lower probability of ever having sexual intercourse ( p < .001). Higher levels of public religiosity had a significant effect on effective birth control at first intercourse ( p < .05), females ever pregnant ( p < .01), and lower emotional stress ( p < .01). Private religiosity was associated with lower probability of ha ving suicidal thoughts (p < .01) or having attempted suicide ( p < .05). The researchers suggested further research be conducted to explain the mechanisms by which religiosity is protective of adolesce nts. The data were self-reported and adolescence may have re sponded along socially acceptable lines. Ball and colleagues (2003) conducted a qua ntitative study as part of a larger randomized controlled trial us ing 492 African American fe males ages 12 – 19 years from the metro Atlanta region of the United St ates to explore the relationship among religiosity, self-esteem, sexuality and psychol ogical functioning. The intervention group was shown a video on teen pregnancy and sexual transmitted infections (STI). The control group was shown a video on alcohol ism. Both groups were given a pre-video survey and a follow-up survey 4 weeks late r which included religiosity, self-esteem, sexuality and psychological f unctioning measures. The author s reported there was a main effect for church attendance on self-esteem ( F = 2.98, p < .05). The highest level of selfesteem was reported among adolescents who re ported themselves as “not really” or somewhat religious and the lowest self -esteem among those adolescents who were “unsure” of their religious level ( p <.01). No main effect was found between selfreligiosity and general ps ychological functioning, ( F = 0.52, p > .05). There were no differences in sexual behavior found wh en compared to selfreligiosity ( X2 = 3.76, p >.05), however, there was a significant difference for sexual activity on church attendance ( X 2 = 8.49, p < .05). The authors concluded that by identifying how religion


24 exerts a positive effect on African American adolescents, healthca re professionals can design interventions to improve the adolescent s’ quality of life. Th e adolescents in the intervention may have given more socially acc eptable responses after viewing the video. Cotton et al., (2006), in a literature re view of 17 peer-reviewed studies (1985 2004) on religion/spirituality a nd adolescent health outcomes, reported that spiritual connectedness, a strong relationship with God, a nd use of spiritual co ping were inversely related to substance use and vol untary sexual activity, independe nt of other social support and across ethnic/ racial and age groups. Inclusion criteria and a conceptual framework were used for this review due to inconsiste nt measurements and limited quantitative data. The authors suggested further st udies be conducted in the role of religion/spirituality on the health and wellb eing of adolescents. Numerous research studies have been c onducted related to adol escent sexual risktaking behaviors (Cotton et al., 2006; McCr ee et al., 2003; & Nonne maker et al., 2003); however researchers have not addressed the effects of spirituality on adolescent pregnancies. Researchers consistently found that high spir ituality/religiosity ha s correlates with decreased levels of sexual ac tivity, delaying the age when sexual activity is initiated and increased level of self efficacy in relati on to wearing of condoms and prevention of pregnancy among adolescents. Thus, religi osity was included as a dimension of empowerment in this study. Health Empowerment in adolescents Empowerment is a process influenced by external social forces and developmental person-environmental processes, is associated with self-esteem, self-


25 worth, inner-confidence, and facilitated by re lational factors such as encouragement and mentoring (Nyatanga & Dann, 2002). Health em powerment is a relational process that emerges from the person’s recognition of his or her own personal and social-contextual resources (Shearer, 2007). Factors that a ffect health empowerment are dynamic and cannot be predicted and are not experience d by everyone. Multiple synergistic factors influence empowerment (Hoden, Messeri, Ev ans, Crankshaw, & Ben-Davies, 2004). According to Kvokkanen & Leino-Kilpi ( 2002), there are th ree categories of empowerment. The first category of empowerm ent is associated with Critical Theory (Freire, 1972) and Emancipatory Theory (Ward & Mullender, 1991) and involves improving the living conditions of oppressed groups. The se cond category is associated with organizational theories (Chandler, 1992; Laschinger, 199 6) and involves delegating and taking power. The third category of em powerment is associated with social psychological theories (Hess, 1984; Rappapor t, 1984) based on indi vidual development and interaction with the environment. Me non (2002) introduced spiritual empowerment as another category of empowerment, wh ich captures the influence of faith on empowerment. The CAPP Program (1984) discussed earlier was evaluated by Philliber, Kaye, Herrling, and West (2002) in a multi-site 3-ye ar randomized controlled longitudinal study in New York City. One hundred participants 13 – 15 years of age (males and females) were recruited from six agencies and random ly assigned to the control group (an ongoing after school program) or the intervention group (CAPP Program ). At the end of the 3 years 79% of the participants were still i nvolved in the study (243 males, 242 females). Females in the CAPP Program were more likel y than the control group to resist being


26 pressured into sexual activity, (75% vs. 36%, p < .05). Females in the CAPP program were less likely than the controls to have ever had sex (54% vs. 66%, p < .05). Sexually experienced females in the CAPP program were more likely to use an effective contraceptive method with condoms (36% vs. 20%, p < .05). At the 3 year evaluation, the females in the program were less likely th an the control group to be pregnant (10% vs. 22%, p <.01). The CAPP program is for non-pre gnant, non-parentin g adolescents and did not address repeat pregnancy; howeve r, the CAPP Program outlines the importance of empowerment in pregnancy prevention. Ssewamala and colleagues (2010), conducte d a randomized controlled trial to determine the effects of economic empowerme nt on attitudes towards sexual risk taking behaviors using adolescents ( n =277) orphaned because of HIV infection in Uganda. The control group received the usual care for orphans; counseling, educational supplies, and the usual health education included in the school curriculum. The intervention group received the usual care for orphans plus an empowerment intervention that included 12 workshops lasting hour each, on asset and financial planning, monthly peer mentor sessions focused on future planning and lif e options and a matched Child Savings Account to save money. At 10months fo llow-up, the intervention group demonstrated a beneficial effect on attitudes towa rd sexual risk-taking behaviors ( F [1, 266] = 40.36, p < .05). In the control group, both boys and girl s demonstrated an increased approval of risky sexual behaviors. In the intervention group, the girl s’ scores remained unchanged and boys’ scores showed a decrease in a pproval of sexual risk-taking behavior. The researchers concluded that additional research is needed to inve stigate the components required to increase the protective attitudes of females towards risky sexual behaviors.


27 Hsu, Lien, Lou, Chen, and Wang (2010) c onducted a qualitative study to explore the effect of sexual empowerment on sexual decision making in female adolescents in Taiwan ( n = 29). The participants for the study were selected from three private vocational high schools in Taiwan. The a dolescents participat ed in a sexual empowerment course together and were then interviewed individually. The themes that emerged as perception of sexual empowermen t were (a) being proactive in seeking knowledge related to sex, (b) reexamining curre nt relationships, (c) having the right to say “no” and (d) expressing the need to ch ange sexual attitudes and behaviors. The authors concluded that peer group interven tions on sexual empowerment may positively impact health decision making in female adolescents. The authors admitted the need for a follow-up study to determine if the sentimen ts expressed in the interview actually translated into a change in sexual attitudes a nd behaviors. The partic ipants were all from private vocational schools which might not reflect the attitudes and opinions of Taiwanese female adolescents. Adolescent pregnancy and repeated adol escent pregnancy have been studied biologically, psychologically and demographicall y. Gaps exist in the literature between initial and subsequent pregnancies. Fact ors known to protect against risk taking behaviors included (a) close parent-child re lationships, (b) high e ducational aspirations, (c) high self-esteem, (d) ties to a network of community supports and (e) aspects of adolescent spirituality (Holder et al., 2000). There have been no studie s identified where researchers determined what characteristics in the adolescents were being met in the interventions, making it difficult to evaluate effectiveness of the program. This research project was designed to study the


28 relationship among the components of h ealth empowerment and the number of pregnancies in adolescents in The Bahamas. No published studies had been identified in The Bahamas that addressed the issue of adol escent pregnancy or the effectiveness or relevance of current interventions. It is im portant to study levels of health empowerment in order to facilitate interventions that ar e designed to empower these young mothers to participate in health-promoting lifestyles and decisions that will lead to optimal wellbeing for herself and her family (Shearer, 2004). In the past, researchers ha ve addressed factors external to the adolescent that can impact the choices that she makes. This study was designed to investigate the psyc hological factors internal to the adolescent that can also impact the decisions that she makes. Theoretical Framework Shearer’s Health Empowerment Theory Theory of Health Empowerment (Shear er, 2007) was used as the theoretical framework for this study. This middle range theory was derived from Rogers’(1980) principle of integrality. The pr inciple of integrality are a pa rt of Rogers’(1970) Science of Unitary Human Beings.Unitary Human Be ings are described as open systems, irreducible, indivisible energy fields identified by patterns and manifesting characteristics that are specific to the whole. As open syst ems, human beings are active and innovative, capable of self organizing and generating change out of ongoing events in life and the environment (Shearer & Reed, 2004). Empowerment theory is not primarily a nursi ng theory; but rather is a theory that has been reformulated and adopted to the perspectives and purposes of nursing. The development of Health Empowerment Theory was based on a review of definitions,


29 historical perspectives and paradigmatic view s from various disciplines to assist nurses to change their practice with patients (Shear er & Reed, 2004). Critical Social Theory (Freire, 1981) and Feminist th eory (Caroselli, 1995) were used from the social paradigm and the developmental paradigm (Baltes, Lindenberger & Staudinger, 1998) to incorporate the unpredictable process influen ced by personal and environmental contexts. From a nursing perspective, the focus is on a paradigmatic shift from the totality paradigm to the simultaneity paradigm. In th e totality paradigm, the nurse knows what is best for the patient. Alternately in the simultaneity paradigm (Parse, 1992) health involves the clients’ purposeful participation in developing and choosing health patterns. The nurse’s role is to facilitate, not dictate, this process. The shift to the simultaneity paradigm, in which human beings are seen as integral to the environment in which they live and to their health expe riences, is supported by several nursing theories, such as Rogerian principles of hemodynamics (Rogers, 1992), Rogerian theory of power (Barrett, 1994) and Theory of Health as E xpanding Consciousness (Newman, 1997). Shearer’s and Reed’s (2004) reformulated view of empowerment is based on four assumptions synthesized from the various theo ries, but primarily is from Rogers’ (1992) principle of integrality. Inte grality is characterized by patterns, self -organization, diversity and innovative change. A person’s e xperiences are manifested in his or her environment, and the pattern of the envi ronment is manifested in the person’s experiences (Reeder et al., 1984).The four a ssumptions of empowerment theory are: (a) empowerment is not external to the indi vidual and cannot be given or forced upon a person, (b) empowerment is a mutual rela tionship between the individual and the environment, (c) empowerment in a continuous process is not a static outcome and (d)


