Applied Nursing Research xxx (2014) xxx–xxx
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Original Article
Perceived social support, self esteem, and pregnancy status among Dominican adolescents Lynn M. Babington, PhD, Rn a,⁎, Linda Malone, DNP, CPNP b, Barbara R. Kelley, MPH, EdD. CPNP b a b
Fairfield University, Fairfield, CT, USA School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
a r t i c l e
i n f o
Article history: Received 12 November 2013 Revised 13 August 2014 Accepted 20 August 2014 Available online xxxx Keywords: Adolescent pregnancy Dominican Republic Self-esteem Social support
a b s t r a c t Adolescent pregnancy is a major health concern among Dominicans in the U.S. and in the Dominican Republic (DR). Twenty three percent of adolescents age 15–19 have experienced pregnancy and this trend is rising. Purpose: The purpose of this study was to explore and compare social support, self-esteem and pregnancy between Dominican adolescents in the DR with those who have immigrated to the U.S. Methods: This study used an exploratory, descriptive design including study samples from both the U.S. and DR. Findings showed that young women with stronger social support and higher self esteem experienced lower pregnancy rates in both the DR and U.S. samples. Results: Neither self esteem nor social support was found to be predictors of pregnancy. Conclusion: Important findings from this study will inform the development of interventions aimed at preventing pregnancy in adolescents. © 2014 Elsevier Inc. All rights reserved.
Adolescent pregnancy is a major health issue among teenage girls in the Dominican Republic (DR). Adolescent pregnancy is largely unplanned leaving these girls poor, with little education as they drop out of school and do not return. Once the teen gives birth, it is extremely uncommon for them to live with the father; they continue to live with and depend on their families for support. Twenty three percent of young women in the DR between the ages of 15 and 19 have had at least one pregnancy accounting for 15% of the total live births and this trend is rising (United Nations, 2011). The Dominican Republic ranks 33rd worldwide in the number of pregnancies aged 15–19 years. Pregnancy is also the leading cause of death for girls in this age group. In the DR, adolescent pregnancy is more common in lower income, rural areas and among young women who have had little schooling. Children born to teen mothers are at greater risk of poverty, less likely to stay in school and more likely to have health problems or engage in problem behaviors (Hoffman, 2006). The researchers' interest in Dominican adolescents evolved from working with Dominican families in Boston who recently have emigrated from the Dominican Republic and working with adolescents in the Dominican Republic. For the past 15 years the researchers have been involved in a volunteer nursing organization, Intercultural Nursing, Inc. (INI). INI sponsors trips twice a year to the Dominican Republic to provide primary health services in rural campos (i.e., villages) on the
⁎ Corresponding author at: 1073 North Benson Rd. Fairfield, CT 06824. Fax: + 1 203 254 4126. E-mail addresses: lbabington@fairfield.edu (L.M. Babington), [email protected] (L. Malone), [email protected] (B.R. Kelley).
western frontier of the country. Understanding the dynamics of teen pregnancy offers health care providers a window of opportunity for both intervention and education regarding the consequences of such behaviors. This is especially true with adolescents from another culture who move to the United States. In light of the Healthy People 2020 goals to improve the healthy development and well-being of adolescents and prevent unplanned and teenage pregnancy, this information will be useful to both health care providers and educators to help new and recent immigrant adolescents prevent pregnancy. During the transition from childhood to adulthood, adolescents establish patterns of behavior and make lifestyle choices that affect both their current and future health. Pregnancy is one of those choices. It is critical that we continue to make progress toward preventing too-early pregnancy and parenthood to give teens the opportunity to finish their education, participate in the workforce and build strong families. It is important to generate knowledge regarding the relationship between social support, self-esteem and pregnancy in adolescent girls so that interventions can be designed to decrease teen pregnancy. 1. Specific aims The purpose of this study was to explore social support, self-esteem and pregnancy among Dominican adolescents, in both the DR and the U.S. The specific aims were to: 1. Measure social support and self-esteem in two groups of Dominican adolescent girls (in both the DR and the U.S.), those who have been pregnant and those who have not.
http://dx.doi.org/10.1016/j.apnr.2014.08.001 0897-1897/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
2. Compare social support and self-esteem between the two groups in both study samples. 3. Measure whether social support and self-esteem predict pregnancy. 2. Background and significance 2.1. Teen pregnancy Today's generation of adolescents is the largest in history. Nearly half of the global population is less than 25 years old (Bearinger, Sieving, Jerguson, & Sharma, 2007). About 16 million women 15–19 years old give birth each year (11% of all births worldwide) (World Health Organization, 2012a). Adolescent childbearing has significant ramifications at the personal, societal and global levels World Health Organization (WHO): Department of Child and Adolescent Health & Development Family & Community Health, 2004a,b. For the young woman and her family, the meaning and consequences of bearing a child during the teenage years range widely. Teenage mothers are more likely to be poor, unmarried, less educated and dependent on their families for financial support (World Health Organization, 2007). From a health perspective, both mother and child are at higher risk for poor outcomes, particularly if high quality prenatal care is not available. In Latin America, the risk of maternal death is four times higher among young women 15–19 years old. Stillbirths and death the first week of life are also 50% higher for the babies of mothers under the age of 20 (World Health Organization, 2012b). The United Nations states that delaying a Dominican mother's first pregnancy until she is at least 18 could reduce infant mortality by 30%. (Advocates for Youth, 2014). Although in the U.S., teen pregnancy has declined over the past two decades, particularly among Latina youth, adolescent mothers in the U.S. remain higher than in any other industrialized nation (DeSocio, Holland, Kitzman, & Cole, 2013). Adolescent childbearing is an intergenerational phenomenon. Children of adolescent mothers are more likely to become pregnant during their teens (Meade, Kersaw, & Ickovics, 2008). From a societal perspective, there is an economic burden associated with teen pregnancy. Throughout their lives, women who have children before the age of 20 are generally less educated, earn less money from work, are unemployed for longer periods of time and remain unmarried through much of their life (Hoffman, 2006). 2.2. Self-esteem Self-esteem is defined as the amount and type of personal respect and worthiness in which an individual views himself or herself in comparison with others (Rosenberg, 1965). Studies have shown that welladjusted adolescents have higher self esteem (Baldwin & Hoffmann, 2002; Dumont & Provost, 1999). Self-esteem has often been examined in relationship to risky sexual behavior, particularly among adolescent females (Babington, Kelley, & Patsdaughter, 2009; Commendador, 2007; Kowaleski-Jones & Mott, 1998). Studies have found that girls with poor self image will be more likely to initiate sexual intercourse, have more sexual partners and less likely to use contraception (Ethier et al., 2006; Portes & Zady, 2002). Further studies have found that lower self-esteem does not statistically increase the odds of teen pregnancy for Whites or Native American but higher self-esteem seems to decrease the odds of pregnancy in Blacks and Hispanics (Berry, Shillington, Peak, & Hofman, 2000). Elmer (2001) summarized current theories of self-esteem and adolescents and postulated that positive self-esteem is central to the adaptive functions of the individual and adolescents with lower self-esteem are predisposed to adopt risk behaviors, particularly risky sexual behaviors. 2.3. Social support Social support as a concept has received considerable attention in social, behavioral and health sciences and has been described in many
ways. Social support in this study is based on Weiss' (1974) model of relational functions and composed of the following dimensions; (a) the indication that one is valued, (b) that one is an integral part of a group, (c) the provision for attachment/intimacy, (d) the opportunity for nurturance, and (e) the availability of information, emotional, and material help (Brandt & Weinert, 1981). Empirical support has been demonstrated for the relationship between social support and positive health practices in adults (Cantrell, 2006; McNichols, 2001) and adolescents (Ayres, 2008; Mahat, Scoloveno, & Whalen, 2002; Mahon, Yarcheski, & Yarcheski, 2004; Yarcheske, Mahon, & Yarcheske, 2004; Yarcheske, Mahon, & Yarcheski, 2001). The link between adolescent self esteem and social support has not been well studied. Hoffman, Ushpiz, and Levy-Shiff (1988) found that maternal support had a strong effect on self esteem, however this study limited social support to that of the mother. Wilkinson (2004) summarized three studies that examined parental attachment, peer attachment and self-esteem and how they influence psychological health and concluded that there was some relationship between positive psychological health and these constructs. Baldwin and Hoffmann (2002) found that self-esteem during adolescence was influenced by shifts in life events and family cohesion. The relationship between teen pregnancy, self esteem and social support is important to understand and the focus of this study. 3. Research design and methods 3.1. Design An exploratory descriptive design guided this study. The Northeastern University Institutional Review Board for the Protection of Human Subjects (IRB) approved the study. 3.2. Participants Since the purpose of the study was to understand pregnancy in Dominican teenage girl, two groups participated in the study, teens who lived in the DR and those that had immigrated to the U.S. within the past 5 years. Efforts were made to match the groups both by age and high school attendance. The first was a group of teens living in the DR: (1) twenty-eight between the ages of 14 and 19 years attending high school and had never been pregnant; (2) nineteen between 15 and 19 years of age who had been pregnant or were currently pregnant. The second study sample included teens in the U.S. who had immigrated to the U.S. within the past 5 years: (1) twenty teens between the ages of 15 and 19 years attending high school; (2) nineteen teens between 15 and 19 who had been pregnant or were currently pregnant. High schools in both the DR and U.S. are identical in terms of including grades 9–12 and students are similar ages. Additional inclusion criteria included a requirement that participants could read or write Spanish or English. Demographics of the sample are found in Tables 1a and 1b. Adolescents in the DR were recruited from two primary sites: a local high school and from rural campos where the investigators provided health care in mobile health clinics. We received permission from the high school principal in Las Matas de Far Fan, DR to recruit teen girls. Once the student returned to school with the consent form signed by their parent (or guardian), we arranged for a time for the students to privately complete the questionnaire. Before distributing the questionnaires, we also obtained written assent from the students, provided a written description of the study and answered any questions. To recruit the adolescents who had been pregnant, we used a similar process with young mothers (or pregnant teens) who sought health care in one of the mobile health clinics where we were working. In the DR, pregnant teens and adolescent mothers are considered emancipated, therefore parental consent was not obtained. The participants completed the questionnaires on-site during the clinic session in a private place. We were available for questions.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 1a Demographics for DR sample.
