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American Journal of Health Studies: 25(4) 2010
PREVENTING TEEN PREGNANCY BY AVOIDING RISK EXPOSURE
Josie A. Weiss, PhD, PNP-BC, FN-BC, FAANP
Abstract: The purpose of this research was to generate a substantive theory that explains how
rural adolescent females think about teen pregnancy and how this influences their sexual choices.
Grounded theory methods were used to analyze data collected from 20 adolescent females. The
participants lived in risk-promoting environments. They saw beyond the immediate appeal of
risky behaviors and avoided risky situations because they appreciated positive input from others,
desired future success, heard encouragement from “point persons”, owned the consequences of
choices, and believed in themselves. The theory created promotes adolescent health by emphasizing
future success as an alternative to teen pregnancy.
BACKGROUND
The US has the highest teen pregnancy rate of
all industrialized nations with one out of three adolescent females becoming pregnant during her teen
years (The National Campaign, 2008). The rates of
pregnancies, births and abortions in the U.S. are
increasing (Kost, Henshaw, & Carlin, 2010) and
these rates are higher in rural communities, particularly among younger teens in the Southeastern U.S.
Socioeconomic and educational levels are lower in
rural communities and rates of poverty are higher,
with teen pregnancy a contributing factor. One way
to decrease persistent child poverty is to prevent teen
pregnancy (Hoffman, 2006). Health educators have
unique opportunities to promote the well-being of
adolescents through the development of creative
teen pregnancy prevention strategies. Gaining insight from teens that live in environments with unusually high teen pregnancy rates could be helpful in
this endeavor. The purpose of this grounded theory
research was to generate a substantive theory to explain how adolescent females living in a rural community with a high teen pregnancy rate think about
teen pregnancy and pregnancy prevention and how
these thoughts influence their choices about sexual
activity.
SIGNIFICANCE
Teen pregnancy often results in hardships for
teen parents, their children, their communities, and
society. Early pregnancy increases the risks of complications for both teens and their infants, often leading
to increased morbidity and mortality and large financial expenditures (Gilbert, Jandial, Field, Bigelow, &
Danielsen, 2004). Children born to teen mothers
are more likely to be premature and under-weight,
increasing their risks for hyperactivity, blindness,
deafness, chronic respiratory problems, infant death,
and mental retardation (Terry-Humen, Manlove, &
Moore, 2005). Rates of abuse and neglect are higher
for children of teen parents and these children are
50% more likely to repeat a grade in school, perform
lower on standardized tests, and they are less likely to
complete high school (Terry-Humen, et al., 2005).
Sons of teen mothers are 13% more likely to go to
prison and daughters are more likely to become teen
parents themselves (Hoffman, 2006).
In teens ages 15 to 19, Florida ranks 12th in
the nation for the highest rate of pregnancies, 21st
for the highest rate of births, and 9th for the highest
rate of abortions (Kost, Henshaw, & Carlin, 2010).
In 2007, the rural south Florida community where
this research was conducted had a teen birth rate that
was double that of the state and has had one of the
highest birth rates of younger teens (13 to 14) for
the last several years (Florida Department of Health,
2009). While many community leaders and educators in the Southeastern US are concerned about the
high rates of teen pregnancy, they also tend to prefer
abstinence-only educational perspectives, especially
in rural communities. As a result, discussing sexual
activity freely within a public school environment,
in the context of instruction or data collection for
research is very difficult. In a prior qualitative study,
conducted in this rural community with incarcerated teens, the participants normalized risky behaviors (believed risky behaviors were normal) and, as a
result, made high risk sexual choices (Weiss Jampol,
Lievano, Smith, & Wurster, 2008). Following the
research with incarcerated females, and recognizing
the high rates of teen pregnancy in younger rural
teens, this study was designed to better understand
the choices of younger rural teens.
Josie A. Weiss, PhD, PNP & FN-BC, FAANP, is an Associate Professor, Clinical Coordinator FNP Program
Christine E. Lynn College of Nursing, Treasure Coast Campus, 500 NW California Avenue, Port St. Lucie,
FL 34986, USA, Phone: 772-873-3374, Fax: 772-873-3388,Email: jweiss21@fau.edu. Please address all
correspondence to: Josie A. Weiss.