30 empowerment is facilitated by nursing knowledge and evidence-based practice. Empowered patients participate in health care and manifest patterns of well-being. Health Empowerment Theory is an emphasis on one’s ability to participate knowingly in health and healthcare decisions (Shearer, 2000). Health empowerment is a relational process that emerges from the pers on’s recognition of he r/his own personal and social contextual resources. The mediators of health empowerment are personal growth, self-acceptance, purpose in life, social support, and social service utilization. Shearer (2004) conducted a quantitative st udy using a descrip tive, correlational design to determine which contextual factor s (personal characteristics) and relational factors (mutual interaction & social support) explained health empowerment (knowing participation and life style behavi ors) in adult women, 21-45 years ( n = 133). The sample was recruited from women visiting a community center in a southwestern city in the United States. This study was also used as a ba sis to test the theoretical model of health empowerment in women. Social support was measured using the Personal Resource Questionnaire-Part 2 (Weinert, 1987) and pr ofessional support was measured using the Nurse-Patient Interaction Tool (Krouse, Krouse & Roberts, 1988). Health Empowerment was measured using two tools: the Power as Knowing Participation in Change Tool Version II (Barrett, 1986) and the Health Prom oting Lifestyle Profile II (Pender, 1996). When health empowerment was measured as knowing participation, social support was reported to be significant ( R2=.38; F = 11.727, p < .01). When health empowerment was measured as life style behaviors, education ( p .005) and social support ( p < .01) were found to be significant. The author concl uded that social support and education contributed to the variance e xplained in health empowerment and suggested that a more


31 comprehensive measurement of other relevant factors be used in the future. The study participants were all Caucasian, educated wo men already attending a clinic and might not reflect the contextual and re lational factors of health em powerment in women of other ethnicities and socio-economic status. Shearer (2007) again tested this theory in a qualitative study, guided by phenomenological methodology to interview homebound older women ( n = 14) ages 69 to 94 years Four themes emerged from this study; 1. Recognizing the potential a nd ability to change. This skill reinforced the women’s place in the world, and attainme nt of personal and health goals. Potential and ability to change was a s ource of inner strength which gave them the power to confront the challenges of life experiences, role changes, and financial stressors. Staying positive encouraged and reinforced positive health decisions and assisted in overcoming life’s obstacles. 2. Transcending boundaries was achieved by recognizing that choosing to ask for help is not a sign of weakness. Acknowledging that supp ort is available and making choices about which res ources to use was an important characteristic. 3. Engaging in life processes involves re lationships with supportive family, friends, care givers and others with similar concerns. Staying connected to services that cater to persons with similar concerns was important. 4. Envisioning the future goals one wants to achieve, continuing to set goals and making preparation for the future was the final theme. Envisioning is an important part of health empowerment.


32 Shearer, Fleury and Belyea (2010) conducted a randomized controlled trial of a health empowerment intervention (HEI) to eval uate the feasibility of the HEI, and to explore the impact of the HEI on the theo retical mediating va riables of health empowerment and purposeful participation in goal attainment with home bound older adults. Fifty-nine home-bound adults 60 years and older were randomly assigned to the control group or the intervention group. The HEI intervention group ( n = 32) received six weekly home visits from a tr ained nurse intervener (NI) fo cused on personal resources, building capacity, buildi ng social networks, identifying and communicating with social service providers and re viewing goal attainment. The interv entions were videotaped with the participants’ permission to ensure valid ity and reliability of the intervention. The comparison group ( n = 27) received a weekly news lett er for six weeks that focused on home safety, medication safety, aging, skin care, dental care, and bone health. The participants were measured at base line, at 6 weeks and at 12 weeks. The measures used in the study were; Ryff’s (1989, 1991) Psychol ogical Well-Being Scales – to measure health empowerment, Power as Knowing Pa rticipation in Change Tool (Barrett & Caroselli, 1998), the Goal Attainment Scale (Kiresuk & Sherman, 1968) and the Wellbeing Picture Scale (Gueldne r et al., 2005). Shearer a nd colleagues found significant difference over time in purposeful particip ation in goal attainment when the Goal Attainment Scale was used ( F( 2, 83) = 3.71, p = .03). No significant main effect between the intervention and the comparison groups were found for health empowerment using the total scores of the Psychological Well-be ing Scale, for purpos eful goal attainment using the total scores from the Power as K nowing Participation in Change Tool and for the Well-being Picture Scale. Significance was obtained in the subscales of the measures.


33 In the Psychological Well-being Scale, the scores in the personal growth subscale increased significantly in the intervention wh en compared to the comparison group from baseline to Time 3 ( F (1, 83) = 3.88, p = .05). There was a significant increase in the scores of the self-acceptan ce subscale in the interventi on group as compared to the comparison group for persons with a high number of co-morbid conditions ( F( 1, 79) = 5.13, p = .03). The results provided beginning information for HEI in home –bound elderly populations. Though Shearer used the theory of Health Empowerment to examine older persons, a population vulnerable to issues of empowerment, the results of these studies provided information that was used to explor e the empowerment of adolescent mothers in The Bahamas. Shearer (2007) defined empowe rment as purposefully participating in the change process of oneself and one’s envi ronment, recognizing and engaging inner resources for wellbeing. Shearer’s theory was us ed to examine adolescent mothers’ level of empowerment by testing their levels of autonomy, environmental mastery, personal growth, relationship with others and purpose in life. In this study, the theory of Health Empowerment was used to examine the contextu al characteristics of pregnant adolescents who are also vulnerable to issues of em powerment and to iden tify the presence or absence of personal resources for Health Empower ment as illustrated in (Figure 1), using Ryff’s (1989) psychological well being scales and Santa Clara Strength of Religious Faith Questionnaire (Plante et al., 2002). These variables are in keeping with Shearer’s empowerment theory.


34 Health Empowerment Construct Figure 1. Diagram of Health Empowerment Construct Empowerment Outcome Delayed / Planned Repeated Pregnancies INDIVIDUAL ENVIRONMENTAL EMPOWERMENT SHEARER’S HEALTH EMPOWERMENT THEORY Religiosity Sel f Acceptance Relationship with others Environmental Mastery Personal Growth Purpose in Life Autonomy


35 Chapter III Methods This chapter is a description of th e methods and procedures that were implemented in this study. The research objec tives, research questions, description of the study design, sample size, and sample criteria are outlined. The method of data collection and analysis, procedures to ha ndle missing data and protection of human subjects are also addressed. Purpose The purpose of this study was to inve stigate the level of empowerment among pregnant adolescents living in The Bahamas aged 18-19 years by testing the levels of autonomy, environmental mastery, personal grow th, relationship with others, purpose in life and religiosity. The findings of the study may well be used to highlight areas for future research in pregnancy prevention programs for adolescents in The Bahamas. Research Questions 1. What is the relationship among levels of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance, and religiosity and the number of pregnancie s of 18 and 19 year old adolescents in The Bahamas? 2. What is the relationship between the overall level health empowerment and the number of pregnancies of 18 and 19 y ear old pregnant adolescents in The Bahamas?


36 Study design A cross-sectional, descri ptive, correlational design was used to describe the relationship among the independent variables of health empowerment and the dependent variable, number of adolescent pregnancies. Sampling procedure A convenience sample of 105 pregnant adolescents ages 18 and 19 years attending any of the antenatal clinics in the Department of Public Health in The Bahamas December 2010 – March 2011 was used for the study. The clients were all required to have an antenatal passport as proof of clin ic attendance and current pregnancy. Flyers were placed in the clinics with contact num bers for interested persons to contact the researcher for further information. The primar y sites used for data collection were Nassau and Grand Bahama (The Bahamas). Sample criteria The primary criteria for study participan ts in this study included 18 and 19 year old females who were born in The Bahamas or who had spent the majority of their formative years in The Bahamas. Identity formation is one of the tasks of adolescence (Erikson, 1968). Cultural iden tity (national and ethnic iden tity) is developed through a sense of belonging and socialization, and school is an important part of this socialization (Phinney, 1992 & Sabatier, 2008). Adolescents who had lived in The Bahamas for at least 10 years were accepted to participate in the study. The late adolescent was used in this study because the age of consent is 18 years in The Bahamas. The process of obtaining parental consent could have limited th e persons eligible to participate in the


37 study. The information gained from the 18 and 19 year olds was considered to possibly give insight into the needs of the younger adolescent mothers. Participants had at leas t one visit at an antenata l clinic and possessed an Antenatal Passport. All trimesters of pregna ncy were included. The adolescent was able to read and understand the English language. Sample size To assure adequate sample size, a review of literature was performed to determine the presence of the phenomenon in the populatio n of interest. A similar study (Shearer et al., 2010) used a large effect size (/ = 1.0) in a randomized cont rolled trial, intervention study. The results from a sample size of 59 (comparison group n = 27, intervention group n = 32) did not yield a significant main e ffect for overall health empowerment using Ryff’s (1989) Psychological s cales. There was an increase in the personal growth subscale in the intervention group ( F (1, 83) = 3.88, p = .05). In this study a more conservative approach was used for a modera te effect size. A larger sample of 105 pregnant adolescents was chosen in an attempt to determine an association between the health empowerment levels and number of pregnancies (Hulley, Cummings, Browner, Grady & Newman, 2007). In order to determine an adequate sample size, a power analysis was performed to obtain a power level of .80. Power is the ability to detect diffe rences in relationships that are significant and actually exists in the population of in terest (Cohen, 1988). A power of .80 allows for a 20% tolerance of a type II error. The power is the proba bility that the test will reject a false null hypothesis. A moderate effect size of 0.15 was used to determine the size of the relationship between variab les. The level of significance (alpha, ) was set


38 at .05, which indicates a 5% chance of making a type I error (Wilson, 1993). The sample size was calculated using G* Power software calculator (Buchner, Erdfelder, & Faul, 1997) and taking into consider ation the six subscales of the Ryff’s SPWB and SCSRFQ instruments. The following parameters were entered: a power of .08, effect size of 0.15, and an alpha of .05. The power analysis rev ealed that a minimum of 103 participants would be needed for this study. The fina l number of pregnant adolescents who participated in this study was N = 105. Measurement The self-administered questionnaires were administered using a pencil and paper format for three tools: a dem ographic tool to obtain the char acteristics of the sample, the medium form of Ryff’s Scales of Psychol ogical Well-Being (Ryff, 1989) and the Santa Clara Strength of Religious Faith Questi onnaire (Plante & Boccacci ni, 1997). The latter two tools were selected to determine levels of empowerment and reli giosity respectively. The questionnaires were self-administered. Demographics The demographic questionnaire of 16 items (Appendix B) was used to determine the characteristics of the respondents. The tool was designed for this study based on review of previous l iterature on the topic. The age, education level, marital status, occupational status and the number of pregnanc ies were included as each of these can impact levels of empowerment and vulnerabil ity to pregnancies in adolescence (Shearer, 2004; & Raneri & Wiemann, 2007) The participan ts were also asked to report their age, birth place, marital status, educational level, educational certificates, employment status,