Participants Age Ever been pregnant Last grade completed Who do you live with? a. By myself b. Parents or family c. Friend d. Husband e. Boyfriend Sisters/cousins/friends pregnant as teenagers
Total sample
Never been pregnant
Been pregnant
47 16.68 (SD = 1.59) 19 yes (40%) 28 no (60%) 8.76 (SD = 2.1)
28 15.75 (SD = 0.52) 0 yes 28 no (100%) 10.52 (SD = .75)
19 18.05 (SD = 1.65) 19 yes (100%) 0 no 7.56 (SD = 2.5)
1 45 0 0 1 24 yes (51%) 20 no (43%) 3 no response (6%)
0 28 0 0 0 6 yes (21%) 19 no (68%) 3 no response (11%)
1 17 0 0 1 18 yes (95%) 1 no (5%)
In the U.S., teens were recruited from English High School in Boston, which has the largest population of Dominican immigrants in the city. The 20 adolescent girls recruited for the study had never been pregnant, were currently enrolled in high school and had immigrated within the last 5 years. The nineteen teen mothers were recruited through word of mouth, as many were friends with current high school students at English High. They had also immigrated within the past 5 years. The same process for obtaining consent that was employed with the study group in the DR was used with this group, although in the U.S. sample, parental consent was obtained for all participants. Materials were provided in both Spanish and English.
3.3. Instruments 3.3.1. Demographic information form An investigator-developed demographic information form was incorporated into the questionnaire along with the research instruments. Two versions of the demographic sheet were developed, with the version for the participants who have had been pregnant containing additional questions. These additional questions addressed the following areas: (a) whether or not they planned their pregnancy, (b) were they planning to or did they plan to keep and raise their baby, (c) if they were not going to keep the child, what were their plans, (d) did they quit school, and (e) why did they quit and did they have plans to return to school. The questionnaire was available in Spanish or English for participants to complete. The demographic information form was translated and back translated to improve its conceptual equivalency.
Table 1b Demographics for U.S. sample.
Participants Age Ever been pregnant Last grade completed Who do you live with? f. By myself g. Parents or family h. Friend i. Husband j. Boyfriend Sisters/cousins/friends pregnant as teenagers
Total sample
Never been pregnant
Been pregnant
39 17.36 (SD = 1.67) 19 yes (49%) 20 no (51%) 10.76 (SD = 1.0)
20 17.65 (SD = 1.90) 0 yes 20 no (100%) 10.65 (SD = 1.0)
19 17.05 (SD = 1.85) 19 yes (100%) 0 no 10.88 (SD = .89)
0 38 1 0 0 38 yes (97%) 1 no (3%)
0 20 0 0 0 20 yes (100%) 0 no
0 18 1 0 0 18 yes (95%) 1 no (5%)
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3.3.2. Rosenberg self-esteem scale First published in 1965, The Rosenberg Self-esteem Scale (RSES) was one of the earliest measures of overall self-esteem. According to Rosenberg (1965), self-esteem is a variable reflecting the general attitude a person has about personal value. Self-esteem is considered a judgment about the self as a whole. The scale is composed of 5 positively and 5 negatively phrased items that are first person evaluative statements about self (e.g., “On the whole, I feel satisfied with myself.”; “At times, I think I am no good at all.”). The 10-item RSES measures global self-esteem on a 4-point Likert scale (strongly agree to strongly disagree). Possible scores range from 0 to 40, with 40 indicating very high selfesteem (Butler & Gasson, 2005; Rosenberg, 1965, 1989). The RSES was developed with a large sample of high school students (N = 5024) of mixed ethnicity. Rosenberg reported a reproducibility coefficient of .92 (Rosenberg, 1965). Two week retest reliability of .86 was documented by Sibler and Tippett (1965). Over time, the scale has demonstrated high reliability estimates, with test–retest correlation typically ranging from .82 to .88 (Gordon, Ingersoll, & Orr, 1998; Owens, 2001; Rosenberg, 1989; Winters, Myers, & Proud, 2002). The RSES has been used extensively with different ethnic groups, particularly Spanish speaking adolescent groups (Banos & Guillen, 2000; Fernandez & Castro, 2003; Lorenzo-Hernandez & Oullette, 1998; Orshan, 1999; Phinney, Cantu & Kurtz, 1997). From a sample of 120 Mexican American teenagers, Joiner and Kashubeck (1996) reported a Cronbach's alpha coefficient of .87. Fleming and Courtner (1980) reported an internal consistency coefficient of .88 with for a similar sample. In studies with Dominican adolescents using the Spanish version of the scale, Orshan (1999) reported an alpha coefficient of .64 and Babington et al. (2009) reported a coefficient of α = .71. The alpha coefficient for the RSES in this study was α = .87. 3.3.3. The Personal Resource Quesionnaire-85 (PRQ85) The PRQ85 part II, a 25 item self-administered instrument, was developed by Brandt and Weinert (1981) based on Weiss (1974). This instrument has been used in many studies over the past two decades and has demonstrated appropriate coefficient alpha values as a measure of reliability (Weinert, 1987). Yarcheske, Mahon, and Yarcheski (1992) established construct validity for the instrument among adolescents resulting in 17 of the original 25 items. The 17 item PRQ85 part II was found to have statistically significant correlations with the original 25 item instrument and was found to be more useful in theory-testing research on social support with adolescents. Recently researchers reported coefficient alpha values ranging from .76 to .92 in samples of adolescents (Ayres, 2008; Cantrell, 2006; Mahat et al., 2002; Mahon et al., 2004; Yarcheske et al., 2001). This instrument has also been translated into Spanish and used with adolescents reporting alpha coefficients ranging from .84 to .89 (Orshan, 1999; Yarcheske et al., 1992). The alpha coefficient in this study for the PRQ85 was α = .87. Permission to use both of these instruments was obtained. 3.3.4. Analysis Data were entered into SPSS v.14 (2005). Descriptive statistics were computed. Means and frequencies were calculated. One way ANOVA was computed to demonstrate if self-esteem and social support varied by pregnancy status. Simple and multiple logistic regression analyses were conducted to answer the research question of whether social support and self-esteem individually or together predict pregnancy. 4. Results The U.S. sample was older than the sample in the DR: U.S. sample mean age = 17.36 (SD = 1.67) and DR mean age = 16.68 (SD = 1.59). The mean age for students in high school (none of whom had ever been pregnant in either sample) was also older in the U.S.: DR sample = 15.75 (SD = .52) and U.S. =17.65 (SD = 1.90); while the mean age for the adolescents who had been pregnant was older in the DR =
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
Table 1c Additional questions for teens who had been pregnant.
Did you plan your pregnancy? Are you going to keep and raise the baby? If you are not in school, why did you quit? a. Got pregnant b. School would not let me return c. I don't like school d. Need to work e. Parents f. Father of the baby Do you plan on going back to school? a. Yes (when-timeline) b. No (explain) c. My parents do not want me to return d. The father of my baby does not want me to return e. I haven't decided yet (explain)
Table 3 Means table for total score (samples combined) on RSES and PQ85 by pregnancy status.
DR
U.S.