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Weiss
METHOD
DESIGN
Grounded theory concepts, originally developed
by Glaser (1998) and Strauss, were derived from
symbolic interactionism (Blumer, 1969). According
to this perspective, persons who share similar circumstances are believed to share a common (social
psychological) problem that is not readily apparent.
In response to this problem these persons develop a
(social psychological) process that is also not apparent. Through data analysis, the researcher seeks to
uncover and articulate the problem the participants
share and the processes they use to deal with the
problem.
RESEARCH QUESTIONS.
1) What is the basic social psychological problem faced by adolescent females living in a
rural community with a high teen pregnancy
rate?
2) What basic social psychological process do
these females use to deal with this problem?
SETTING AND SAMPLE
This research took place in a rural South Florida
high school, where only ninth grade students attend.
Following approval by the Institutional Review
Board of the sponsoring university and local school
officials, adolescent females were invited to participate. Criteria for participation were: female gender,
attendance at the ninth-grade campus, ability to
speak English, and a signed parental/guardian consent agreeing to the female’s participation. School
personnel, particularly the school nurse, assisted by
advertising the research and by scheduling the interviews. A convenience sample was used for this
research with snowball sampling assistance by some
of the participants. Because the researchers initially
had difficulty recruiting participants, incentives
were provided to increase interest in participation.
Adolescents who were interested in participating
were given a packet which contained information
about the research and two copies of the parental
consent. Each female who returned a signed paren-
tal consent form (with or without parental/guardian
agreement for participation) was given a $15 WalMart gift card and her name was placed in a drawing
for an iPod. Even though a convenience/snowball
sample was used, the demographic characteristics
of the participants (shown in Table 1) are similar to
the demographics of the rural community where this
research was conducted (U.S. Census Bureau).
DATA COLLECTION AND ANALYSIS
Before each interview the research plan and
purpose were explained again and each participant
was asked to sign an adolescent assent form. The
researcher interviewed each participant separately in
a private room at the school, during school hours.
With parental consents and adolescent assents, each
interview was audio-recorded. The recorded interviews were transcribed by a transcriptionist and
proofed by the PI.
The semi-structured interviews were guided by
probing questions (see Table 2). Data analysis began
after the first interview. The grounded theory methods of data collection, line-by-line theoretical coding, constant comparison and memoing were conducted concurrently. As categories emerged during
coding, the findings provided guidance for further
data collection. As a result the probing questions
were refined to capture emerging relevant data. The
findings were compared and contrasted within each
interview and among all interviews. This process of
data collection and analysis continued until saturation occurred, which required interviews with 20
adolescent females.
Data were coded on three levels. Initially the interviews were coded line by line and then these codes
were sorted into categories. During this second level
of coding, the core category of “seeing beyond the
immediate,” became apparent. In the third level of
coding, the Theory of Avoiding Risk Exposure by
Seeing Beyond the Immediate was fully developed.
Five graduate students, one doctoral student and
four master’s students, assisted with the initial data
analysis. Prior to the initiation of the student participation, the PI instructed these assistants in grounded
theory methods and data analysis techniques. The
Table 1. Participant Demographics
All participants were females attending the ninth grade in a rural community
Age 14
African American
2
Caucasian
8
Caucasian/Hispanic
1
Hispanic
3
Native American
1
Age 15
Age 16
Total
Ever Pregnant
1
3
1
9
0
1
0
6
0
1
0
1
2
1
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American Journal of Health Studies: 25(4) 2010
Table 2 Probing Questions
1. How do you think about teen pregnancy?
2. What do you think it would be like to have a baby as a teen?
3. How do you feel about teens being sexually active?
4. Is there a right or wrong to teens being sexually active? Please explain…
5. Who influences teens the most about being sexually active and about teen pregnancy? How?
6. How do friends (girlfriends and boyfriends) influence teens’ choices about being sexually active?
7. How do friends (girlfriends and boyfriends) influence teens’ choices about pregnancy prevention?
8. How do family members influence teens’ choices about being sexually active? About teen pregnancy?
9. What kind of influences do teachers or other school personnel have on the choices teens make?
10. How do media (TV, radio, videos, magazines, etc.) affect teen choices about sexual issues? About teen
pregnancy?