39 religious affiliation, and obstetr ic history. Participants were asked to report on the source of emotional support and to report an y previous history of depression. Health empowerment measure Health empowerment for each participant was measured with the medium form of Ryff’s Scales of Psychological Well-Being (SPWB) (Ryff, 1989, Appendix B). Ryff’s SPWB is a 54 item pencil and paper questionn aire. The questionnaire consists of six 9item scales reflecting six ar eas of psychological wellbei ng: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life and selfacceptance. The items from each scale were mixed to form one continuous instrument. Each subscale has 9-items which include pos itively and negatively worded statements. The respondents rate each statement on a sixpoint Likert Scale, w ith 1 indicating strong disagreement and 6 indicating strong agreem ent. The negatively worded items were reverse scored for analysis. Each subscale has a score range of 9 to 54, totaled to measure each dimension of psychological well-being and the total of all scales were calculated to measure overall psychological well-being and level of empowerment (54 to 324). A high score in self-acceptance indicates a positive attitude toward self; a low score indicates dissatisfaction and disappointme nt with one’s life. A high score in the subscale positive relations with others indicate s a trusting relationship with others and an understanding of the dynamics of human relati onships; a low score is indicative of isolated, frustrated or distru sting relationships. High scores in the autonomy subscale are indicative of the ability to evaluate self fr om personal standards; low scores indicate conformity to social pressures when maki ng decisions. High scores in environmental


40 mastery indicate an ability to make effectiv e use of opportunities de pending on individual needs and values; low scores indicate a lack of control over external environment. High scores in the purpose in life subscale indicate that there ar e goals and direction to one’s life; a low score is indicative of lack of direction in life. A high score in the personal growth subscale indica tes feelings of improvement in self and moving toward one’s potential; a low score indicates a sense of personal stagnation. The parent scale of 20-items per scale wa s tested by Ryff (1989) with a sample of 321 men and women from thr ee age groups; young adults ( n = 133, mean age = 19.53, SD = 1.57), middle aged adults ( n = 108, mean age = 49.85, SD = 9.35) and older adults ( n = 80, mean age = 74.96, SD = 7.11). The parent scale had an internal consistency coefficient ranging from 86 to .91. The test-retes t reliability over a 6-week period ranged from .81 to .88. Each construct was derived fr om specific psychological theories in the literature and the items developed by expe rts in the field of psychology. The scales correlated positively with prior scales of positive functioning (life satisfaction and selfesteem, r = .25 to .79) and negatively with measures of depression and external control ( r = -.30 to -.70). The 14-item scales were corre lated with the parent scale and items were chosen based on the item-to-scale coeffici ents (.97 to .99) and the guidance of the theoretical definition. Dierendonck (2005) conducted two studies on a Dutch population to examine the construct validity of the three versions of Ryff’s Scales of Psychological Well-being and its extension with spiritual well-being; 14item scales, 9-item scales and 3-item scales on a Dutch population. In the first study 233 firs t year college student s (156 females & 77 males) completed the survey. The mean age was 22years ( SD = 6) The internal


41 consistency of the 9-item scales rang ed from 0.65 – 0.83. In the second study the participants were 420 professionals from diverse occupations, mean age 36 years ( SD = 8). The internal consistency was 0.61 to 0.77. Dierendonck concluded that a medium length version should be used and an additi onal spiritual well-being scale be added to complete the psychological as sessment of the individual. The 9-item version of the scale was al so used in the Wisconsin Longitudinal Study. This was a 40-year study of a ra ndom sample of 10,317 men and women who graduated from Wisconsin high schools in 1957 focused primarily on work and occupational experience. In the 1992/93 su rvey there were 8,493 telephone respondents, of whom approximately 6,875 also complete d a mail questionnaire. Articles published from the study contained reports of an inte rnal consistency coeffi cient ranging from .70 to .78 (Carr & Friedman, 2005; Pudrovska, 2009 ; & Taylor, 2009). Ryff’s Scales of Psychological Well-be ing was used in this study because empowerment is best studied by focusing on the psychological state of the individual (Menon, 2001).The six scales of the instrument are congruent with th e characteristics of empowerment proposed by Shearer (2004) and th e instrument has been tested in the adolescent population with accepta ble reliability and validity. Religiosity measure Religiosity for each participant was measured using the brief version of the Santa Clara Strength of Religious Faith Questionna ire (SCSRFQ) (Plante et al., 2002, Appendix B) to capture the influence of faith on em powerment (Menon, 2002). The brief version is a 5item questionnaire. The respondents rate each statement on a 4-poi nt Likert scale; 1 indicates strongly disagree and 4 indicates strong ly agree. A score of 5 indicates low faith


42 and 20 indicates high faith. The SCSRFQ is de signed for researchers or practitioners who wish to measure the strength of religious faith without assuming a specific religious denomination (Plante & Boccaccini, 1997). The validity of the parent scale has been supported by st rong correlations with the short form of the SCSRFQ and other measur es of religiosity such as Age Universal Religious Orientation which measures both intrinsic and extrinsic religiousness ( r = .70 to .83, p < .05) and the Intrinsic Religious Moti vation Scale that measures religious motivation ( r = .69 to .82, p < 0.5). The Duke Religious Index which measures selfreligiousness, depression, and need for a lliance correlates negativ ely with SCSRFQ ( r = -.71 to -.85, p < .05; Plante et al., 1999). There is high internal consistency ( = .95) and high split-half reliability ( r = .92; Plante & Boccaccini, 1997) which confirms the reliability of the measure. The brief form of the SCSRFQ was cr eated by analyzing the 10-item scale for moderate means (below 2.89) and high standard deviations (above .95) to avoid ceiling or floor effects in the questionnaire. The data were analyzed usin g the results from 1,584 questionnaires administered to 4 different sample groups over a 3-year period. The mean age of the groups ranged from 19.47 years to 55.74 years. Five items that met the moderate means and high correlation with th e overall scale were selected for the brief version of the SCSRFQ. There is a strong correlation betwee n the brief version and the parent version of SCSRFQ ( r = .95 to .99, p < 0.01). Factor analysis revealed that SCSRFQ if a one factor scal e with high correlations between the factor and each item ( r = 0.68 to 0.91, p < 0.05). The SCSRFQ was chosen for this study because it has been tested with older adolescents and showed accep table validity and reliability levels that


43 question the strength of religious faith without as suming a specific religious denomination and because of the brevity of tool. Data Collection and Analysis Procedure for data collection The population for this study was pregnant adolescent females between the ages 18 and 19 years of age who attended an ante natal clinic in Nassau and Grand Bahama, Bahamas. Flyers (Appendix C) were posted in the clinics informing the clients of the study. As the clients registered for the clinic, they were a pproached by the investigator, who invited them to volunteer to participate in the study. The inves tigator explained the purpose of the study to adolescents who were willing to partic ipate. The client was given a consent form (Appendix D) to read and sign. Once the participant was consented, she was given a questionnaire (Appe ndix B) to complete in a qui et area of the clinic. Upon completion of the consent and the questi onnaire, the forms were reviewed by the investigator for completeness and a $5.00 gi ft card was given to the participant along with business cards (Appendix E) to distribute to other pers ons who met the criteria for the study. Protection of human subjects Permission to conduct the study was obtai ned from the Ministry of Health’s Department of Public Health Ethics Co mmittee, Nassau, Bahamas (Appendix F) and the Institutional Review Board (IRB) of the Univ ersity of Miami, Miami, Florida (Appendix G). The consent forms and questionnaires were coded to protect the identity of the participants. The consents and the questionnaire s were stored separate ly in a locked filing cabinet in the office of the investigator at the University of Miami School of Nursing and


44 Health Studies. The data were entered on a password protected computer of the investigator and backed up on a password pr otected jump drive. The data from the research will be destroyed five y ears after the comple tion of the study. Missing data Participants were asked to give a response to each que stion to the best of their ability. The investigator was available to cl arify any queries the participants may had while the questionnaire was being comple ted. Each questionnaire was browsed for completeness not content prior to the gift car d being issued. Mean or mode substitution was applied to missing data within the Re ligiosity and Psychologi cal wellbeing scales (Munro, 2001). Any questionnaire with greater than 30% missing data was discarded. Data analysis Data were entered into SPSS for analys is. Descriptive statistics were obtained on the demographic data. Correlation analyses were obtained to dete rmine the significance between demographic data and the number of pregnancies. Correlation analysis was used to describe the relationship among the psychol ogical and religiosit y scales. Regression analyses were performed to determine th e variance explained between the number of pregnancies and level of empowerment and re ligiosity after controlling for significant factors in the demographic data.


45 Chapter IV Results Overview The purpose of this study was to inve stigate the level of empowerment among pregnant adolescents living in The Bahamas aged 18-19 years by testing the levels of autonomy, environmental mastery, personal grow th, relationship with others, purpose in life and religiosity. The findings of the study may well be used to highlight areas for future research in pregnancy prevention pr ograms for adolescents in The Bahamas. Research questions 1. What is the relationship among the levels of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance and religiosity and the number of pregnancie s of 18 and 19 year old adolescents in The Bahamas? 2. What is the relationship between the overa ll level of health empowerment and the number of pregnancies of 18 and 19 year old pregnant adolescent females in The Bahamas? Description of the sample Convenience and snowball sampling t echniques were used to recruit 105 participants from the antepartum clinics in Nassau and Grand Bahama Island in The Bahamas. The data were collected over a two months period using an IRB approved questionnaires which included demographic information, Ryff’s Psychological Well Being Scale (Ryff, 1989) and the short form of the Santa Clara Strength of Religious Faith Questionnaire (Plant e & Boccaccini, 1997).