ANOVA RSES
Sum of squares
df
0 yes 19 no 19 yes 0 no Total responses = 19 Responded to more that one question. a. 19 b. 0
0 yes 19 no 18 yes 1 no Total responses = 2 Responded to more that one question. a. 1 b. 0
Between groups Within groups Total
6.078 4.500 44
16 28 44
ANOVA PQ85
Sum of squares
df
Between groups Within groups Total
8.663 2.167 10.800
24 20 44
c. 15 d. 19 e. 19 f. 0 Total responses = 17 Responded to more that one question. a. 0 b. 17 c. 13
c. 1 d. 1 e. 0 f. 0 Total responses = 19 Responded to more that one question. a. 16 b. 1 c. 0
d. 3
d. 0
e. 1
e. 2
18.05 (SD = 1.65) than the U.S. = 17.05 (SD = 1.85). In this study the U.S. participants had completed between grades 10 and 11 while in the DR, participants mean last grade completed in school was 8.76 (SD = 2.1). For the students currently in school the mean last grade completed was 10.52 (SD = .75) in the DR sample and 10.65 (SD = 1.0) in the U.S. sample. The teen mothers highest grade completed was grade 7.56 (SD = 2.5) in the DR and 10.88 (SD = .89) in the U.S. Eighteen out of the 19 teenage mothers in both the U.S. and DR samples (95%) reported that they had a sister, cousin or close friend who had been pregnant as a teenager. There was a notable difference between the U.S. and DR samples for study participants who had never been pregnant. In the U.S., all of the participants (20) reported having a sister, cousin or close friend who had been pregnant as a teenager while only 6 (21%) of the 28 DR participants reported the same (Tables 1a and 1b). The additional questions on the demographic questionnaire that the teens who had been pregnant answered are presented in Table 1c. In both the DR (19) and U.S. (19) samples, all of the participants indicated that they did not plan their pregnancies. All of the study participants from the DR sample were planning to keep their babies, but one of the U.S. participant was not. In the DR sample, all 19 pregnant teens reported that they quit school because they were pregnant and because their parents did not want them to return and they needed to work. Additionally, 15 of the participants reported not liking school. In the U.S. sample, only two participants responded to this question. This was expected since all but one of them actually returned to school. In the U.S. sample 16 of the 19 participants responded that they planned to go back to school. This doesn't correlate to the previous question where 18 reported continuing in school. In the DR sample, 17
Total sample
RSES PRQ85
30.24 (SD = 8.02) 91.01 (SD = 31.84)
.380 .161
Mean square .360 .108
participants responded to this question and all of them reported that they did not plan to return to school. Table 2 describes the total mean scores on the RSES and the PRQ85. The study participants who had never been pregnant in both the U.S. and DR reported higher mean self-esteem scores: U.S. (RSES = 36), DR (RSES = 33) in comparison to the participant who had been pregnant: U.S. (RSES = 30) and DR (RSES = 25). Mean scores on the PRQ85 measuring social support were also higher in the participants who had never been pregnant: U.S. = 103 and DR = 99 compared to the U.S. = 90 and DR = 80. Table 3 demonstrates how RSES and PRQ85 scores vary between these two groups. The study found a statistically significant difference in both selfesteem and social support between the two groups. Self esteem and social support were lower in teenage girls who had been pregnant. Simple logistic regression analysis showed that adolescents with higher self-esteem and social support were less likely to have ever been pregnant. Self-esteem had a stronger relationship to pregnancy. Those with higher self-esteem were 26% less likely to have been pregnant. Social support has less effect; higher scores on the social support scale decreased the odds of having been pregnant by 3%. The multiple logistic regression models included both self-esteem and social support. Self-esteem as measured by RSES was the lone significant predictor of pregnancy (Table 4). 5. Limitations This study has some notable limitations. In the DR, data were collected in a medium size town and in the surrounding poor, rural campos and in the U.S., data were collected in a single east coast city. These samples may not reflect the beliefs and practices of adolescents in other parts of the DR or the U.S. The sample was also a convenience sample. Data were collected through self-report measures and only from adolescents who were literate. Self-esteem and social support were measured at a single point in time, therefore it is possible that the pregnancy experience itself lead to lower reported self esteem and social support for that group. Limitations notwithstanding, this study represents an important step toward understanding the relationship between selfesteem, social support and pregnancy for adolescents in the DR. 6. Discussion and implications This study examined self-esteem and social support in adolescent girls and sought to determine if there was a relationship between
Table 2 Descriptive statistics. Total scores DR sample
Mean square
Never been pregnant 33.36 (SD = 4.44) 98.56 (SD = 20.75)
Experienced pregnancy 25.12 (SD = 9.93) 79.89 (SD = 41.77)
Total scores U.S. sample
Total sample
Never been pregnant
Experienced pregnancy
RSES PRQ85
34.24 (SD = 5.21) 99.41 (SD = 30.04)
36.36 (SD = 2.04) 102.56 (SD = 13.55)
30.32 (SD = 3.93) 89.89 (SD = 31.74)
Table 4 Regression tables.
Step1 RSES_T Constant PRQ85_T RSES_T PRQ85_T
B
S.E.
Wald
df
Sig.
Exp(B)
−.297 8.549 −.029 −.263 −.016
.101 3.079 .0.14 .103 .013
8.688 7.710 3.967 6.563 1.365
1 1 1 1 1
.003 .005 .046 .010 .243
.743 5160.707 .972 .769 .984
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
these constructs on whether a teen become pregnant. Self-esteem and social support were lower in the group of teenagers who have experienced pregnancy. In the DR, none of the study participants from the high school had ever been pregnant. The regional high school, located about one half mile from the downtown business area, draws students from the town, the surrounding campos and from poor rural campos as far as a 3 hour drive. Often students who lived a distance from the town would stay with a relative during the school week. Students came from all social strata. The majority of students who remained in school were from more intact extended families who were farmers, land-owners or small business owners. Attendance at school requires money for uniforms, books and transportation. The investigators, who have spent the last 15 years working in the DR, have had multiple opportunities to interact with teenagers in the larger town and the surrounding rural campos. Discussions with teenagers attending the high school indicated that the adults caring for them, parents or grandparents, had expectations that they would attend school. These teenagers were more focused on attending and finishing high school. The teenage girls also said that they knew a pregnancy would preclude their high school attendance or graduation. In the investigators' experience, as well as in this study sample, pregnant teenage girls in the DR do not marry and do not live with the father of their baby who are often 5 to 7 years older. The care of the baby is the responsibility of the teen, often with help from their mother or grandmother, older sister or aunt. Even though initially getting pregnant is sometimes viewed as a failure, young mothers are readily embraced into the social system of ‘mothers of young children’. Their families help them raise their children and there exists no incentive to return to school. In fact, many young mothers stated that they ‘could not’ return to school because they had a child. Although there are no stated rules within the school system there appears to be an unwritten policy of not accepting students who have had a child. Additionally, there is no opportunity to complete high school in a different format such as the GED as in the U.S. Even though these teenage mothers are supported in raising their children, they have little opportunity for good jobs without a high school diploma and generally end up poor. These observations and realities are not true in the U.S. It is typical for teenage mothers to return to high school after the birth of their children. In fact, the high school in the U.S. where the study sample was obtained from has an onsite day care and parenting program for teen mothers. One of the researchers practiced in the school based health center where data were collected for this study and stated that “one of the challenges in the Dominican community in Boston is that services are rich and readily available for teen mothers in the school system and community at large, thus the stigma of teen pregnancy is mitigated”. While the strong support teen mothers receive in the U.S. helps them raise their children, in some families, there is little stigma associated with teen pregnancy. Similar to the DR, teen mothers in the U.S. study sample lived with their families and were rarely supported by the father of the child. In contrast to the DR, often the teen mother returns to school in the U.S., bringing the child to the onsite daycare and continues to be involved in their same social circles. Schools are an important place to base pregnancy prevention interventions. In the U.S., it is required for children to attend school and in the DR, many children also attend at least grammar school. In addition to providing sex education curricula, schools should focus on helping young people, particularly girls develop positive self esteem. In recent studies by Chapman and Werner-Wilson (2008), and Karcher (2009), positive youth development and self esteem were noted to correlate with decreased risky behaviors. Sternas, Scharf, and Peterkin (2013) used a post intervention design and found that teenagers enrolled in pregnancy prevention interventions at school reported significant outcomes related to abstinence behaviors and attitudes than comparison group participants. The study findings that self-esteem and social support were lower in teens who been pregnant is an important finding as we try to influence
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teen pregnancy in the DR and the U.S. Teenage girls need to improve their self-esteem and schools should allow opportunities for girls to be successful in activities that will lead toward greater self-esteem. Since adolescent girls with stronger social support are less likely to get pregnant, families and communities need to support girls during their teenage years. Also, girls who drop out of school need strong social support to avoid early pregnancy. These are important findings and will help to inform the development of interventions aimed at preventing pregnancy by increasing self-esteem and building strong social support aimed at pregnancy prevention. Programs aimed at increasing self-esteem in early adolescence may prove to be beneficial in decreasing the teen pregnancy rate among Dominican adolescents in both the U.S. and the DR. Culture and ethnicity affect both personality and surrounding social conditions and are also important determinants in adolescent self-esteem and the prevalence of adolescent risk-taking behaviors (Babington, Kelley, & Patsdaughter, 2007). In the Dominican culture, both in the DR and the U.S., family cultural values support teen girls staying in school and avoiding pregnancy. One of the problems is that once the teen becomes pregnant, those same families continue to support the teen mother and help to raise the child. Interventions that strengthen the culturally based family value of preventing teen pregnancy may deter teens from getting pregnant in the first place. In addition to improving teen girls self esteem, providing information to families on the many issues related to teen pregnancy and providing them with the skills to have conversations with their children about pregnancy may result in preventing teen pregnancy. Therefore, the timing of adolescence presents a critical window of opportunity to intervene and help adolescents make healthy lifestyle decisions. Completing an education leads to better job opportunities and delaying pregnancy beyond the teen years results in healthier mothers and babies. Teen pregnancy is not only physically stressful for young mothers, but often leads to poverty and limited choices throughout their lives. Understanding what may influence pregnancy outcomes for adolescents will help those who work with teens develop culturally specific interventions aimed at improving adolescent health.