group also reviewed and discussed pertinent articles
describing qualitative research techniques and findings. Due to the large group of research assistants,
traditional data analysis measures were used, rather
than computerized software. Members of the research team coded the data independently and then
met together regularly to compare codings, and propose categories. The team worked together until a
core variable was identified.
Data collection and analysis were concluded
when saturation occurred and the theory fully developed. Trustworthiness, confirmability, credibility and
transferability were addressed to assure the rigor of
this research (Macnee & McCabe, 2008). Adherence
to the established research plan and consistently using the probing questions assures trustworthiness.
Comparisons of data analysis until consensus was
reached by the members of the research team assure
confirmability. Corroboration of the research findings through discussions with other adolescents who
were not participants assures transferability. Refining
and clarifying the findings based on discussions with
other colleagues and researchers with expertise in
qualitative methods and/or adolescent health assure
credibility.
lent or positive attitudes toward pregnancy, normalized risky behaviors by peers, examples of others,
provocative media, living in a rural community, peer
and/or partner pressure, and substance use. One participant described her risk-promoting environment
this way, “When I got into 6th grade, people were
having sex in the bathrooms and we were hearing
about it on TV.” Another discussed the influences
of peer pressure leading to ambivalence toward teen
pregnancy: “That is a form of peer pressure, I see my
cousin having fun with her baby and I would be like,
‘Oh, that’s cute. I can’t wait to have children’.”
Some of the participants’ peers normalized risky
behaviors. Seeing their examples and the examples
of others, including parents, was influential, as one
participant explained,
Results
I think that parents are a big influence. If
they see their parents going out and doing
anything they can, to have sex and have fun,
saying it’s fun, then they are going to be,
“Well, if my parents can do it then why not I
do it?” . . .It seems like their parents are having no consequences, so they think that they
won’t have any consequences. I think parents
are probably the biggest influence on teen
pregnancy.
PROBLEM:
LIVING
IN
RISK-PROMOTING
ENVIRONMENTS
These participants lived in environments with
many risk promoting influences, including ambiva-
PROCESS: SEEING BEYOND THE IMMEDIATE
The process these participants used to deal with
the problem of living in risk promoting environments was labeled “seeing beyond the immediate.”
The participants in this study saw beyond the immediate appeal of the risky behaviors promoted in
their environments because they appreciated positive input from others; desired future success; heard
“point persons” (individuals who “pointed” them in
positive directions); “owned” the consequences of
their choices; and believed in themselves. As a result,
they avoided exposure to risky situations.
Positive input from others. The participants
appreciated positive input from others. Positive input came from family members, other adults, and
While a broad variety of perspectives toward
teen pregnancy were sought, the females who chose
to participate in this research primarily discussed the
importance of avoiding teen pregnancy. In response
to the first research question, the problem shared by
these participants was living in risk promoting environments. In response to the second question, the
process these participants used to deal with the problem of their risk-promoting environments was seeing
beyond the immediate appeal of risky behaviors, and
avoiding risky situations (see Figure 1.)
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Weiss
Figure 1. Theory of Avoiding Risk Exposure by Seeing Beyond the Immediate
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American Journal of Health Studies: 25(4) 2010
peers, and often promoted safe sexual choices. One
participant explained, “The lady that comes here and
talks about sexual harassment from Martha’s House
has talked to us about some things and she’s good
help.”
Future success. The desire for future success
was powerful in the lives of these females. Most of
the participants believed education is key to future
success. One female explained: “I want a good job
and I want a good salary. I want to be smart and I
want to be able to say I went to college and tell my
kids that I went to college.” Most of the participants
saw teen pregnancy as a barrier to future success for
teens. One explained this well: “The people that get
pregnant early and have all these goals set for their
future life; they’re not going to be able to accomplish those goals that they want because they have
kids…”.