46 Flyers were posted in seven community he alth clinics in Nassau and three clinics in Grand Bahama. Clients who expressed in terest in the study were contacted via telephone, eligibility was confirmed, and the study was explained. All persons who were contacted via telephone consented and were directed to come into the clinic to sign the consent form and complete the questionnaires. Other participants were approached at the time of their scheduled appointment at th e clinic. All eligible persons who were approached agreed to participate in the su rvey. One hundred and ten (110) questionnaires were collected but five were not included in the data analysis because of incomplete survey or age ineligibility, l eaving a sample of 105 particip ants. All participants were given a $5.00 telephone card upon comp letion of the questionnaires. Missing data from the demographic section of the questionnaire were indicated in the report. The mean score was calculated fo r the domain and a substitution applied to missing data from the SPWB and SCSRFQ. Demographics Age: Forty-five (42.9%) of the participants reported their ages as 18 years and 60 (57.1%) reported their age as 19 years. Birth Place: One hundred (95.2%) of the participan ts were born in The Bahamas. Four (3.8%) were born in Haiti and one (1%) was born in Jamaica. Marital status: Marital status was reported as si ngle for 67 (63.8%), partnered for 36 (34%), separated for one (1%) and other for one (1%) of the participants. Educational Achievements: Seventy-eight (74.3%) of th e participants reported completing high school, 15 (14.3%) reported having some college education, seven (6.7%) reported attending some high school and 5 (4.8%) had less than high school


47 education. Eighty (76%) were not currently en rolled in any educa tional programs and 25 (23.8%) were enrolled. Eighty-six (81.9%) of the participants reported obtaining Bahamas Junior Certificate su bjects (BJCs). BJCs are qualifyi ng subject exams at junior high (9th grade) level. The number ranged fr om 0 9 subjects. Seventeen (16.2%) respondents reported having no subjects at th e BJC level. Twenty-n ine (27.6%) reported having 1-3 subjects, 47 (44.8%) reported ha ving 4-6 subjects a nd 10 (9.6%) reported having 7-9 subjects. Two persons did not res pond. Sixty-five (61.9%) of the participants reported having obtained Bahama s General Certificat e of Secondary Education subjects (BGCSEs). BGCSEs are qualifying s ubject exams at high school (12th grade) level. The number obtained ranged from 0 7 subjects. Thirty-eight (36.2 %) reported having no subjects at the BGCSE level. Fourteen (13.4 %) of the respondents reported having 1 or 2 subjects, 25 (23.8%) reported having 3 or 4 subjects, and 26 (24.8%) reported having 5-7 subjects. Employment Status: Seventy-eight (74.3%) of th e respondents reported being unemployed and 27 (25.8%) were employed. Religious Affiliation: Ninety-one (86.7%) of the respondents admitted being affiliated with a religious organization. Thir teen (12.4%) respondents did not respond to this question and one (1%) person said she had no religious affiliation. History of Depression: Ninety (85.7%) of the responde nts reported no history of depression. Thirteen (12.4%) admitted past history of depression and 2 (1.9%) did not respond to this question. Source of advice: The respondents were asked to identify two sources of help and advice. Seventy-three (76.5%) persons indicated that their mother was a source of advice,


48 38 (42.9%) persons indicated other family me mbers, 20 (11.8%) indicated friends. Other sources of advice were; siblin gs, 13 (7.6%), significant ot her 11 (6.5%), church, four (2.3%), teacher, three (1.8%), healthcare pr ovider, one (0.6%) and six persons indicated other. Forty persons only indicate d one source of advice and help. Pregnancy: Eighty-six (81%) of the participants reported th e current pregnancy as their first. Nineteen (18.1 %) reported having a previous pregnancy. Of those with previous pregnancies, four (21.0%) ended in miscarriage and four (21.0%) in abortions. Ten (52.6%) were full term and one (5.3%) pr e-term deliveries. There were 17 (89.5%) vaginal births and two (10.5%) cesarean secti ons. Of those participants with previous pregnancies 2(10.5%) did not report the year of the previous birth. Four (23.5%) reported giving birth one year ago, 3 (17.6%) reported births 2years ago, 5 (29.3%) reported births 3years ago, 2 (11.8%) reported births 4years a go, 2 (11.8%) reported havi ng births 5years ago and 1 (5.9%) reported having a birth 7years ago. Family Planning: Forty-four (41.9%) indicated th ey used no form of family planning, 29 (27.9%) used condoms, 16 (15.2 %) used oral contraceptives, 15 (14.3%) used injections and 1(1%) indicated other. Of those who indicated they used some form of family planning 5(8.2%) indicated a second method. Study ariables Health Empowerment: This section of the analysis is a description of the results of the Ryff’s Scales of Psychological We ll-being (SPWB, 1989). Ryff’s SPWB consists of six 9-item scales refl ecting six areas of psychologi cal wellbeing; autonomy, environmental mastery, personal growth, positiv e relations with others, purpose in life and selfacceptance. Each subscale has 9-items which include positively and negatively


49 worded statements. The total of all scales are summed resulting in possible total scores ranging from 54 to 324. For the purpose of this study the overall score of this measure was used to determine the le vel of health empowerment of the respondents. For the purpose of this analysis the subscales were di vided into three categor ies: a score of 1-18 was considered low level of the dimension be ing measured, 19 -36 is indicative of some level of the dimension was demonstrated and 37-54 demonstrates a high level of that dimension. The analysis of the overall hea lth empowerment was also subdivided using Ryff’s SPWB; 1-108 indicating a low level of health empowerment, 109-216 some level of health empowerment and 217-324 a high le vel of health empowerment. The internal consistency of the measure was tested by using the Cronbach’s Coefficient Alpha and resulted in = .92 and internal consistency coeffi cient ranging from .77 to .89 which is higher than the .61 to .83 reported by Ca rr and Friedman, 2005; Pudrovska, 2009 and Taylor, 2009. All respondents scored between 109 a nd 324 on the overall health empowerment; 37 (35.2%) scored 109-216, indicating some level of health empowerment and 68 (64.2%) scored 217-324 indicating high levels of health empowerment. The sub-scales reflect a similar distribution of scores; self – acceptance was the only sub-scale to reflect scores in the low category (Table 1). Religiosity: The brief form of the Santa Cl ara Strength of Religious Faith Questionnaire (SCSRFQ) (Plante et al., 2002) was used to measure the strength of religious faith, without assuming a specifi c religious denomination. The respondents rated 5 statements on a 4-point Likert scale; 1 indicates strongly di sagree and 4 indicates strongly agree. A score of 5 indicates low faith and 20 indicates high faith. For the


50 purpose of this analysis the results were divide d into 4 categories: a score of 1-5 indicates very low religious faith, 6-10 indicates low re ligious faith, 11-15 indicates some religious faith and 16-20 indicates high religious faith. Fifty-nine (56.2%) responde nts reported high religious faith, 41% (43) some religious faith, 1.9% (2) low religious faith and 1% (1) very low religious faith. Cronbach’s Alpha = .76 which falls within th e range of correlations reported by Plante and colleagues, 2002 ( r = .68 to .91). Table 1 Descriptive Statistics of the Subscales of the SPWB and Overall Health Empowerment for Pregnant Adolescents (N = 105) Subscale Low Some High Level Level Level n (%) n (%) n (%) M SD Autonomy 21(20%) 84(84%) 42.7 7.2 Environmental 32(30.5%) 73(69.5%) 40.3 7.9 Mastery Personal 24(22.9%) 81(77.1%) 41.9 7.3 Growth Positive Relationship 34(32-4%) 71(67.6%) 41.3 8.1 With Others Purpose in Live 19(18.1%) 86(81.9%) 44.8 7.4 Self-Acceptance 1(1%) 25(23.8%) 79(75.2%) 41.3 8.5 Psychological 37(35.2%) 68(64.2%) 252.2 37.1 Well-being ______________________________________________________________________________ Correlations The correlations between overall health empowerment that, for the purpose of this study, is equated to Ryff’s Overall Psyc hological Well-Being sc ore, religiosity and demographic variables can be found in Ta ble 2. Overall health empowerment and


51 educational level earned, number of BJCs and BGCSEs, were posit ive and statistically significant ( p < .01). History of depressi on was negatively correlated ( p < .01). The correlation between religiosity and history of depression wa s negative and statistically significant ( p < .01). History of Depression was also negatively correlated with educational level earned ( p = .002). The correlation between overall health empowerment and religious faith was positive and statistically significant, p < .01. Table 2 Correlations Among Total Health Empowerment, Religiosity and Demographic Variables of Pregnant Adolescents (N= 105) EMPLOY DEPRESS AGE MARITAL EDU BJC BGCSE ENROLL RELIG 1.Empower -.02 -.31** .13 .01 .44** .43** .41** .10 .36** 2.Employ .01 .10 .06 .10 .06 .16 -.05 -.04 3.Depres -.14 .17 -.30* -.23* -.15 -.002 -.26** 4.Age -.07 .18 .05 .05 -.04 .11 5.Marita -.07 .16 .12 -.001 .12 6. EDU .34* .34** .32** .10 7. BJC .63** .05 .11 8.BGCE .10 .01 9.Enroll .06 *. Correlation is significant at the 0.05 level (2-tailed) **. Correlation is significant at the 0.01 level (2-tailed) The correlation of overall empowerment and religious faith to the five dimensions of psychological well-being are found in Ta ble 3. All dimensions of SPWB were positively correlated to overall empowerm ent and statistically significant ( p < .01). The correlations between religiosity and autonomy w ith personal growth we re not statistically


52 significant ( p > .01). The correlation between religios ity and the all dimensions of SPWB were weak to moderate ( r = .09 .47). Table 3 Correlations Between Empowerment, Relig ious Faith and the Dimensions of Psychological Well-Being Scale of Pregnant Adolescent (N=105) __________________________________________________________________________ Health Empowerment Religiosity (Psychological Well-Being) Autonomy .81** .16 Environmental .83** .29** Mastery Personal Growth .72** .09 Positive Relations .78** .39** With Others Purpose in Life .81** .31** Self Acceptance .85** .47** __________________________________________________________________________ ** p < .01. Number of pregnancies was negativel y correlated with overall health empowerment, religiosity and all dimensi ons of the SPWB. The correlations were statistically insignificant (p > .05) except personal growth (p < .05). The effect size was calculated using the coefficient of determ ination to determine what proportion of variance in the number of pregnancies is e xplained by overall empowerment, religiosity and the dimensions of SPWB (Table 4) The relationships among the number of pregnancies and the variables were sma ll, ranging from 0.68% 3.8%. Number of pregnancies was negatively correlated with cu rrent educational enro llment (p < .05), type of delivery and delivery outcome (p < .001).