References Advocates for Youth. Early pregnancy can endanger the life and health of a child. retrieved February 15, 2014. http://www.advocates:foryouth.org/publications/ publications-a-z/432-the-impact-of-early-pregnancy-and-childbearing-onadolescent-mothers-and-their-children Ayres, C. G. (2008). Mediators of the relationship between social support and positive health practices in middle adolescents. Journal of Pediatric Health Care, 22(2), 94–102. Babington, L. M., Kelley, B. R., & Patsdaughter, C. A. (2007). Risk behaviors of Dominican adolescents in their homeland and in the United States. Journal of Pediatric Health Care, 21, 372–380. Babington, L. M., Kelley, B. R., & Patsdaughter, C. A. (2009). Self-esteem and risk behaviors of Dominican adolescents. Issues in Comprehensive Pediatric Nursing, 32, 131–144. Baldwin, S. A., & Hoffmann, J. P. (2002). The dynamics of self-esteem: A growth-curve analysis. Journal of Youth and Adolescence, 31(2), 101–113. Banos, R. M., & Guillen, V. (2000). Psychometric characteristics in normal and social phobic samples for a Spanish version of the Rosenberg self-esteem scale. Psychological Reports, 87, 269–274. Bearinger, L. H., Sieving, R. E., Jerguson, J., & Sharma, V. (2007). Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention and potential. Lancet, 369(9568), 1220–1231. Berry, E. H., Shillington, A. M., Peak, T., & Hofman, M. M. (2000). Multi-ethnic comparison of risk and protective factors for adolescent pregnancy. Child and Adolescent Social Work Journal, 17(2), 79–98. Brandt, P. A., & Weinert, C. (1981). The PRQ: A social support measure. Nursing Research, 30(5), 277–280. Butler, R. J., & Gasson, S. L. (2005). Self-esteem/self concept scales for children and adolescents: A review. Child and Adolescent Mental Health, 10(4), 190–210. Cantrell, B. (2006). Mediators of the relationship between social support and positive health practices in pregnant women. Nursing Research, 55(6), 427–445. Chapman, E., & Werner-Wilson, J. (2008). Does positive youth development predict adolescent attitudes about sexuality? Adolescence, 43(171), 505–523. Commendador, K. (2007). Relationship between female adolescent self-esteem, decision making, and contraceptive behavior. Journal of the American Academy of Nurse Practitioners, 19, 614–623. DeSocio, J. E., Holland, M., Kitzman, H. J., & Cole, R. E. (2013). The influence of social developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers. Research in Nursing & Health, 36, 158–170.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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Dumont, M., & Provost, M. A. (1999). Resilience in adolescents: protective role of social support, coping strategies, self-esteem, and social activities on experience of stress and depression. Journal of Youth and Adolescence, 28(3), 343–363. Elmer, N. (2001). Self esteem: The costs and causes of self worth. New York: Joseph Rowntree Foundation. Ethier, K. A., Kershaw, T. S., Lewis, J. B., Milan, S., Niccolai, L. M., & Ickovics, J. R. (2006). Self- esteem, emotional distress and sexual behavior among adolescent females: Inter-relationships and temporal effects. Journal of Adolescent Health, 38, 268–276. Fernandez, L. M., & Castro, R. Y. (2003). Age and sex differences in self-esteem among Spanish adolescents. Psychological Reports, 93(3), 876–888. Fleming, J. S., & Courtner, W. A. (1980). The dimensionality of self-esteem: Some results for a college sample. Journal of Personality and Social Psychology, 5, 921–929. Gordon, R. K. A., Ingersoll, G. M., & Orr, D. P. (1998). Longitudinal health endangering behavior risk among resilient and nonresilient early adolescents. Journal of Adolescent Health, 23(5), 297–302. Hoffman, S. (2006). By the numbers: The public costs of teen childbearing. Washington, DC: The National Campaign to Prevent Teen Pregnancy (Retrieved July 23, 2013, from http://www.thenationalcampaign.org/costs/pdf/report/BTN_National_Report.pdf). Hoffman, M. A., Ushpiz, V., & Levy-Shiff, R. (1988). Social support and self-esteem in adolescence. Journal of Youth and Adolescence, 17(4), 307–316. Joiner, G. W., & Kashubeck, S. (1996). Acculturation, Body Image, Self-Esteem, And EatingDisorder Symptomatology In Adolescent Mexican American Women. Psychology of Women Quarterly, 20, 419–435. Karcher, M. (2009). Increases in academic connectedness and self esteem among high school students who serve as cross-age peer mentors. Professional School Counseling, 12(4), 292–299. Kowaleski-Jones, L., & Mott, F. L. (1998). Sex, contraception and childbearing among high risk youth: Do different factors influence males and females? Family Planning Perspectives, 30, 163–169. Lorenzo-Hernandez, J., & Oullette, S. (1998). Ethnic identity, self-esteem, and values in Dominicans, Puerto Ricans, and African Americans. Journal of Applied Social Psychology, 28(21), 2007–2024. Mahat, G., Scoloveno, M. A., & Whalen, C. C. (2002). Positive health practices of urban minority adolescents. Journal of School Nursing, 18, 244–260. Mahon, N. E., Yarcheski, A., & Yarcheski, T. J. (2004). Social support and positive health practices in early adolescents: A test of mediating variables. Clinical Nursing Research, 13, 216–236. McNichols, S. L. (2001). An investigation of the mediators of the relationship between social support and positive health practices in middle-aged adults. (Doctoral dissertation). Dissertation Abstract International, 62. (pp. 1322). Rutgers: The State University of New Jersey, 1322. Meade, C. S., Kersaw, T. S., & Ickovics, J. R. (2008). The intergenerational cycle of teenage motherhood: An ecological Approach. Health Psychology, 27, 419–429. Orshan, S. (1999). Acculturation, perceived social support, self-esteem, and pregnancy status among Dominican adolescents. Health Care for Women International, 20, 245–257. Owens, R. T. J. (2001). Extending self-esteem theory and research. New York: Cambridge University Press. Portes, P. R., & Zady, M. F. (2002). Self-esteem in the adaptation of Spanish-speaking adolescents: The role of immigration, family conflict and depression. Hispanic Journal of Behavior Sciences, 24(3), 296–318. Phinney, J. S., Cantu, C. L., & Kurtz, D. A. (1997). Ethnic and American identity as a predictor or self-esteem among African American, Latino, and White adolescents. Journal of Youth and Adolescents, 26(2), 165–185.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Rosenberg, M. (1989). Society and adolescent self-image. Middletown, CT: Wesleyan University Press. Sibler, E., & Tippett, J. S. (1965). Self-esteem: Clinical assessment and measurement of validation. Psychological Reports, 16, 1017–1071. Statistical Package for the Social Sciences, Inc. (2005). SPSS 14.0 [computer software]. Chicago, IL: SPSS, Inc. Sternas, K. A., Scharf, M. S., & Peterkin, R. M. (2013). Teenage pregnancy prevention: Comparison of outcomes for teenage girls and boys participating in an evidence-based intervention. Abstract from 24th International Nursing Research Congress, Sigma Theta Tau, July 22–26, 2103 (Retrieved July 24, 2013 from https://stti.confex.com/stti/ congrs13/webprogram/Paper56865.html). United Nations Statistic Division (2011). Demographic Yearbook (2009-2010) Retrieved September 20, 2014 from http://unstats.un.org/unsd/demographic/products/dyb/ dyb2009-2010/notes/notes01.pdf. Weinert, C. (1987). A social support measures: PRQ85. Nursing Research, 36(5), 273–277. Weiss, R. (1974). The provisions of social relationships. In Z. Rubin (Ed.), Doing unto Others (pp. 1702). Englewood Cliffs, NJ: Prentice-Hall. Wilkinson, R. B. (2004). The role of perental and peer attachment in the psychological health and self-esteem of adolescents. Journal of Youth and Adolescents, 33(6), 479–493. Winters, N. C., Myers, K., & Proud, L. (2002). Ten-year review of rating scales, III: Scales assessing suicidality, cognitive style, and self-esteem. Child & Adolescent Psychiatry, 41(10), 1150–1181. World Health Organization (2007). Adolescent Pregnancy: Unmet needs and undone deeds. (Retrieved July 24, 2013 from http://whqlibdoc.who.int/publications/2007/ 9789241595650_eng.pdf). World Health Organization (2012a). Adolescent pregnancy fact sheet. (Retrieved July 24, 2013 from http://www.who.int/maternal_child_adolescent/topics/maternal/ adolescent_pregnancy/en/index.html). World Health Organization (2012b). Adolescent reproductive health: What needs to be done to promote the sexual and reproductive health of adolescents and to prevent adolescent mothers and their babies from dying in pregnancy? (Retrieve July 24, 2013 from http://www.who.int/maternal_child_adolescent/topics/maternal/ reproductive_health/en/index.html). World Health Organization (WHO): Department of Child and Adolescent Health and Development Family and Community Health (2004a). Risk and protective factors affecting adolescent reproductive health in developing countries: An analysis of adolescent sexual and reproductive health literature from around the world. Geneva: WHO. World Health Organization (WHO): Department of Child and Adolescent Health and Development Family and Community Health (2004b). Risk and protective factors affecting adolescent reproductive health in developing countries: An analysis of adolescent sexual and reproductive health literature from around the world. (Retrieved February 15, 2014 from http://158.132.116.146/adh/2_AD_sexual_reproductiveH/WHO%20-% 20Risk%20and%20protective%20factors%20affecting%20ASRH%20in%20developi.pdf). Yarcheske, A., Mahon, N. E., & Yarcheske, A. (2004). Depression, optimism, and positive health practices in young adolescents. Psychological Reports, 95, 932–934. Yarcheske, A., Mahon, N. E., & Yarcheski, T. J. (1992). Validation of the PRQ85 social support measure for adolescents. Nursing Research, 41(6), 332–337. Yarcheske, A., Mahon, N. E., & Yarcheski, T. J. (2001). Social support and well-being in early adolescents: The role of mediating variables. Clinical Nursing Research, 10, 99–103.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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Original Article
Perceived social support, self esteem, and pregnancy status among Dominican adolescents Lynn M. Babington, PhD, Rn a,⁎, Linda Malone, DNP, CPNP b, Barbara R. Kelley, MPH, EdD. CPNP b a b
Fairfield University, Fairfield, CT, USA School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
a r t i c l e
i n f o
Article history: Received 12 November 2013 Revised 13 August 2014 Accepted 20 August 2014 Available online xxxx Keywords: Adolescent pregnancy Dominican Republic Self-esteem Social support
a b s t r a c t Adolescent pregnancy is a major health concern among Dominicans in the U.S. and in the Dominican Republic (DR). Twenty three percent of adolescents age 15–19 have experienced pregnancy and this trend is rising. Purpose: The purpose of this study was to explore and compare social support, self-esteem and pregnancy between Dominican adolescents in the DR with those who have immigrated to the U.S. Methods: This study used an exploratory, descriptive design including study samples from both the U.S. and DR. Findings showed that young women with stronger social support and higher self esteem experienced lower pregnancy rates in both the DR and U.S. samples. Results: Neither self esteem nor social support was found to be predictors of pregnancy. Conclusion: Important findings from this study will inform the development of interventions aimed at preventing pregnancy in adolescents. © 2014 Elsevier Inc. All rights reserved.
