Running Head: a Socio-Ecological Approach

Socio-Ecological Approach 1 Running head: A Socio-Ecological Approach

1. A Socio-Ecological Approach to Preventing Adolescent Pregnancy

2. Dominique Brown

3. Concordia University

MPH 515 Socio-Ecological Approach 2 4. Abstract

Today, adolescent pregnancy continues to reach epidemic proportions impacting society both socially and economically. In this paper, the need for effective pregnancy prevention programs geared toward teenage girls will be discussed. The need for programs that are designed around the framework of the socio-ecological model will be emphasized as one of the most efficacious approaches to tackling this widespread public health threat. The multiple social levels that influence and factors into the increased risk of teenage pregnancy and the barriers toward adopting safer sex behaviors will be analyzed. HOPE, a program developed following the socio-ecological approach will be highlighted throughout this paper. Socio-Ecological Approach 3 5. A Socio-Ecological Approach to Preventing Adolescent Pregnancy

Pregnancy is simply defined as 'the condition of a woman that is going to have a baby'

(Merriam Webster, 2013). It is described as the period from conception to birth and usually lasts 40 weeks. Pregnancy is typically associated with the maternal physiological changes that occur as a baby grows inside of a woman's womb. Unfortunately, what is often not discussed is that along with physical changes, pregnancy also impacts a woman's social life. In the case of teenage pregnancy this is particularly true. Teenage pregnancy is described as a pregnancy that occurs during a woman's adolescent years of 13-19. In fact, not only is teenage pregnancy more of a challenge socially than an adult pregnancy, but it can be physically even more demanding as it elevates the health risk for both mother and baby. Nevertheless, this has not prevented the United

States from having one of the highest teen pregnancy rates in the western industrialized world.

Despite, its efforts to tackle teenage pregnancy, prevention programs have not been able to find an approach that does away with this public health problem. After careful consideration of why a prevention program needs to do more than what is being done now, highlights focusing on a socially designed program named HOPE will be discussed.

Due to its widespread and frequent nature, teenage pregnancy has often been described as an epidemic. It has gained national attention from concerned parents, religious leaders, and public health officials. Although, teen birth rates have seen a decline over the last several years, socioeconomic, racial and ethnic disparities continue to persist (CDC, 2013). The epidemic of teenage pregnancy, with nearly 4 of every 10 teenage girls becoming pregnant at least once before the age of 20, has often been depicted as a new adolescent obstacle or unprecedented problem that requires advanced intervention, but the problem is not new nor does it require advanced services

(Vinovskis,1988). In fact, many of the interventions that currently exist have been quite successful in helping to reduce the amount of annual teenage pregnancies that occur. So the problem is not that the majority of prevention programs are not modernized, it is that they are not specialized; and Socio-Ecological Approach 4 unless the efficacy of attempts to solve this problem are not critically analyzed and carefully considered and evaluated- premature sexual activity, teenage pregnancy, and teenage parenting will continue to reveal the undeniable flaws that comprise the teenage prevention programs of both past and present.

Prevention programs for adolescent pregnancy often focuses its attention on the consequences that are associated with teenage pregnancy. Fear appeals are frequently used to arouse fear in teenagers in hopes it will modify risky behavioral choices and habits. Unfortunately, campaign attempts at inciting fear without properly educating teenagers does little to help this predicament that undeniably impacts public health, but is ultimately deeply rooted as a social problem. "Effective campaigns are desperately needed to combat the serious social problem of teen pregnancy" (Witte, 1997). In order for this to occur, campaign messages need to work in conjunction with other social networks to combat optimistic bias among teenagers, positive attitudes toward teenage pregnancy, negative attitudes toward obtaining and using birth control, and also highlight the negative consequences associated with sexual intercourse outside of pregnancy

(Witte, 1997). Effective prevention programs need to be specifically designed and distinctively tailored to meet the needs of the target audience.