53 Table 4 Correlation and Effect Size of Number of Pr egnancies with Dimensions of Psychological Well-Being and Religiosity of Pr egnant Adolescents (N=105) Number of Pregnancies Correlation( r ) Effect size( r2) Autonomy -0.182 0.033 Environmental Mastery -0.098 0.009 Personal Growth -0.196 0.038 Positive Relations with Others -0.160 0.026 Self Acceptance -0.125 0.016 Purpose in Life -0.083 0.007 Religiosity -0.130 0.017 Overall Health Empowerment -.174 0.348 Regression analysis Regression analysis was c onducted to examine the association between the number of pregnancies (dependent variab le) and personal growth, pregnancy outcome, delivery type, and current educational enrollmen t, (the independent variables that were found to be significantly corre lated with the number of pregnancies). The variables accounted for 93% of the variance in the numbe r of pregnancies. The omnibus test was statistically significant, R2= .929, F (4,100) = 328.80, p <.001. Personal growth and current educational enrollment did not accoun t for a statistically significant change ( p >.05) in the number of pregnancies after c ontrolling for pregnancy outcome and type of delivery. There was a change in the number of pregnancies given a 1-unit change in pregnancy outcome after controlling for pe rsonal growth, deliver y type and current


54 school enrollment, p <.001. There was a change in the number of pregnancies given a 1unit change in the type of delivery after controlling for personal growth, pregnancy outcome and current school enrollment, p < .001. Regression analysis was c onducted to examine the association between empowerment (dependent variable) and th e statistically significant demographic variables, history of depression, number of BJ Cs, number of BGCSEs, level of education and religiosity. The variables accounted fo r 40.0% of the variance in the level of empowerment. The omnibus test was statistically significant, R2 = .404, F (5,95) = 12.86, p < .001. Depression, number of BJCs, and BG CSEs did not account for a statistically significant change in overall empowerment afte r controlling for reli giosity and education level completed. There was a change in leve l of empowerment given a 1-unit change in religiosity after controlling for level of depression, earned ed ucation level and numbers of BJCs and BGCSE’s, p =.001. There was change in empow erment level given a 1-unit increase in earned education after control ling for religiosity, history of depression, and numbers of BJCs and BGCSEs, p = .003. Summary The Pearson’s correlation was calcu lated to answer the rese arch questions of the relationship of level of autonomy, environm ental mastery, personal growth, relationship with others, purpose in life, self acceptance, religiosity a nd overall health empowerment with number of pregnancies of 18 and 19 y ear old pregnant females. Number of pregnancies was negatively correlated with all dimensions of ps ychological well-being, religiosity and overall health empowerment. Due to the small number in the sample with repeated pregnancy (19 of 105) the correlations were not statis tically signific ant, except


55 personal growth. The higher number of pregnanc ies are associated with lower levels of overall health empowerment, autonomy, environmental mastery, purpose in life, positive relations with others, self acceptance, personal growth and religiosity. Number of pregnancies was ne gatively correlated but not statistically significant with personal growth, which measured the in dividual feeling of improvement in self and moving toward one’s goals. Number of pr egnancies was negatively correlated and statistically significant with current enrollment in school, which measured whether the adolescent was currently enrolled in a fo rmal educational program. Pregnancy outcome and delivery type were positively correlated a nd statistically significant with number of pregnancies. Pregnancy outcome indicated how the first pregnancy ended whether in abortion, miscarriage, pre-term or full term and delivery type indicated the mode of delivery, whether vaginally or cesarean s ection. These findings suggests that the likelihood of repeated pregnancie s increases when there is an adverse outcome in the first pregnancy such as an abortion, miscarriage, pre-term birth or if the delivery was by cesarean section. Overall health empowerment le vels were negatively and significantly correlated with history of depression, which indicated adolescents who had a pr evious diagnosis of depression. Overall health empowerment was positively and significantly correlated with religiosity, which measured the strength of th e adolescent’s religious faith and level of education. Overall health empowerment was also positively and significantly correlated with earned education and the number of BJCs and BGCSEs, which determined the highest level of earned education which in dicated the number and level of subjects successfully completed in the national exams respectively.


56 Level of education and religiosit y were positively correlated and statistically significant to the level of health empowerm ent for the adolescents in this study. These findings indicate that the pregna nt adolescents in this study wi th high levels of religiosity and those who were still enrolled in formal educational programs showed higher levels of health empowerment.


57 Chapter V Discussion and Conclusions Overview This chapter is a summary of the st udy. The discussion of the findings is presented in relation to the research questi ons. Study limitations a nd the implications for nursing practice, education and future research are also included. Summary of the Study Adolescent pregnancy accounts for 11% of all births globally (WHO, 2008). Teenage pregnancy rate in the United States is the highest in i ndustrialized countries (Singh & Darroch, 2003). In Latin America and the Caribbean (LAC), 25% of the females become pregnant before the age of 20 years (Economic Commission for LAC, 2008). In The Bahamas, single mothers account ed for 11.3% 12.7% of all births in the country between the years 2000 -2007. Adoles cent pregnancy can result in economic, social and health problems in the adoles cent and her child (Klerman, 2004). Delaying subsequent childbearing may be an important factor promoting success in adolescent mother’s later life (K oniak-Griffin et al., 2002). A review of the literature supports the presence of phys ical and social effects of adolescent pregnancy and subsequent pre gnancies on the adolescent and her family (Blum & Nelson-Mmari, 2004; Raneri & Wi emann, 2007; & Partington et al., 2009). Pregnancy prevention programs evaluated in the literature were most successful when there was one-on-one intervention or group sessions geared towards enhancing the participants’ feeling of bel onging (Barnet et al., 2009; Boar dman et al., 2006; & Carter, 2008). High religiosity and spirituality were correl ated with a delay in initiation of sexual


58 activity, increase self efficacy in wearing of condoms and decrease in sexual activity among adolescents (Ball et al., 2003, McCr ee et al., 2003, Nonnemaker et al., 2003). Empowerment is influenced by multiple synergic factors which include self esteem, inner confidence, external and social forces (Nyatanga & Dann, 2002). The importance of the empowerment of adolesce nts has been recognized by the UN in the Millennium Development Goals (UN, 2000; UNFPA 2003; 2007) and the CDC in its Youth Empowerment Strategy (YES) program (Wilson et al., 2008). The importance of empowerment in pregnancy prevention is suppor ted in literature but researchers have not investigated the levels of empowe rment in pregnant adolescents. Shearer’s (2007) Theory of Health Empowerment was the theoretical framework used to examine levels of health empowerment in adolescent pregnant females in this study. Shearer’s theory has emphasis on th e importance of a person engaging inner resources while interacting with the environmen t to effect change. From this theoretical framework, two research questions were generated and tested: 1. What is the relationship among the levels of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance and religiosity and the number of pregnancie s of 18 and 19 year old adolescents in The Bahamas? 2. What is the relationship between the overa ll level of health empowerment and the number of pregnancies of 18 and 19 year old pregnant adolescent females in The Bahamas? A cross–sectional, descriptive, correla tion design was used with a convenience sample ( N = 105) of pregnant 18 and 19 year old adolescents attending antenatal clinics


59 in Nassau and Freeport, The Bahamas. All par ticipants were born in The Bahamas or had been living in The Bahamas for at least 10 ye ars. Data were collect ed via self-reported questionnaires over a two month period – Febr uary and March, 2011. Data were analyzed using SPSS 18.0. The questions were tested us ing Pearson’s correlation coefficients ( r ) and multiple regressions. Discussion The focus of this study was to investigate the level of health empowerment among pregnant adolescents living in The Bahamas aged 18-19 years by testing the levels of autonomy, environmental mastery, personal grow th, relationship with others, purpose in life, and religiosity. Psychologi cal well-being (used as a prox y for health empowerment) and religiosity along with demographic inform ation were used to study these variables. Shearer’s Health Empowerment theory is a bout the ability of one to participate in healthcare decisions by taking into account one’s own social and personal resources (Shearer, 2000). Research Question 1 What is the relationship among the leve ls of autonomy, environmental mastery, personal growth, relationship with others, purpose in life, self acceptance and religiosity and the number of pregnancies of 18 and 19 year old adolescents in The Bahamas? In this study, the adolescents scored mode rate to high in all dimensions of the SPWB scale: autonomy, environmental mast ery, personal growth, positive relationship with others and purpose in life. Only one pa rticipant earned a low score in the self acceptance domain. No similar study was identifie d in the literature in which to compare


60 the health empowerment levels of pregnant adolescents. In pr evious studies, high levels of empowerment were measured in non-pregnant adolescents after interventions, such as a sexual empowerment course and mentoring programs (Philliber et al., 2002; & Hsu et al., 2010). The adolescents in this study might be highly empowered for a number of reasons; more than 75% of them have at l east a high school educa tion and 81% of them are just experiencing their first pregnancy at 18 and 19 years of age. These adolescents probably feel as if they are in control of their life situation. Research Question 2 What is the relationship between the overall level of health empowerment and the number of pregnancies of 18 and 19 yea r old pregnant adolescent females in The Bahamas? In this study, overall level of health em powerment was moderate to high, (Table 1) in the pregnant adolescen ts. Overall level of health empowerment was negatively associated with number of pregnancies in th is population but not st atistically significant due to disproportion of first time vs. repeat ed pregnancies in the study. The moderate effect size (Table 4) indicates there is a relationship between health empowerment and number of adolescent pregnancies. The negati ve correlation indicates that the number of pregnancies does have a moderate effect on the level of empowerment in these adolescents. Further research with a larg er sample size and/or a younger population may establish the direction and st rength of the relationshi p. In this study, 41.1% of the adolescents who had repeated pregnancies be came pregnant within 2 years of the first birth which exceeds the 25% reported by Schelar and colleagues (2007).