Adolescent pregnancy is a major health issue among teenage girls in the Dominican Republic (DR). Adolescent pregnancy is largely unplanned leaving these girls poor, with little education as they drop out of school and do not return. Once the teen gives birth, it is extremely uncommon for them to live with the father; they continue to live with and depend on their families for support. Twenty three percent of young women in the DR between the ages of 15 and 19 have had at least one pregnancy accounting for 15% of the total live births and this trend is rising (United Nations, 2011). The Dominican Republic ranks 33rd worldwide in the number of pregnancies aged 15–19 years. Pregnancy is also the leading cause of death for girls in this age group. In the DR, adolescent pregnancy is more common in lower income, rural areas and among young women who have had little schooling. Children born to teen mothers are at greater risk of poverty, less likely to stay in school and more likely to have health problems or engage in problem behaviors (Hoffman, 2006). The researchers' interest in Dominican adolescents evolved from working with Dominican families in Boston who recently have emigrated from the Dominican Republic and working with adolescents in the Dominican Republic. For the past 15 years the researchers have been involved in a volunteer nursing organization, Intercultural Nursing, Inc. (INI). INI sponsors trips twice a year to the Dominican Republic to provide primary health services in rural campos (i.e., villages) on the
⁎ Corresponding author at: 1073 North Benson Rd. Fairfield, CT 06824. Fax: + 1 203 254 4126. E-mail addresses: lbabington@fairfield.edu (L.M. Babington), [email protected] (L. Malone), [email protected] (B.R. Kelley).
western frontier of the country. Understanding the dynamics of teen pregnancy offers health care providers a window of opportunity for both intervention and education regarding the consequences of such behaviors. This is especially true with adolescents from another culture who move to the United States. In light of the Healthy People 2020 goals to improve the healthy development and well-being of adolescents and prevent unplanned and teenage pregnancy, this information will be useful to both health care providers and educators to help new and recent immigrant adolescents prevent pregnancy. During the transition from childhood to adulthood, adolescents establish patterns of behavior and make lifestyle choices that affect both their current and future health. Pregnancy is one of those choices. It is critical that we continue to make progress toward preventing too-early pregnancy and parenthood to give teens the opportunity to finish their education, participate in the workforce and build strong families. It is important to generate knowledge regarding the relationship between social support, self-esteem and pregnancy in adolescent girls so that interventions can be designed to decrease teen pregnancy. 1. Specific aims The purpose of this study was to explore social support, self-esteem and pregnancy among Dominican adolescents, in both the DR and the U.S. The specific aims were to: 1. Measure social support and self-esteem in two groups of Dominican adolescent girls (in both the DR and the U.S.), those who have been pregnant and those who have not.
http://dx.doi.org/10.1016/j.apnr.2014.08.001 0897-1897/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
2. Compare social support and self-esteem between the two groups in both study samples. 3. Measure whether social support and self-esteem predict pregnancy. 2. Background and significance 2.1. Teen pregnancy Today's generation of adolescents is the largest in history. Nearly half of the global population is less than 25 years old (Bearinger, Sieving, Jerguson, & Sharma, 2007). About 16 million women 15–19 years old give birth each year (11% of all births worldwide) (World Health Organization, 2012a). Adolescent childbearing has significant ramifications at the personal, societal and global levels World Health Organization (WHO): Department of Child and Adolescent Health & Development Family & Community Health, 2004a,b. For the young woman and her family, the meaning and consequences of bearing a child during the teenage years range widely. Teenage mothers are more likely to be poor, unmarried, less educated and dependent on their families for financial support (World Health Organization, 2007). From a health perspective, both mother and child are at higher risk for poor outcomes, particularly if high quality prenatal care is not available. In Latin America, the risk of maternal death is four times higher among young women 15–19 years old. Stillbirths and death the first week of life are also 50% higher for the babies of mothers under the age of 20 (World Health Organization, 2012b). The United Nations states that delaying a Dominican mother's first pregnancy until she is at least 18 could reduce infant mortality by 30%. (Advocates for Youth, 2014). Although in the U.S., teen pregnancy has declined over the past two decades, particularly among Latina youth, adolescent mothers in the U.S. remain higher than in any other industrialized nation (DeSocio, Holland, Kitzman, & Cole, 2013). Adolescent childbearing is an intergenerational phenomenon. Children of adolescent mothers are more likely to become pregnant during their teens (Meade, Kersaw, & Ickovics, 2008). From a societal perspective, there is an economic burden associated with teen pregnancy. Throughout their lives, women who have children before the age of 20 are generally less educated, earn less money from work, are unemployed for longer periods of time and remain unmarried through much of their life (Hoffman, 2006). 2.2. Self-esteem Self-esteem is defined as the amount and type of personal respect and worthiness in which an individual views himself or herself in comparison with others (Rosenberg, 1965). Studies have shown that welladjusted adolescents have higher self esteem (Baldwin & Hoffmann, 2002; Dumont & Provost, 1999). Self-esteem has often been examined in relationship to risky sexual behavior, particularly among adolescent females (Babington, Kelley, & Patsdaughter, 2009; Commendador, 2007; Kowaleski-Jones & Mott, 1998). Studies have found that girls with poor self image will be more likely to initiate sexual intercourse, have more sexual partners and less likely to use contraception (Ethier et al., 2006; Portes & Zady, 2002). Further studies have found that lower self-esteem does not statistically increase the odds of teen pregnancy for Whites or Native American but higher self-esteem seems to decrease the odds of pregnancy in Blacks and Hispanics (Berry, Shillington, Peak, & Hofman, 2000). Elmer (2001) summarized current theories of self-esteem and adolescents and postulated that positive self-esteem is central to the adaptive functions of the individual and adolescents with lower self-esteem are predisposed to adopt risk behaviors, particularly risky sexual behaviors. 2.3. Social support Social support as a concept has received considerable attention in social, behavioral and health sciences and has been described in many
ways. Social support in this study is based on Weiss' (1974) model of relational functions and composed of the following dimensions; (a) the indication that one is valued, (b) that one is an integral part of a group, (c) the provision for attachment/intimacy, (d) the opportunity for nurturance, and (e) the availability of information, emotional, and material help (Brandt & Weinert, 1981). Empirical support has been demonstrated for the relationship between social support and positive health practices in adults (Cantrell, 2006; McNichols, 2001) and adolescents (Ayres, 2008; Mahat, Scoloveno, & Whalen, 2002; Mahon, Yarcheski, & Yarcheski, 2004; Yarcheske, Mahon, & Yarcheske, 2004; Yarcheske, Mahon, & Yarcheski, 2001). The link between adolescent self esteem and social support has not been well studied. Hoffman, Ushpiz, and Levy-Shiff (1988) found that maternal support had a strong effect on self esteem, however this study limited social support to that of the mother. Wilkinson (2004) summarized three studies that examined parental attachment, peer attachment and self-esteem and how they influence psychological health and concluded that there was some relationship between positive psychological health and these constructs. Baldwin and Hoffmann (2002) found that self-esteem during adolescence was influenced by shifts in life events and family cohesion. The relationship between teen pregnancy, self esteem and social support is important to understand and the focus of this study. 3. Research design and methods 3.1. Design An exploratory descriptive design guided this study. The Northeastern University Institutional Review Board for the Protection of Human Subjects (IRB) approved the study. 3.2. Participants Since the purpose of the study was to understand pregnancy in Dominican teenage girl, two groups participated in the study, teens who lived in the DR and those that had immigrated to the U.S. within the past 5 years. Efforts were made to match the groups both by age and high school attendance. The first was a group of teens living in the DR: (1) twenty-eight between the ages of 14 and 19 years attending high school and had never been pregnant; (2) nineteen between 15 and 19 years of age who had been pregnant or were currently pregnant. The second study sample included teens in the U.S. who had immigrated to the U.S. within the past 5 years: (1) twenty teens between the ages of 15 and 19 years attending high school; (2) nineteen teens between 15 and 19 who had been pregnant or were currently pregnant. High schools in both the DR and U.S. are identical in terms of including grades 9–12 and students are similar ages. Additional inclusion criteria included a requirement that participants could read or write Spanish or English. Demographics of the sample are found in Tables 1a and 1b. Adolescents in the DR were recruited from two primary sites: a local high school and from rural campos where the investigators provided health care in mobile health clinics. We received permission from the high school principal in Las Matas de Far Fan, DR to recruit teen girls. Once the student returned to school with the consent form signed by their parent (or guardian), we arranged for a time for the students to privately complete the questionnaire. Before distributing the questionnaires, we also obtained written assent from the students, provided a written description of the study and answered any questions. To recruit the adolescents who had been pregnant, we used a similar process with young mothers (or pregnant teens) who sought health care in one of the mobile health clinics where we were working. In the DR, pregnant teens and adolescent mothers are considered emancipated, therefore parental consent was not obtained. The participants completed the questionnaires on-site during the clinic session in a private place. We were available for questions.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 1a Demographics for DR sample.