In 2011 alone, nearly 330,000 babies were born to women aged 15–19 years of age (CDC,

2012). This statistic is reported as a positive outlook on the future of teenage pregnancy seeing as it is a decline of 8% from 2010. Realistically however, the United States is still faced with hundreds of thousands of young women who are becoming pregnant unprepared. In 2008, teen pregnancy and subsequent childbirth accounted for an annual amount of nearly $11 billion in costs to taxpayers in the United States. This burden on taxpayers was due to consequences associated with teenage pregnancy. These young women are often ill prepared financially, emotionally, and mentally, and as a result are unable to meet the needs of their children's health care and nutritional costs. Higher rates of both foster care and incarceration among children of teenage parents have also been the result of inadequate preparedness to parenting among teenage mothers. Teenage pregnancy also Socio-Ecological Approach 5 increases the risk that young women will drop out of high school, aspire to lower career aspirations, and live a life encircled in poverty (Domenic & Jones, 2007). The Centers for Disease Control and

Prevention (CDC) reports that only about 50% of teen mothers receive a high school diploma by the age of 22. For this reason, it is imperative that developers for prevention programs understand their audience. This includes the cultural makeup of the teenage girls, the financial limitations they face, the time restraints associated with being in school, and for many today, the linguistic diversity.

The problem with many teenage prevention programs is that it does not tailor its curriculum to meet the needs of specific communities. Many teenagers are excluded by prevention programs due to their limited accessibility to them. Effective prevention programs acknowledge a young person's limited finances to travel far distances or afford health clinic sponsored prevention education programs. In this respect, many of the most effective pregnancy prevention programs for teenagers have been linked to school based approaches, but that does not mean other approaches are not influential in tackling this epidemic nor does it mean that all young women will benefit from a school based approach (Frost & Forrest, 1995).

A major issue in many schools have always been the debate between the abstinence only approach versus the comprehensive sex education approach which continues to create divisions in the way young people are educated about sexual health. Effective teenage pregnancy prevention programs also consider the stigma often attached to many of the pregnancy prevention methods and seek to engage the young women in programs that boost self efficacy, knowledge, and helps to build such life skills as efficient and thoughtful decision making. Working with diverse communities linguistically, culturally, ethnically and morally is something that a prevention program for teenage pregnancy also considers during the design and development stage.

During the development stage of a teen pregnancy prevention program it is also wise to consider the causes and risk factors of why teenage pregnancy occurs. Many studies have been conducted on this issue and should be considered as a guide to tackle risk factors. The etiology of teen pregnancy has often been associated with young women who struggled in academic Socio-Ecological Approach 6 performance in school, young women who came from a family of economic disadvantage, young women who were romantically involved with older male partners, and young women raised by single or teen parents themselves (PubMed Health, 2011). These risk factors emphasize the social connectivity teenage pregnancy is so closely linked to. Teenage pregnancy is a deeply rooted social issue that undeniably impacts public health. Although, it may not seem that way at first as it is not a health issue like cardiovascular disease or cancer, but upon careful research and consideration, one can see how it does require broad-based preventative action as is the case with all of these areas.

Effective prevention programs for teen pregnancy must keep this close link in mind when developing approaches to this problem.

Some examples of approaches of both past and present that were designed to focus on adolescent pregnancy prevention utilized various methods to tackle this problem. In 1984, Dr.

Carrera and The Children's Aid Society developed an Adolescent Pregnancy Prevention Program that sought to empower youth by way of using a holistic approach. The objective of the prevention program was to help teens develop goals for their future, while simultaneously educating them about the consequences of sexual activity. This approach sought to boost self efficacy and helped to build decision making skills. The holistic model considers the whole of a person and emphasizes the interconnection between all parts of a person. The next example used a different method to encourage safe sex habits in its attempt to reduce teenage pregnancy. In New York City (NYC) the

Human Resource Administration's department of social services developed a campaign that centered its approach around the health belief model with an emphasis on fear appeal. The campaign used persuasive messages in an attempt to scare young women from becoming teenage mothers. The next example is similar in that is uses the health belief model, but the similarities cease there. The health belief model used in a program named Teen Pep focuses on both perceived severity and perceived susceptibility and is a peer to peer education group. By having teenagers speak to other teenagers using modern linguistics and conceivably common interests, this program used a different angle to help reduce the likelihood of teen pregnancy. The most effective type of Socio-Ecological Approach 7 program, however, will seek to use the highlights of all these programs in its design and development.