61 Culturally, adolescent pregnancy ha s become acceptable in The Bahamas, particularly if the adolescen t has completed high school or has a job. The religious community has taken a posture of love as opposed to ostracizing the adolescent. The adolescent’s level of autonomy, relations with others, purpose in life, environmental mastery, and religiosity might not be affected if the pregnanc y is accepted by those in her environment. Personal growth was statistica lly significant, which indicates that even though the adolescent is empowered she rec ognizes that pregnancy might slow her personal growth. Additional Findings In this Bahamian populati on, pregnancy outcome and type of delivery were contributing factors to the number of adolesce nt pregnancies. Those adolescents who had adverse outcomes, such as miscarriage, a bortion or cesarean sect ion in their first pregnancy were more likely to have a repeat pregnancy in adoles cence. The adolescents in this study with high levels of religiosity and higher le vels of education had higher levels of empowerment. These findings are cons istent with previous studies. Coard and colleagues (2000) and Boardman and colleagues (2006) reported that adolescents with a history of miscarriages and pr evious poor outcomes were more likely to have a repeated pregnancy in adolescence. Hofferth and Reid (2002) also found that adolescent mothers who completed fewer years of high school and those who did not retu rn to school after the first child were more likely to have a rapid repeat pregnancy. The significance of religiosity to empower ment is consistent with studies by Ball and colleagues (2003), McCree and colleague s (2003), and Nonnemaker and colleagues (2003) who found high levels of religiosity/spirituality are as sociated with components of


62 empowerment such as self-esteem, self-effi cacy and autonomy. This sample of Bahamian pregnant adolescents was hi ghly empowered. Health empowerment was greater in those who were religious and educated, which is c onsistent with Shearer’ s (2007) definition of health empowerment as those who are purposeful ly participating in th e change process of oneself and one’s environment. Even though hi gher education and hi gher religiosity were associated with higher levels of health em powerment these adolescents did not use their teachers (1.8%) or churches (2.3%) as a primar y source of advice. This factor should be further investigated and researched. There is some evidence that higher leve ls of health empowerment may lead to fewer pregnancies. There is a chance that this group of adolescents may be empowered independent of the number of pregnancies due to their age and level of education. Further studies with a larger population of adoles cents with multiple births and younger age group should be undertaken. Implications for Nursing Implications for Education Nurses come into contact with pregnant adolescents at several areas of practice such as primary health care clinics, community health, sc hool health, labor and delivery, antepartum and postpartum care, yet adolescent health is not a signi ficant part of the nursing curriculum (Lee et al 2006). Adolescent health is normally nested in the pediatric or maternal and child health c ourse. In advanced practice curricula more emphasis is given to adolescent health in the community health, family nurse practitioner and the midwifery programs. Adolescent hea lth is an important component of the pediatric nurse practitioners program. The needs of the pregnant adolescent should be


63 stressed at all levels of nursing educati on. The physical, as well as, the psychological needs should be emphasized. There should be a more defined focus on providing nursing students with tools necessary to encourag e adolescents in the areas of continuing educational pursuits, support after a perinatal loss or a dverse outcome. Nurses becoming sensitized to the importance of religious support and counse ling for this population might be beneficial. Implications for research In this study, the research er used a convenience sample to determine the health empowerment levels of Bahamian born pre gnant adolescents rela ted to the number of pregnancies. Future research ers may want to conduct furt her studies ensuring adequate sample size with multiple pregnancies to comp are with a sample size of adolescents with one pregnancy to increase the chances of detecting significance in the relationship.. The Bahamian 18 and 19 year olds in th is study demonstrated a high level of health empowerment as measured by Ryff’s SPWB. Researchers may wish to investigate health empowerment levels in other cu ltures in the same age group or among a young adolescent group. Researchers may also wish to investigate health empowerment using another instrument to compare th e levels of health empowerment. If low levels of health empowerment are identified, a longitudina l study can be undertaken involving an appropriate health empowerment interven tion, and a follow-up health empowerment evaluation.


64 Implications for Theory Researchers have documented the ro le of religiosity (Ball et al., 2003, Nonnemaker et al., 2003) and continuing educ ation (Hofferth & Reid, 2002) in the decision making process of adolescents. Usi ng data from previous research, a theory could be developed useful for indentifying the importance of religiosity and education in the health empowerment proces s and the psychological well -being of adolescents. This theory might be used to guide the developm ent of future programs and research in the area of adolescent decisionmaki ng and health empowerment. Shearer’s health empowerm ent theory may also be utilized to explore how a person’s experiences and the environment work together to determine the health care decisions made by adolescents. Other theories of empowerment may also be tested in this population. Implications for Practice Nurses are in a position to ensure ho listic management of pregnant adolescent females. Nurses are able to coordinate and collaborate with other healthcare workers and professionals to ensure that the needs of pregnant adolescents are being met. At the school health level, nurses can communicate wi th the educators. At the community health level, nurses can collaborate with civic and religious leaders to ensure that programs do not isolate or ostracize pregnant adolescents. Nurses can encourage pregnant adolescen t to adhere to antepartum management and clinic appointments as; adherence will fost er early detection and proper management of problems and improve prenatal outcomes in this population of clients. Nurses can also


65 ensure that the care given to pregnant adolescents is sensit ive and fosters confidence in the adolescents’ capabilities. Study Limitations The statistically significant relationships which emerged from this study must be examined while considering the limitations. The sample size for adolescents with multiple births was small and significant findings may not have been detected. The information obtained from the study was based on a self-report survey that could be linked to potential biases towa rd reporting more socially desirable outcomes. The study was a cross-sectional design using a conve nience sample. The study was limited to 18 and 19 year olds, so the findings cannot necessa rily be generalized to adolescents of other ages. The sample was drawn from a conveni ence sample of Bahamian adolescents who were attending antepartum clinic; the resu lts may not be generalized to pregnant adolescents of other populations The empowerment levels may not necessarily reflect the levels of defaulters or thos e with no antepartum care. Th e design of the study was crosssectional so the results from the analysis of the data cannot be said to causal, but the findings and patterns are cons istent with previous findi ngs related to repeated pregnancies. Conclusions Based on the findings of this study, the number of pregnancies was negatively correlated with all dimensions of psychologica l well-being, religiosity and overall health empowerment. The correlations were not st atistically significant in environmental mastery, autonomy, purpose in life, relations with others and reli giosity. The correlation was statistically significant with personal gr owth. These adolescents are concerned about


66 their personal growth in their current situ ation Number of pregnancies was negatively correlated and statistically si gnificant with current enrollment in school. The adolescents who were currently enrolled in school were less likely to have repeated pregnancies. This finding suggests a need for more emphasis on tertiary or technical education after high school. Pregnancy outcome and delivery type we re positively correlate d and statistically significant with number of pregnancies. Th e likelihood of repeat ed pregnancies in adolescence increases when there are adverse ou tcomes in the first pregnancy such as an abortion, miscarriage, pre-term birth or if the delivery was by cesarean section. Education and religiosity had a signifi cant effect on overall health empowerment levels of the 18 and 19 year old pregnant a dolescents in Nassau and Grand Bahama in The Bahamas. Here again the importance of educational programs for adolescents after high school is highlighted. The im portance and relevance of re ligious influence in the life of adolescence is highlighted. These findings indicate th at the pregnant adolescents in this study with high levels of religiosity and those who were still enrolled in form al education programs showed higher levels of health empowerment. However these findings are not related to the number of pregnancies. Further studies should be conducted to va lidate these findings with a larger group of adolescents with multiple births. Having a larger sample may also establish direction and significance to the negative correlati on between the number of pregnancies and health empowerment levels.


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75 Singh, S. & Darroch, J. (2003). Adolescent pregna ncy and childbearing: levels and trends in developed countries. Family Planning Perspectives, 32 : 14-23. Ssewamala, F., Ismayilova, L. McKay, M., Sp erber, E., Bannon, W. & Alicea, S. (2010). Gender and the effects of an economic empowerment program on attitudes towards sexual risk-taking among aids-o rphaned adolescent youth in Uganda. Journal of Adolescent Health, 46: 372-378. doi: 10.1016/j.jadohealth.2009.08.010 Stephens, S. (2006). Faith-based social work in reducing adolescent pregnancy. Social Work, 51 (2): 190 191. Taylor, J. (2009). Midlife imp acts of adolescent parenthood. Journal of Family Issues, 30 : 484 -510. doi: 10.1177/0192513X08329601. The Children’s Aid Society (1984). Carrera Adolescent Pregnancy Prevention Program. http://stopteenpregnancy.childre nsaidsociety.org/our-program United Nations (2000). Resolution by the General Assembly 55/2. United Nations Millennium Declarations. New York: UN. http://www.un.org/miienium/declaration/ares552e.htm United Nations Millennium Project, (2005). Taking action: Achieving gender equality and empowering women New York: Task force on education and gender equality. UN Millennium Project. United Nations Population Fund (UNFPA) (2003). State of the world population, 2003. Making 1 billion count: Investing in adolescents’ health rights. www. unfpa.org / swp / 2003 / swpmain htm United Nations Population Fund (UNFPA) (2007). State of world popula tion: Unleashing the potential of urban growth New York: United Nations. United States Department of Health and Human Services (USDHHS). (2009). National Vital Statistics Reports: Bi rths: Final Data for 2006, 57(7). Cdc.gov/nchs/data/nvsr57_10htm United States Department of Health and Human Services (USDHHS). (2000). Healthy People 2010: Understanding & Improving Health 2nd ed. Washington DC: US Government Printing Office. Ward, D. & Mullender, A. (1991). Empowerment and oppression: an indissoluble pairing for contemporary social work. Critical Social Policy, 11 : 21-30. Watt, L. (2001). Pregnancy prevention in primary care for adolescent males. Journal of Pediatric Health Care, 15 : 223–228.


76 Weinert, C. (1987). A soci al support measure: PRQ85. Nursing Research, 36 : 273-277. Wilson, H. (1993). Introducing research in nursing (2nd ed.). Redwood City, CA: Addison-Wesley Nursing Wilson, N., Minkler, M., Dasho, S., Wallerstei n, N. & Martin, A. (2008). Getting a social action: The youth empowerment strategies (YES!) project. Health Promotion Practice, 9 (4), 395-403. doi: 10.1177/1524839906289072 World Health Organization (1986). Young peopl e’s health – a challenge for society. Report of a WHO Study Group on Young People and “Health for All by the Year 2000”. http://whqlibdoc. who.int/trs/WHO_TRS_731.pdf World Health Organization (2000). Global programme on evidence for health policy (GPE) World Health Organization (2006). Pregnant adolescents: Delivering on global promises of hope http://www.int/child-adolesce nt-health/publicati ons/publist.htm World Health Organization (2008). Making pregnancy safer: Notes, 1 :(1). WHO: Geneva World Health Organization (2010). Child and Adolescent Health and Development: Highlights and progress report 2009. WHO Press: Geneva who.int/entity/child_adoles cent_health/…/en/index.html