Participants Age Ever been pregnant Last grade completed Who do you live with? a. By myself b. Parents or family c. Friend d. Husband e. Boyfriend Sisters/cousins/friends pregnant as teenagers
Total sample
Never been pregnant
Been pregnant
47 16.68 (SD = 1.59) 19 yes (40%) 28 no (60%) 8.76 (SD = 2.1)
28 15.75 (SD = 0.52) 0 yes 28 no (100%) 10.52 (SD = .75)
19 18.05 (SD = 1.65) 19 yes (100%) 0 no 7.56 (SD = 2.5)
1 45 0 0 1 24 yes (51%) 20 no (43%) 3 no response (6%)
0 28 0 0 0 6 yes (21%) 19 no (68%) 3 no response (11%)
1 17 0 0 1 18 yes (95%) 1 no (5%)
In the U.S., teens were recruited from English High School in Boston, which has the largest population of Dominican immigrants in the city. The 20 adolescent girls recruited for the study had never been pregnant, were currently enrolled in high school and had immigrated within the last 5 years. The nineteen teen mothers were recruited through word of mouth, as many were friends with current high school students at English High. They had also immigrated within the past 5 years. The same process for obtaining consent that was employed with the study group in the DR was used with this group, although in the U.S. sample, parental consent was obtained for all participants. Materials were provided in both Spanish and English.
3.3. Instruments 3.3.1. Demographic information form An investigator-developed demographic information form was incorporated into the questionnaire along with the research instruments. Two versions of the demographic sheet were developed, with the version for the participants who have had been pregnant containing additional questions. These additional questions addressed the following areas: (a) whether or not they planned their pregnancy, (b) were they planning to or did they plan to keep and raise their baby, (c) if they were not going to keep the child, what were their plans, (d) did they quit school, and (e) why did they quit and did they have plans to return to school. The questionnaire was available in Spanish or English for participants to complete. The demographic information form was translated and back translated to improve its conceptual equivalency.
Table 1b Demographics for U.S. sample.
Participants Age Ever been pregnant Last grade completed Who do you live with? f. By myself g. Parents or family h. Friend i. Husband j. Boyfriend Sisters/cousins/friends pregnant as teenagers
Total sample
Never been pregnant
Been pregnant
39 17.36 (SD = 1.67) 19 yes (49%) 20 no (51%) 10.76 (SD = 1.0)
20 17.65 (SD = 1.90) 0 yes 20 no (100%) 10.65 (SD = 1.0)
19 17.05 (SD = 1.85) 19 yes (100%) 0 no 10.88 (SD = .89)
0 38 1 0 0 38 yes (97%) 1 no (3%)
0 20 0 0 0 20 yes (100%) 0 no
0 18 1 0 0 18 yes (95%) 1 no (5%)
3
3.3.2. Rosenberg self-esteem scale First published in 1965, The Rosenberg Self-esteem Scale (RSES) was one of the earliest measures of overall self-esteem. According to Rosenberg (1965), self-esteem is a variable reflecting the general attitude a person has about personal value. Self-esteem is considered a judgment about the self as a whole. The scale is composed of 5 positively and 5 negatively phrased items that are first person evaluative statements about self (e.g., “On the whole, I feel satisfied with myself.”; “At times, I think I am no good at all.”). The 10-item RSES measures global self-esteem on a 4-point Likert scale (strongly agree to strongly disagree). Possible scores range from 0 to 40, with 40 indicating very high selfesteem (Butler & Gasson, 2005; Rosenberg, 1965, 1989). The RSES was developed with a large sample of high school students (N = 5024) of mixed ethnicity. Rosenberg reported a reproducibility coefficient of .92 (Rosenberg, 1965). Two week retest reliability of .86 was documented by Sibler and Tippett (1965). Over time, the scale has demonstrated high reliability estimates, with test–retest correlation typically ranging from .82 to .88 (Gordon, Ingersoll, & Orr, 1998; Owens, 2001; Rosenberg, 1989; Winters, Myers, & Proud, 2002). The RSES has been used extensively with different ethnic groups, particularly Spanish speaking adolescent groups (Banos & Guillen, 2000; Fernandez & Castro, 2003; Lorenzo-Hernandez & Oullette, 1998; Orshan, 1999; Phinney, Cantu & Kurtz, 1997). From a sample of 120 Mexican American teenagers, Joiner and Kashubeck (1996) reported a Cronbach's alpha coefficient of .87. Fleming and Courtner (1980) reported an internal consistency coefficient of .88 with for a similar sample. In studies with Dominican adolescents using the Spanish version of the scale, Orshan (1999) reported an alpha coefficient of .64 and Babington et al. (2009) reported a coefficient of α = .71. The alpha coefficient for the RSES in this study was α = .87. 3.3.3. The Personal Resource Quesionnaire-85 (PRQ85) The PRQ85 part II, a 25 item self-administered instrument, was developed by Brandt and Weinert (1981) based on Weiss (1974). This instrument has been used in many studies over the past two decades and has demonstrated appropriate coefficient alpha values as a measure of reliability (Weinert, 1987). Yarcheske, Mahon, and Yarcheski (1992) established construct validity for the instrument among adolescents resulting in 17 of the original 25 items. The 17 item PRQ85 part II was found to have statistically significant correlations with the original 25 item instrument and was found to be more useful in theory-testing research on social support with adolescents. Recently researchers reported coefficient alpha values ranging from .76 to .92 in samples of adolescents (Ayres, 2008; Cantrell, 2006; Mahat et al., 2002; Mahon et al., 2004; Yarcheske et al., 2001). This instrument has also been translated into Spanish and used with adolescents reporting alpha coefficients ranging from .84 to .89 (Orshan, 1999; Yarcheske et al., 1992). The alpha coefficient in this study for the PRQ85 was α = .87. Permission to use both of these instruments was obtained. 3.3.4. Analysis Data were entered into SPSS v.14 (2005). Descriptive statistics were computed. Means and frequencies were calculated. One way ANOVA was computed to demonstrate if self-esteem and social support varied by pregnancy status. Simple and multiple logistic regression analyses were conducted to answer the research question of whether social support and self-esteem individually or together predict pregnancy. 4. Results The U.S. sample was older than the sample in the DR: U.S. sample mean age = 17.36 (SD = 1.67) and DR mean age = 16.68 (SD = 1.59). The mean age for students in high school (none of whom had ever been pregnant in either sample) was also older in the U.S.: DR sample = 15.75 (SD = .52) and U.S. =17.65 (SD = 1.90); while the mean age for the adolescents who had been pregnant was older in the DR =
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
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L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
Table 1c Additional questions for teens who had been pregnant.
Did you plan your pregnancy? Are you going to keep and raise the baby? If you are not in school, why did you quit? a. Got pregnant b. School would not let me return c. I don't like school d. Need to work e. Parents f. Father of the baby Do you plan on going back to school? a. Yes (when-timeline) b. No (explain) c. My parents do not want me to return d. The father of my baby does not want me to return e. I haven't decided yet (explain)
Table 3 Means table for total score (samples combined) on RSES and PQ85 by pregnancy status.
DR
U.S.