Point persons. Each participant described one
or more individuals who “pointed” her in positive directions. These point persons encouraged the participants to avoid risky situations and often promoted
future success. For most, this encourager was a family member. One participant explained this clearly:
My grandmother and my oldest brother are
the main ones who really encouraged me to
push through and to persevere about what
I would like to do. Well technically, my
brother’s like, I have no choice but to have an
education and to go to college.
Owning consequences. The females who
participated in this study were very aware of the
consequences of their choices. According to one
participant, “There are a lot of consequences if you
have sex.” These participants strongly believed they
would pay the consequences for violating family
rules, disappointing family members, making risky
choices, and especially for getting pregnant as a teen.
One participant recognized consequences through
the examples of her peers who became pregnant,“…
seeing that makes me know, I don’t need that in my
life until I’m older.”
The consequences of greatest concern to these
participants were the increased time and responsibilities required for child rearing, the likelihood of being
abandoned by the teen father following pregnancy
disclosure, and the loss of opportunities for further
education and success. One participant posed questions related to the consequences she feared if she
became pregnant:
Would the teachers look at me differently?
Would people look at me differently? Is my
dad still going to talk to me the way he used
to? Is my family going to hate me? Am I go-206-
ing to get through college? Am I going to do
something? Am I going to get out of this small
town? Am I going to live with my dad for the
rest of my life? It’s just all those consequences.
Am I going to be alone after this?
Believing in self. These participants believed
in themselves and their ability to make their own
choices. One participant explained this well: “I am
my own person; I’m not going to follow the crowd.
I am going to have a crowd follow me and make the
right choices.”
Many of the participants spoke of taking a
stand in response to risky opportunities they or their
friends encountered. One described her stand in
response to pressure from males: “I just tell them,
‘Hey, take me for who I am or hit the road.’ That’s
what I believe and, ‘If you don’t like me and if you
just want to date me to have sex with me, then you
can leave’.” While not being boastful, many spoke
of their own capabilities, and their willingness to be
different from their peers because of their beliefs.
Avoiding exposure to risky situations. These
participants were empowered to avoid exposure to
risky situations because they saw beyond the immediate appeal of risky choices. Avoidance was accomplished by staying busy with non-risk-promoting
activities such as school and after-school activities,
and other obligations. The teens also avoided exposure by being particular about peers and boyfriends
and by having friends with similar values. They valued their reputations, their virginity, and condom/
contraceptive use, and most expected a commitment
prior to sexual intercourse, and childbearing. One
participant summed up her convictions:
I have had people say, “Come over to my
house, this guy is coming here.” I’m like, “I’m
not doing that.” They’re like, “Why not?” I’m
like, “Because that’s just not me.” They’re like,
“What do you mean, it’s not you?” It’s like,
my goal for myself is to keep myself for that
one special person and I don’t want to go and
blow it while I’m a teenager.
DISCUSSION
The participants in this research provided unexpected information about teen pregnancy prevention. While adolescents in prior research and clinical
practice have spoken freely about the normalcy of
risky sexual behaviors placing them at risk for teen
pregnancy, these participants spoke more of the consequences. Initially the research team believed that
these females were simply young, inexperienced,
and/or had not been pressured or had opportunities
to be sexually active. However, as more participants
were interviewed and data analyzed, this clearly was
Weiss
not the case. These participants saw beyond the immediacy of risky temptations and avoided risk-promoting situations. The theory that emerged from the
data helps explain how some adolescents avoid risky
situations, while other adolescents do not.
The participants in this research lived in environments where risky behaviors were prevalent and
often encouraged. At the time of their interviews,
the attitudes of these participants about sexual issues
were well-established. Their attitudes were influenced
by positive input from others. Our participants could
not explain why they are receptive to positive input,
while some adolescents are not.
Each participant spoke of her desire for success
in the future, which usually included finishing high
school an …
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