T a n p T d P a A g f r m a c m T i n Wha t h e Millenniu m n d specific d e rovide concr e h ey include g i sease, inad e a rtnership fo dopted by w o lobal and loc a r amework fo r m aking sure t h c hieved, wor m ore people w h e eight MD G n dicators t are the M m Developm e e velopment g e te, numeric a g oals and tar g e quate shelte r Developme o rld leaders i a l, tailored b y r the entire i n h at human d ld poverty w i w ill have the o G s break do w Goal 1 Goal 2 Goal 3 : Goal 4 : Goal 5: Goal 6: Goal 7: Mil l M illenniu m e nt Goals (M D g oals the wo r a l benchmar k g ets on inco m r, gender in e nt. n the year 2 0 y each count n ternational c evelopment r i ll be cut by h o pportunity t w n into 21 q u 1 : Eradicate 2 : Achieve u : Promote g : Reduce ch Improve m Combat HI V Ensure en v 77 Appe n l ennium De v m Develop m D Gs) are the r ld has ever a k s for tacklin g m e poverty, h e quality, envi 0 00 and set t ry to suit sp e c ommunity t o r eaches ever y h alf, tens of m t o benefit fro u antifiable t a extreme p o niversal pri ender equa ild mortalit y m aternal he a V /AIDS, m a v ironmental n dix A v elopment G o m ent Goal s most broadl y a greed upon. g extreme p o h unger, mat e ronmental d e t o be achiev e e cific develo p o work toget h y one, every w m illions of liv m the global argets that a o verty and h mary educ a lity and em y a lth a laria and o t sustainabi l o als s ? y supported, These eight o verty in its m e rnal and chi l e gradation a n e d by 2015, t p ment needs. h er towards a w here. If the s v es will be sa v economy. are measure d h unger a tion power wo m t her diseas e l ity comprehens i time-bound m any dimens l d mortality, n d the Globa l t he MDGs ar e They provid a common e n s e goals are v ed, and billi d by 60 m en e s i ve goals ions. l e both e a n d – ons


I m A p o A e x fi v 2 A m c o t h c o o v M p o r e T w fl o e n r a A f o o m plement a t the midpoi n o verty by ha frica and So u x panding, wi t v e in sub-Sa h 0 00. One poi longside the m ore action i s o nsidered to h an 500,000 o mplications v er a dollar a M exico, Brazil o verty’ – soc e ach the MD G h e global ec o w orld’s most v o ws and don o n sure social s a ther than re t the interna t o r Developm e r ganizations 1. • Rais e adopt 2. • Pro v what i and pl resea r 3. • Pro v achie v mana g 4. • Assi s Goal 8: a tion of t h n t in MDG ti m l f is within r e u th Asia, pri m t h widesprea h aran Africa. nt six billion successes a r s taken urge n be underwei g prospective m from pregna a day is unlik e Romania, M ially-exclude G s. o nomic crisis v ulnerable p e o r support. A s tability, sec u voke their c o t ional level, U e nt. At the n a to: e awareness and adapt M v ide leadershi s needed to a ans. For this r ch, develops v ide hands-o n v e the MDGs, g ement. s t countries t Develop a G h e MDGs m eline, great e ach for the w m ary school e d increases i In 16 out of people have r e an array o f n tly: about o n g ht and are a m others in d e ncy; in SubS e ly to be cut M acedonia, a n d groups tha also threate n e ople could f a A t a time wh e u rity and pro o mmitment t o U NDP works w a tional level, of MDGs an d DGs. p and UN co o a chieve the M purpose, U N planning an d n support to c in areas suc t o report on t G lobal Part n progress ha s w orld as a w h e nrolment is a n insecticide 20 countrie s gained acce s f goals and t a n e quarter of a t risk of lon g e veloping co u S aharan Afri c in half. Addi t n d Indonesia t will need s p n s to destabi l a ll victim to c e n investing i sperity, don o o reaching th w ith the UN f UNDP works d advocate f o o rdination to M DGs, to con N DP organize s d informatio n c ountries to s h as procure t heir progres s n ership for D s already be e h ole. With th e a t least 90 p e treated bed s use has at s s to safe dri a rgets that a all children i g -term effect u ntries die a n c a, the prop o t ionally, in m inequality h p ecific attent i l ize progress ontraction o f n developm e o r governme n h e MDGs. f amily to ad v in close coll a o r countries a develop cap ceptualize p o s consultatio n n manageme s cale up impl ment, huma n s D evelopme n e n made. Re d e exception o e rcent. Mala r net use am o least tripled nking water s re likely to b e n developin g s of underno n nually in ch i o rtion of peo p m iddle incom e as also led t o ion if their c o as a better f trade, remi t e nt is more v i n ts are calle d v ance the Gl o a boration wi t a nd sub-nati o acity in coun o licies and to n s and traini n nt tools. ementation o n resources a n t d ucing absol u o f Sub-Sahar a r ia preventio n o ng children u since aroun d since 1990. e missed unl e g countries a r urishment; m i ldbirth or of p le living on j e countries li k o ‘pockets of o untries are t future for th e t tances, capi t i tal than eve r d upon to ren o bal Partners h t h UN o nal regions t tries to asse s design strat n g, conducts o f initiatives t a nd financial 78 u te a n n is u nder d e ss r e m ore ust k e t o e t al r to ew h ip t o s s egies t o


79 Appendix B Participant Questionnaire Questionnaire Thank you for consenting to participate in this important study. A. What is your date of birth ____Date ____Month____Year. B. How old are you? ______ Years. C. Where were you born? (Island, Country) ________________ ______________ ____________ D. What is your marital status? Single Married Partnered Separated Divorced Widow Other (specify) _____________ ___________ E. What is the highest education you have earned? Less than high school Some high school High school graduate Some college College graduate Master’s degree F. How many Bahamas Junior Certificates (BJCs) did you obtain? Part 1. Instructions: Please complete this section that gives us some information about you


80 G. How many General Certificate of Education (GCEs) or Bahamas General Certificate of Secondary Education (BGCSEs) did you obtain? H. Are you currently enrolled in an educational programme? YES NO I. Are you employed? YES NO If yes, state occupation _____________ __________ J. Who do you turn to for help and advice? Mother Siblings Other Family members Friends Teacher Healthcare provider Church Significant other Other (specify) ___________ ____________ K. What is your religious affiliation? (Specify) ___________ ___________ L. Do you have any previous history of depression? yes No M. How many times have you been pregnant? (Include this one) ___________ N. What was the outcome of each pregnancy? (Tick all that are appropriate and state which year it occured) Abortions state year(s): __________________ _____________


81 Miscarriages state year(s): ________________ ______________ Preterm (before 8 months) state year(s): __________________ _____________ Term (9 months) state year(s): __________________ _____________ O. What type of delivery did you have? (State the amount in each box) Vaginal C Section P. What method of birth control (family planning) have you used in the past? (Tick all that are appropriate) None Injections Condoms Oral (pill) Other (Specify) ________________ _____________


82 Statements Strongly Disagree Disagree Somewhat Disagree Slightly Agree Slightly Agree Somewhat Strongly Agree 1 I am not afraid to voice my opinions, even when they are in opposition to the opinions of most people. 1 2 3 4 5 6 2 In general, I feel I am in charge of the situation in which I live. 1 2 3 4 5 6 3 I am not interested in activities that will expand my horizons. 1 2 3 4 5 6 4 Most people see me as loving and affectionate 1 2 3 4 5 6 5 I live life one day at a time and don't really think about the future. 1 2 3 4 5 6 6 When I look at the story of my life, I am pleased with how things have turned out. 1 2 3 4 5 6 7 My decisions are not usually influenced by what everyone else is doing. 1 2 3 4 5 6 8 The demands of everyday life often get me down. 1 2 3 4 5 6 9 I don't want to try new ways of doing things--my life is fine the way it is. 1 2 3 4 5 6 10 Maintaining close relationships has been difficult and frustrating for me 1 2 3 4 5 6 11 I tend to focus on the present, because the future nearly always brings me problems. 1 2 3 4 5 6 12 In general, I feel confident and positive about myself. 1 2 3 4 5 6 13 I tend to worry about what other people think of me 1 2 3 4 5 6 PART 2. The following set of questions deals with how you feel about yourself and your life. Circle the number that best describes your present agreement or disagreement with each statement. Please remember that there are no right or wrong answers. Ryff’s Scales of Psychological Wellbeing (1989)


83 Statement Strongly Disagree Disagree Somewhat Disagree Slightly Agree Slightly Agree Somewhat Strongly Agree 14 I do not fit very well with the people and the community around me. 1 2 3 4 5 6 15 I think it is important to have new experiences that challenge how you think about yourself and the world. 1 2 3 4 5 6 16 I often feel lonely because I have few close friends with whom to share my concerns. 1 2 3 4 5 6 17 My daily activities often seem trivial and unimportant to me. 1 2 3 4 5 6 18 I feel like many of the people I know have gotten more out of life than I have. 1 2 3 4 5 6 19 Being happy with myself is more important to me than having others approve of me 1 2 3 4 5 6 20 I am quite good at managing the many responsibilities of my daily life. 1 2 3 4 5 6 21 When I think about it, I haven't really improved much as a person over the years. 1 2 3 4 5 6 22 I enjoy personal and mutual conversations with family members or friends. 1 2 3 4 5 6 23 I don't have a good sense of what it is I'm trying to accomplish in life. 1 2 3 4 5 6 24 I like most aspects of my personality 1 2 3 4 5 6 25 b e influenced by people with strong opinions. 1 2 3 4 5 6 26 I often feel overwhelmed by my responsibilities 1 2 3 4 5 6 27 I have the sense that I have developed a lot as a person over time. 1 2 3 4 5 6 28 I don't have many people who to listen when I need to talk. 1 2 3 4 5 6

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84 Statements Strongly Disagree Disagree Somewhat Disagree Slightly Agree Slightly Agree Somewhat Strongly Agree 29 I used to set goals for myself, but that now seems like a waste of time. 1 2 3 4 5 6 30 I made some mistakes in the past, but I feel that all in all everything has worked out for the best. 1 2 3 4 5 6 31 I have confidence in my opinions, even if they are contrary to the general consensus. 1 2 3 4 5 6 32 I generally do a good job of taking care of my personal finances and affairs. 1 2 3 4 5 6 33 I do not enjoy being in new situations that require me to change my old familiar ways of doing things 1 2 3 4 5 6 34 It seems to me that most other people have more friends than I do 1 2 3 4 5 6 35 I enjoy making plans for the future and working to make them a reality. 1 2 3 4 5 6 36 In many ways, I feel disappointed about my achievements in life. 1 2 3 4 5 6 37 It's difficult for me to voice my own opinions on controversial matters. 1 2 3 4 5 6 38 I am good at juggling my time so that I can fit everything in that needs to get done. 1 2 3 4 5 6 39 For me, life has been a continuous process of learning, changing, and growth 1 2 3 4 5 6 40 People would describe me as a giving person, willing to share my time with others. 1 2 3 4 5 6 41 I am an active person in carrying out the plans I set for myself. 1 2 3 4 5 6