Understandably, teen pregnancy is an epidemic that has spanned more than a few decades and has caused concern throughout society. It is apparent effective programs are needed to step in and tackle this issue. The program developed for the purpose of this assignment was designed with all of those factors taken into consideration. It was designed using the socio-ecological model to tackle the deeply rooted social issues that comprise this public health threat (Bonell, 2004).The program,

Hope through Outreach and Prevention Education (HOPE) focuses its attention on prevention efforts that considers the factors that influence behaviors. It is imperative to create a program that analyzes behavior as a result of many of its influences.

The socio-ecological model provides a pragmatic framework to understand the multiple factors and barriers that impact sexual behaviors(Robinson, 2008). The socio-ecological model provides a framework to develop effective prevention programs. It is a multiple level approach that examines a person's social influences individually and then the relation in parallel to one another.

The levels examined in application of this model are: societal, community and organizational, interpersonal, and individual. The program HOPE will be designed into curriculum format for the appropriate grade levels of middle and high school students. HOPE will pair with community health clinics, community outreach centers, and cooperative churches and other interfaith groups led by innovative respected leaders to reach a larger audience. In an effort to develop an effective program,

HOPE does not seek to reinvent the wheel, but in fact, use what has been the strengths of many of its predecessors and design a program that will reduce this public health threat. In doing so, the program HOPE seeks to incorporate the socio-ecological levels of social influences in its teen pregnancy prevention program with the objective of reducing teen pregnancy rates among young women but also to increase safer sex practices as a whole.

Mass media in all its channels whether through television, magazines, movies, music, or the

Internet provides frequent portrayals of sexuality (Brown,2010). In today's technologically Socio-Ecological Approach 8 advanced world, teenagers have more access to mass media than they have ever had in previous generations. So this level of influence is incredibly imperative to evaluate. HOPE's approach to this level of influence is to survey the teenagers prior to beginning the program, about their favorite television shows, music artists, and magazines in an attempt to remain one step ahead, so to say. In having an idea what teenagers interests are, group leaders and health educators working with HOPE can use "teachable moments" from episodes still fresh on the minds of these teenagers. For example, if the main characters in the previous night's favorite television program engaged in sexual activity, group leaders can use this as a perfect beginning point of conversation the next day during the prevention program meeting. Additionally, media, in the form of advertisements, will also be used to bring awareness about the program. Social media is also a great way to connect and disseminate information to a large number of teenagers in today's world. It can help the program challenge misrepresentations about sex education, birth control and other misconceptions young people may have regarding prevention. Controversy about sexual implications in today's music occurs frequently, group leaders and health educators can use this as another opportunity to discuss and reflect about messages that are sent out about sex. Reflective discussions about sex can create ample opportunities for health educators to dismiss and tackle media's misconstrued depiction of sex that much too often are the only messages that these young women receive. Fighting teen pregnancy on this level also involves battling inhibitions created by society that does little to encourage adopting healthier sex behavior choices. Teenager's 'concerns with how others perceive and evaluate them can lead to behaviors that increase the risk of { pregnancy}' (Leary,Tchividijian

& Kraxberger, 1994). HOPE seeks to combat stigmas associated with the purchasing of condoms, carrying and using condoms as well as contraceptives by attempting to increase self confidence and helping to build the skills of better decision making in the teenagers by using the holistic approach like the Children's Aid Society.

Another component to consider are the way many pregnancy prevention methods are obtained. Often, health insurance covers a person's contraceptive services. In a case with teenagers, Socio-Ecological Approach 9 it is very likely that they are still insured by parents and other guardians that they are in care of.