ANOVA RSES
Sum of squares
df
0 yes 19 no 19 yes 0 no Total responses = 19 Responded to more that one question. a. 19 b. 0
0 yes 19 no 18 yes 1 no Total responses = 2 Responded to more that one question. a. 1 b. 0
Between groups Within groups Total
6.078 4.500 44
16 28 44
ANOVA PQ85
Sum of squares
df
Between groups Within groups Total
8.663 2.167 10.800
24 20 44
c. 15 d. 19 e. 19 f. 0 Total responses = 17 Responded to more that one question. a. 0 b. 17 c. 13
c. 1 d. 1 e. 0 f. 0 Total responses = 19 Responded to more that one question. a. 16 b. 1 c. 0
d. 3
d. 0
e. 1
e. 2
18.05 (SD = 1.65) than the U.S. = 17.05 (SD = 1.85). In this study the U.S. participants had completed between grades 10 and 11 while in the DR, participants mean last grade completed in school was 8.76 (SD = 2.1). For the students currently in school the mean last grade completed was 10.52 (SD = .75) in the DR sample and 10.65 (SD = 1.0) in the U.S. sample. The teen mothers highest grade completed was grade 7.56 (SD = 2.5) in the DR and 10.88 (SD = .89) in the U.S. Eighteen out of the 19 teenage mothers in both the U.S. and DR samples (95%) reported that they had a sister, cousin or close friend who had been pregnant as a teenager. There was a notable difference between the U.S. and DR samples for study participants who had never been pregnant. In the U.S., all of the participants (20) reported having a sister, cousin or close friend who had been pregnant as a teenager while only 6 (21%) of the 28 DR participants reported the same (Tables 1a and 1b). The additional questions on the demographic questionnaire that the teens who had been pregnant answered are presented in Table 1c. In both the DR (19) and U.S. (19) samples, all of the participants indicated that they did not plan their pregnancies. All of the study participants from the DR sample were planning to keep their babies, but one of the U.S. participant was not. In the DR sample, all 19 pregnant teens reported that they quit school because they were pregnant and because their parents did not want them to return and they needed to work. Additionally, 15 of the participants reported not liking school. In the U.S. sample, only two participants responded to this question. This was expected since all but one of them actually returned to school. In the U.S. sample 16 of the 19 participants responded that they planned to go back to school. This doesn't correlate to the previous question where 18 reported continuing in school. In the DR sample, 17
Total sample
RSES PRQ85
30.24 (SD = 8.02) 91.01 (SD = 31.84)
.380 .161
Mean square .360 .108
participants responded to this question and all of them reported that they did not plan to return to school. Table 2 describes the total mean scores on the RSES and the PRQ85. The study participants who had never been pregnant in both the U.S. and DR reported higher mean self-esteem scores: U.S. (RSES = 36), DR (RSES = 33) in comparison to the participant who had been pregnant: U.S. (RSES = 30) and DR (RSES = 25). Mean scores on the PRQ85 measuring social support were also higher in the participants who had never been pregnant: U.S. = 103 and DR = 99 compared to the U.S. = 90 and DR = 80. Table 3 demonstrates how RSES and PRQ85 scores vary between these two groups. The study found a statistically significant difference in both selfesteem and social support between the two groups. Self esteem and social support were lower in teenage girls who had been pregnant. Simple logistic regression analysis showed that adolescents with higher self-esteem and social support were less likely to have ever been pregnant. Self-esteem had a stronger relationship to pregnancy. Those with higher self-esteem were 26% less likely to have been pregnant. Social support has less effect; higher scores on the social support scale decreased the odds of having been pregnant by 3%. The multiple logistic regression models included both self-esteem and social support. Self-esteem as measured by RSES was the lone significant predictor of pregnancy (Table 4). 5. Limitations This study has some notable limitations. In the DR, data were collected in a medium size town and in the surrounding poor, rural campos and in the U.S., data were collected in a single east coast city. These samples may not reflect the beliefs and practices of adolescents in other parts of the DR or the U.S. The sample was also a convenience sample. Data were collected through self-report measures and only from adolescents who were literate. Self-esteem and social support were measured at a single point in time, therefore it is possible that the pregnancy experience itself lead to lower reported self esteem and social support for that group. Limitations notwithstanding, this study represents an important step toward understanding the relationship between selfesteem, social support and pregnancy for adolescents in the DR. 6. Discussion and implications This study examined self-esteem and social support in adolescent girls and sought to determine if there was a relationship between
Table 2 Descriptive statistics. Total scores DR sample
Mean square
Never been pregnant 33.36 (SD = 4.44) 98.56 (SD = 20.75)
Experienced pregnancy 25.12 (SD = 9.93) 79.89 (SD = 41.77)
Total scores U.S. sample
Total sample
Never been pregnant
Experienced pregnancy
RSES PRQ85
34.24 (SD = 5.21) 99.41 (SD = 30.04)
36.36 (SD = 2.04) 102.56 (SD = 13.55)
30.32 (SD = 3.93) 89.89 (SD = 31.74)
Table 4 Regression tables.
Step1 RSES_T Constant PRQ85_T RSES_T PRQ85_T
B
S.E.
Wald
df
Sig.
Exp(B)
−.297 8.549 −.029 −.263 −.016
.101 3.079 .0.14 .103 .013
8.688 7.710 3.967 6.563 1.365
1 1 1 1 1
.003 .005 .046 .010 .243
.743 5160.707 .972 .769 .984
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
these constructs on whether a teen become pregnant. Self-esteem and social support were lower in the group of teenagers who have experienced pregnancy. In the DR, none of the study participants from the high school had ever been pregnant. The regional high school, located about one half mile from the downtown business area, draws students from the town, the surrounding campos and from poor rural campos as far as a 3 hour drive. Often students who lived a distance from the town would stay with a relative during the school week. Students came from all social strata. The majority of students who remained in school were from more intact extended families who were farmers, land-owners or small business owners. Attendance at school requires money for uniforms, books and transportation. The investigators, who have spent the last 15 years working in the DR, have had multiple opportunities to interact with teenagers in the larger town and the surrounding rural campos. Discussions with teenagers attending the high school indicated that the adults caring for them, parents or grandparents, had expectations that they would attend school. These teenagers were more focused on attending and finishing high school. The teenage girls also said that they knew a pregnancy would preclude their high school attendance or graduation. In the investigators' experience, as well as in this study sample, pregnant teenage girls in the DR do not marry and do not live with the father of their baby who are often 5 to 7 years older. The care of the baby is the responsibility of the teen, often with help from their mother or grandmother, older sister or aunt. Even though initially getting pregnant is sometimes viewed as a failure, young mothers are readily embraced into the social system of ‘mothers of young children’. Their families help them raise their children and there exists no incentive to return to school. In fact, many young mothers stated that they ‘could not’ return to school because they had a child. Although there are no stated rules within the school system there appears to be an unwritten policy of not accepting students who have had a child. Additionally, there is no opportunity to complete high school in a different format such as the GED as in the U.S. Even though these teenage mothers are supported in raising their children, they have little opportunity for good jobs without a high school diploma and generally end up poor. These observations and realities are not true in the U.S. It is typical for teenage mothers to return to high school after the birth of their children. In fact, the high school in the U.S. where the study sample was obtained from has an onsite day care and parenting program for teen mothers. One of the researchers practiced in the school based health center where data were collected for this study and stated that “one of the challenges in the Dominican community in Boston is that services are rich and readily available for teen mothers in the school system and community at large, thus the stigma of teen pregnancy is mitigated”. While the strong support teen mothers receive in the U.S. helps them raise their children, in some families, there is little stigma associated with teen pregnancy. Similar to the DR, teen mothers in the U.S. study sample lived with their families and were rarely supported by the father of the child. In contrast to the DR, often the teen mother returns to school in the U.S., bringing the child to the onsite daycare and continues to be involved in their same social circles. Schools are an important place to base pregnancy prevention interventions. In the U.S., it is required for children to attend school and in the DR, many children also attend at least grammar school. In addition to providing sex education curricula, schools should focus on helping young people, particularly girls develop positive self esteem. In recent studies by Chapman and Werner-Wilson (2008), and Karcher (2009), positive youth development and self esteem were noted to correlate with decreased risky behaviors. Sternas, Scharf, and Peterkin (2013) used a post intervention design and found that teenagers enrolled in pregnancy prevention interventions at school reported significant outcomes related to abstinence behaviors and attitudes than comparison group participants. The study findings that self-esteem and social support were lower in teens who been pregnant is an important finding as we try to influence
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teen pregnancy in the DR and the U.S. Teenage girls need to improve their self-esteem and schools should allow opportunities for girls to be successful in activities that will lead toward greater self-esteem. Since adolescent girls with stronger social support are less likely to get pregnant, families and communities need to support girls during their teenage years. Also, girls who drop out of school need strong social support to avoid early pregnancy. These are important findings and will help to inform the development of interventions aimed at preventing pregnancy by increasing self-esteem and building strong social support aimed at pregnancy prevention. Programs aimed at increasing self-esteem in early adolescence may prove to be beneficial in decreasing the teen pregnancy rate among Dominican adolescents in both the U.S. and the DR. Culture and ethnicity affect both personality and surrounding social conditions and are also important determinants in adolescent self-esteem and the prevalence of adolescent risk-taking behaviors (Babington, Kelley, & Patsdaughter, 2007). In the Dominican culture, both in the DR and the U.S., family cultural values support teen girls staying in school and avoiding pregnancy. One of the problems is that once the teen becomes pregnant, those same families continue to support the teen mother and help to raise the child. Interventions that strengthen the culturally based family value of preventing teen pregnancy may deter teens from getting pregnant in the first place. In addition to improving teen girls self esteem, providing information to families on the many issues related to teen pregnancy and providing them with the skills to have conversations with their children about pregnancy may result in preventing teen pregnancy. Therefore, the timing of adolescence presents a critical window of opportunity to intervene and help adolescents make healthy lifestyle decisions. Completing an education leads to better job opportunities and delaying pregnancy beyond the teen years results in healthier mothers and babies. Teen pregnancy is not only physically stressful for young mothers, but often leads to poverty and limited choices throughout their lives. Understanding what may influence pregnancy outcomes for adolescents will help those who work with teens develop culturally specific interventions aimed at improving adolescent health.