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85 Statements Strongly Disagree Disagree Somewhat Disagree Slightly Agree Slightly Agree Somewhat Strongly Agree 42 My attitude about myself is probably not as positive as most people feel about themselves. 1 2 3 4 5 6 43 I often change my mind about decisions if my friends or family disagree. 1 2 3 4 5 6 44 I have difficulty arranging my life in a way that is satisfying to me. 1 2 3 4 5 6 45 I gave up trying to make big improvements or changes in my life a long time ago 1 2 3 4 5 6 46 I have not experienced many warm and trusting relationships with others. 1 2 3 4 5 6 47 Some people wander aimlessly through life, but I am not one of them. 1 2 3 4 5 6 48 The past had its ups and downs, but in general, I wouldn't want to change it. 1 2 3 4 5 6 49 I judge myself by what I think is important, not by the values of what others think is important. 1 2 3 4 5 6 50 I have been able to build a home and a lifestyle for myself that is much to my liking. 1 2 3 4 5 6 51 There is truth to the saying you can't teach an old dog new tricks. 1 2 3 4 5 6 52 I know that I can trust my friends, and they know they can trust me. 1 2 3 4 5 6 53 m es feel as if I've done i s to do in life. 1 2 3 4 5 6 54 When I compare myself to friends and acquaintances, it makes me feel good about who I am. 1 2 3 4 5 6

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86 Statements Strongly Disagree Disagree Agree Strongly Agree 1 I pray daily 1 2 3 4 2 I look to my faith as providing meaning and purpose in my life 1 2 3 4 3 I consider myself active in my faith or church 1 2 3 4 4 I enjoy being around others who share my faith 1 2 3 4 5 My faith impacts many of my decisions 1 2 3 4 PART 3. The following set of questions deals with your religious faith. Indicate your level of agreement or disagreement to each statement. There are no right or wrong answers. Santa Clara Strength of Religious Faith Questionnaire (1997)

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87 Appendix C Research Flyer

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88 Appendix D Consent Form RESEARCH SUBJECT INFORMATION AND CONSENT FORM EMPOWERMENT IN ADOLESCENT PREGNANCY You are being asked to volunteer to participate in a research study about feelings and needs of adolescent mothers. Before you agree to participate in this research study, please read the following and ask as many questions as you need to understand the study and what we are asking you to do. The purpose of the study is to collect information to determine the level of empowerment in young mothers. A total of 75 100 adolescent mothers are expected to participate in this initial study. You will be invited to answer questions on a questionnaire that should take 20 – 30 minutes. The questions ask you about your relationship with self, others and your environment, as well as how you feel about your life. If you feel uncomfortable answering any of the questions, you can choose not to answer them. No direct benefits can be promised to you for taking part in this study; however, it is hoped that the information obtained will be used to give direction to future studies as well as programs to assist adolescents in the future. Each questionnaire will be allocated a code number that will be used to identify all your information. All information will be maintained in locked cabinets. Only the study researchers will have access to this information. When we report the results of this study, we will be reporting group results. Your records and results will not be identified as belonging to you without your expressed permission. Your questionnaire may be reviewed for audit purposes by authorized University of Miami employees who will be bound by the same provisions of confidentiality as the researcher. Your responses will be kept confidential to the extent permitted by law. The only exception is if information is revealed concerning harm to yourself or others, child abuse and/or neglect, or other forms of abuse that are required by law to be reported to the appropriate authorities Your participation in this study is voluntary. You may decide not to participate in this study. If you do participate, you may freely withdraw from the study at any time. Your

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89 decision will not result in any penalty or loss of benefits to which you are entitled. The care you receive at Antenatal Clinic will not be affected. PI CONTACT INFORMATION: Shirley Curtis, University of Miami 305 284 4099 If you have any questions relating to your rights as a research subject, please contact the University of Miami’s HUMAN SUBJECTS RESEARCH OFFICE (HRSO), at 305 243 3195. I have read (or have had read to me) the information in this consent form and associated information. I have been given the opportunity to ask questions about this study. I freely agree to participate. By signing this consent form, I have not waived any of the legal rights which I otherwise would have as a subject in a research study. CONSENT SIGNATURE: Name of Participant Signature of Participant Date (Typed or printed) Name of Person Obtaining Signature of Person Obtaining Informed Consent InformedConsent Date

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90 Appendix E Sample of the e Business Card

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91 Appendix F Application to the Ethics Committee (Bahamas) MINISTRY OF HEALTH NASSAU BAHAMAS ETHICS COMMITTEE APPLICATION TO CONDUCT RESEARCH EC ID #________ SECTION A 1. Name: Shirley E. Curtis Address____ 15 00 Venera Ave ____________________ City /State____ Coral Gables Florida ______ Phone: (day time)________ 1-305-812-6162 (C) 1-305-284-4099 (W) ___________ Phone: (evening) _________1-305-456-8328 ___________________________ Fax ________1-305-284-4221 ________________________________________ E mail Address___ s.curtis1@umiami.edu ______________________________ Title___ MS _______________________________________________________ 2. Project Review: X New Project (ID No. will be assigned) ____________________________ Revised Project (enter EC ID #) ____________________________ Renewal (enter EC ID #) ____________________________ 3. Data Collection Dates: From ___ Nov_/_/ _2010____ to __FEB_/_/__2011 __

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92 4. Project Period from____ November 2010____________ to ____June 2011 _____________ 5. Project Title ____ An Empowerment Theory Approach to Repeated Pregnancies in Adolescents, in The Bahamas. 6. Description of Participants (Enter approx. no. of participants and categories that apply) Number__ 110 ________ Gender: Female X Male Prisoners Children (16yrs or younger) Patients in institutions X Pregnant Women College Students Other______________________________________ 7. Funding Source______________ NONE ____________________________________ 8. Where will this study be conducted __ In the antenatal clinics in Nassau, & Grand Bahama. Other islands will be used if nece ssary to acquire an adequate sample ___________________________________________________________________________ 9. How far is the nearest emergency facility from the research site__ N/A ________________ 10. Does this project utilize an investigational drug, device or procedure ? Yes No X (If yes attach copy of protocols for administration of drug type or dosage). 11. Does this project involve the use of materials of human origin (e.g. human blood or tissue?) Yes No X SECTION B: Please provide information as requested under the following headings, additional sheets of paper may be used to respond fully. 1. Project Description Provide a brief description of the research project, objectives of your research, hypothesis study population, methodology and, data collection procedures, data analysis, any other procedures or special conditions or locations.

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93 2. Participant Recruitment Describe in detail the sources of potential participants, how will they be selected and recruited (attach copies of letters or announcements), how and where will you contact them. Describe age, ethnic background, gender, institutional affiliation and general mental and physical health. What inducement is offered if any? __ $5.00 phone card or gift certificate Could the Participants incur additional financial costs as a result of their participation in this study? Yes No X If a cooperating institution (school, hospital prison etc.) is involved, prior written permission must be obtained. (Submit approval letter). IRB at the University of Miami would like to see approval (at least in principle) from the parti cipating country or institution before final approval is given 3. Confidentiality of Data Describe procedures that will be used to safeguard identifiable records and insure confidentiality and anonymity of participants and related information. No names will be placed on the questionnaires only a number that will be used for data coding. Names will only be requested for the consent forms. Consent forms and questionnaires will not be kept together. Once collected they will be placed in separate envelopes. Upon completion, the questionnaires and consent forms will be kept by the researcher in a secured satchel and transported back to the United States in carry-on luggage. Once in the United States the questionnaires will be secured in a locked filing cabinet in the researchers locked

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94 office at the School of Nursing at the University of Miami. The data will be entered in a password protected computer and backed up on a password protected UBS drive. No names will used in the analysis or th e discussion of the findings. 4. Risks and Benefits Describe any actual or anticipated risks (psychological, social, legal or economic risks, side effects, risk of placebo, normal treatment etc) whether immediate or long term to the participants. Indicate any precautions that will be taken to minimize these risks. Describe any benefits to the participant and to society from the knowledge gained from this study. There are no actual or anticipated psychological, social, legal or economic risks to the participants from participating in this study. The benefits to the participants are not direct, although the questions might encourage them to think about the meaning and direction in their lives. 5. Informed Consent Informed consent can be either in written or oral format. If oral consent is planned a copy of the statement must be submitted. The consent should include: (include copy of consent form) Identification of researcher(s) Explanation of the nature and purpose of the study and research method Duration of research participation Description of how confidentiality/anonymity will be maintained The right to refuse to answer any specific question that may be asked Participants’ right to withdraw anytime they wish without penalty The voluntary nature of the study

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95 Information about potential or anticipated risks or lack thereof Contact person regarding questions about rights or injuries Consent form attached 6. Debriefing Statement This is required if deception was used to obtain results from the participants. State why deception justified and how participants will be debriefed about your project. Not Applicable SECTION C 1. The researcher /investigator is required to notify the EC if there are any substantive changes to research protocol, any unexpected adverse events experienced by participants during the research.. NOTE When the research project is nearing completion, the researcher/investigator must submit a Notice of Project Ending to the NEC. If the research project lasts longer than one year, the researcher/investigator must submit a Request for Continuation at the end of each year. Failure to do so may result in disciplinary actions. Copies of informed consent forms and data must be kept for at least three years. Noted 2. Compliance Agreement I agree to follow the procedures outline in the summary descriptions and any attachments to ensure the rights and welfare of human participants in my projects. I

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96 understand that the study will not commence until h have received approval from the EC. I have complied with any required modification in connection with that approval. Any additions or changes in the procedures involving human participants or any problems with the rights or welfare of the human participants must promptly be reported to the EC. I also understand that if the project continues for more than one year from the approval date, it must be resubmitted as a renewal application. I acknowledge that the information contained in this application is accurate and I accept responsibility for the conduct of this research, supervision of human participants and the maintenance of informed consent documents as required by the EC. Shirley Curtis______________ ___s.curtis1@umiami.edu _1st October 2010 Signature of Principal Investigator E mail address Date ___________________________ ___________________________ _________ Signature of Co Investigators (s) E – mail address Date SECTION D: OFFICIAL USE ONLY Date received: ________________________ EC ID#____________________________ EC Action: Approved Disapproved Modification required ____________________________ ______________________ Chief Medical Officer Date _____________________________ _______________________ Chairperson EC Date

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97 _____________________________ _______________________ Secretary EC Date Before submitting your Application please review the check list on the following page