References Advocates for Youth. Early pregnancy can endanger the life and health of a child. retrieved February 15, 2014. http://www.advocates:foryouth.org/publications/ publications-a-z/432-the-impact-of-early-pregnancy-and-childbearing-onadolescent-mothers-and-their-children Ayres, C. G. (2008). Mediators of the relationship between social support and positive health practices in middle adolescents. Journal of Pediatric Health Care, 22(2), 94–102. Babington, L. M., Kelley, B. R., & Patsdaughter, C. A. (2007). Risk behaviors of Dominican adolescents in their homeland and in the United States. Journal of Pediatric Health Care, 21, 372–380. Babington, L. M., Kelley, B. R., & Patsdaughter, C. A. (2009). Self-esteem and risk behaviors of Dominican adolescents. Issues in Comprehensive Pediatric Nursing, 32, 131–144. Baldwin, S. A., & Hoffmann, J. P. (2002). The dynamics of self-esteem: A growth-curve analysis. Journal of Youth and Adolescence, 31(2), 101–113. Banos, R. M., & Guillen, V. (2000). Psychometric characteristics in normal and social phobic samples for a Spanish version of the Rosenberg self-esteem scale. Psychological Reports, 87, 269–274. Bearinger, L. H., Sieving, R. E., Jerguson, J., & Sharma, V. (2007). Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention and potential. Lancet, 369(9568), 1220–1231. Berry, E. H., Shillington, A. M., Peak, T., & Hofman, M. M. (2000). Multi-ethnic comparison of risk and protective factors for adolescent pregnancy. Child and Adolescent Social Work Journal, 17(2), 79–98. Brandt, P. A., & Weinert, C. (1981). The PRQ: A social support measure. Nursing Research, 30(5), 277–280. Butler, R. J., & Gasson, S. L. (2005). Self-esteem/self concept scales for children and adolescents: A review. Child and Adolescent Mental Health, 10(4), 190–210. Cantrell, B. (2006). Mediators of the relationship between social support and positive health practices in pregnant women. Nursing Research, 55(6), 427–445. Chapman, E., & Werner-Wilson, J. (2008). Does positive youth development predict adolescent attitudes about sexuality? Adolescence, 43(171), 505–523. Commendador, K. (2007). Relationship between female adolescent self-esteem, decision making, and contraceptive behavior. Journal of the American Academy of Nurse Practitioners, 19, 614–623. DeSocio, J. E., Holland, M., Kitzman, H. J., & Cole, R. E. (2013). The influence of social developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers. Research in Nursing & Health, 36, 158–170.
Please cite this article as: Babington, L.M., et al., Perceived social support, self esteem, and pregnancy status among Dominican adolescents, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.08.001
6
L.M. Babington et al. / Applied Nursing Research xxx (2014) xxx–xxx
Dumont, M., & Provost, M. A. (1999). Resilience in adolescents: protective role of social support, coping strategies, self-esteem, and social activities on experience of stress and depression. Journal of Youth and Adolescence, 28(3), 343–363. Elmer, N. (2001). Self esteem: The costs and causes of self worth. New York: Joseph Rowntree Foundation. Ethier, K. A., Kershaw, T. S., Lewis, J. B., Milan, S., Niccolai, L. M., & Ickovics, J. R. (2006). Self- esteem, emotional distress and sexual behavior among adolescent females: Inter-relationships and temporal effects. Journal of Adolescent Health, 38, 268–276. Fernandez, L. M., & Castro, R. Y. (2003). Age and sex differences in self-esteem among Spanish adolescents. Psychological Reports, 93(3), 876–888. Fleming, J. S., & Courtner, W. A. (1980). The dimensionality of self-esteem: Some results for a college sample. Journal of Personality and Social Psychology, 5, 921–929. Gordon, R. K. A., Ingersoll, G. M., & Orr, D. P. (1998). Longitudinal health endangering behavior risk among resilient and nonresilient early adolescents. Journal of Adolescent Health, 23(5), 297–302. Hoffman, S. (2006). By the numbers: The public costs of teen childbearing. Washington, DC: The National Campaign to Prevent Teen Pregnancy (Retrieved July 23, 2013, from http://www.thenationalcampaign.org/costs/pdf/report/BTN_National_Report.pdf). Hoffman, M. A., Ushpiz, V., & Levy-Shiff, R. (1988). Social support and self-esteem in adolescence. Journal of Youth and Adolescence, 17(4), 307–316. Joiner, G. W., & Kashubeck, S. (1996). Acculturation, Body Image, Self-Esteem, And EatingDisorder Symptomatology In Adolescent Mexican American Women. Psychology of Women Quarterly, 20, 419–435. Karcher, M. (2009). Increases in academic connectedness and self esteem among high school students who serve as cross-age peer mentors. Professional School Counseling, 12(4), 292–299. Kowaleski-Jones, L., & Mott, F. L. (1998). Sex, contraception and childbearing among high risk youth: Do different factors influence males and females? Family Planning Perspectives, 30, 163–169. Lorenzo-Hernandez, J., & Oullette, S. (1998). Ethnic identity, self-esteem, and values in Dominicans, Puerto Ricans, and African Americans. Journal of Applied Social Psychology, 28(21), 2007–2024. Mahat, G., Scoloveno, M. A., & Whalen, C. C. (2002). Positive health practices of urban minority adolescents. Journal of School Nursing, 18, 244–260. Mahon, N. E., Yarcheski, A., & Yarcheski, T. J. (2004). Social support and positive health practices in early adolescents: A test of mediating variables. Clinical Nursing Research, 13, 216–236. McNichols, S. L. (2001). An investigation of the mediators of the relationship between social support and positive health practices in middle-aged adults. (Doctoral dissertation). Dissertation Abstract International, 62. (pp. 1322). Rutgers: The State University of New Jersey, 1322. Meade, C. S., Kersaw, T. S., & Ickovics, J. R. (2008). The intergenerational cycle of teenage motherhood: An ecological Approach. Health Psychology, 27, 419–429. Orshan, S. (1999). Acculturation, perceived social support, self-esteem, and pregnancy status among Dominican adolescents. Health Care for Women International, 20, 245–257. Owens, R. T. J. (2001). Extending self-esteem theory and research. New York: Cambridge University Press. Portes, P. R., & Zady, M. F. (2002). Self-esteem in the adaptation of Spanish-speaking adolescents: The role of immigration, family conflict and depression. Hispanic Journal of Behavior Sciences, 24(3), 296–318. Phinney, J. S., Cantu, C. L., & Kurtz, D. A. (1997). Ethnic and American identity as a predictor or self-esteem among African American, Latino, and White adolescents. Journal of Youth and Adolescents, 26(2), 165–185.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Rosenberg, M. (1989). Society and adolescent self-image. Middletown, CT: Wesleyan University Press. Sibler, E., & Tippett, J. S. (1965). Self-esteem: Clinical assessment and measurement of validation. Psychological Reports, 16, 1017–1071. Statistical Package for the Social Sciences, Inc. (2005). SPSS 14.0 [computer software]. Chicago, IL: SPSS, Inc. Sternas, K. A., Scharf, M. S., & Peterkin, R. M. (2013). Teenage pregnancy prevention: Comparison of outcomes for teenage girls and boys participating in an evidence-based intervention. Abstract from 24th International Nursing Research Congress, Sigma Theta Tau, July 22–26, 2103 (Retrieved July 24, 2013 from https://stti.confex.com/stti/ congrs13/webprogram/Paper56865.html). United Nations Statistic Division (2011). Demographic Yearbook (2009-2010) Retrieved September 20, 2014 from http://unstats.un.org/unsd/demographic/products/dyb/ dyb2009-2010/notes/notes01.pdf. Weinert, C. (1987). A social support measures: PRQ85. Nursing Research, 36(5), 273–277. Weiss, R. (1974). The provisions of social relationships. In Z. Rubin (Ed.), Doing unto Others (pp. 1702). Englewood Cliffs, NJ: Prentice-Hall. Wilkinson, R. B. (2004). The role of perental and peer attachment in the psychological health and self-esteem of adolescents. Journal of Youth and Adolescents, 33(6), 479–493. Winters, N. C., Myers, K., & Proud, L. (2002). Ten-year review of rating scales, III: Scales assessing suicidality, cognitive style, and self-esteem. Child & Adolescent Psychiatry, 41(10), 1150–1181. World Health Organization (2007). Adolescent Pregnancy: Unmet needs and undone deeds. (Retrieved July 24, 2013 from http://whqlibdoc.who.int/publications/2007/ 9789241595650_eng.pdf). World Health Organization (2012a). Adolescent pregnancy fact sheet. (Retrieved July 24, 2013 from http://www.who.int/maternal_child_adolescent/topics/maternal/ adolescent_pregnancy/en/index.html). World Health Organization (2012b). Adolescent reproductive health: What needs to be done to promote the sexual and reproductive health of adolescents and to prevent adolescent mothers and their babies from dying in pregnancy? (Retrieve July 24, 2013 from http://www.who.int/maternal_child_adolescent/topics/maternal/ reproductive_health/en/index.html). World Health Organization (WHO): Department of Child and Adolescent Health and Development Family and Community Health (2004a). Risk and protective factors affecting adolescent reproductive health in developing countries: An analysis of adolescent sexual and reproductive health literature from around the world. Geneva: WHO. World Health Organization (WHO): Department of Child and Adolescent Health and Development Family and Community Health (2004b). Risk and protective factors affecting adolescent reproductive health in developing countries: An analysis of adolescent sexual and reproductive health literature from around the world. (Retrieved February 15, 2014 from http://158.132.116.146/adh/2_AD_sexual_reproductiveH/WHO%20-% 20Risk%20and%20protective%20factors%20affecting%20ASRH%20in%20developi.pdf). Yarcheske, A., Mahon, N. E., & Yarcheske, A. (2004). Depression, optimism, and positive health practices in young adolescents. Psychological Reports, 95, 932–934. Yarcheske, A., Mahon, N. E., & Yarcheski, T. J. (1992). Validation of the PRQ85 social support measure for adolescents. Nursing Research, 41(6), 332–337. Yarcheske, A., Mahon, N. E., & Yarcheski, T. J. (2001). Social support and well-being in early adolescents: The role of mediating variables. Clinical Nursing Research, 10, 99–103.
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