HOPE will work with health clinics, in this manner, to help provide health insurance to uninsured teenagers and link both already insured and newly insured teenagers to other low cost and free service options that are available to them. It is imperative that teenagers are able to have services that they feel are easily accessible to them. Health educators working with HOPE will also consider pre and post testing participants of the program about national, state, and local laws associated with contraceptives and health insurance. Knowledge and an understanding of these things will help teenagers move positively through society's level of influence.

The next level of the socio-ecological model takes into consideration how the community influences and contributes to teenage pregnancy. On this level, debates regarding how students are taught, if at all, about sex is explored. Seeing as how everyone is entitled to and justifiably so has an opinion about sexuality education, debates surrounding whether to apply for federal funding for abstinence-only-until-marriage programs or more comprehensive sexuality programs, or both, or neither often occur (Malone& Rodriguez, 2011). While everyone is entitled to their reasons as to why a certain program fits their morals, values and lifestyle choices, HOPE believes teenagers should be provided with options. HOPE ensures that a linguistically appropriate comprehensive sex education curriculum is developed that emphasizes the benefits of abstinence. Although, much debate will circulate around the approach , past studies have revealed the stronger and more effective unplanned pregnancy prevention programs are usually the result of a comprehensive sex education curriculum (Advocates for Youth, 2009).

The next level of the socio-ecological model focuses on the interpersonal influences of teenage pregnancy. This may in fact be one of the most influential and challenging levels of this model. This level asks prevention programs to examine familial and peer relationships that impact the decisions and choices of many teenagers. In the instance of teenage pregnancy, often teenagers are influenced by attitudes, values and cultural norms of the people around them. This can work both as a benefit and as a risk factor. Family structure is considered as a major factor that Socio-Ecological Approach 10 contributes to adolescent pregnancy (Domenico & Jones, 2007). Often young women at risk of teen pregnancy come from unstable family situations and parents that showed lack of affection. The absence of fathers is also noted as a strong factor in increased risk of adolescent pregnancy.

Keeping this in mind, HOPE will encourage parents and other guardians to participate in monthly sessions to help foster better relationships between these young women and their parents. These sessions will include answering parents questions about how to talk to their teenagers about sex and how they feel about new FDA approvals like that of the Plan B One step being accessible to girls as young as 15. These sessions will allow health educators working with HOPE to educate parents on many topics that they may not be sure about themselves. It will also open discussions about how parents and prevention programs working together are the most effective approach at protecting youth. Unfortunately, not even the most effective of programs can force a relationship with resistant or absent parents, but HOPE will provide both older and peer female and male mentors to work with the young women so as to help reduce the risk of pregnancy. Friends are also cited as being a major influence on this level of the socio-ecological model. HOPE intends on promoting events like game nights and movie nights to allow participants of the program to introduce friends to the program. In an effort to reach as many youth as possible, events will also include young men to help increase awareness of safer sex practices for everyone.

Lastly, the socio-ecological model discusses the individual influences that increase the chances of teen pregnancy. In this aspect, HOPE seeks to use the program as a foundation for teaching young women skills to build self confidence in uncomfortable situations. One activity in particular, HOPE seeks to use is reenactment. By reenacting uncomfortable situations in small groups within the program, that may involve encouraging young women to say "NO" or "Let's use a condom" it may help to build effective techniques when these young women deal with these scenario's in real life. The most important component of this level is encouragement. This level requires that young women believe they can prevent pregnancy and they are capable of adopting safe sex practices. This level is centered around self-efficacy. Socio-Ecological Approach 11 By applying the socio-ecological model to an adolescent pregnancy prevention program, multiple levels of how social influences impact young women are measured, examined and tackled.

For a problem like that of teen pregnancy where the matter is deeply rooted in issues revolving around social influences, this model allows a health professional to intervene and create strategies at each level of influence. A program like HOPE takes the highlights of its predecessors and develops a program that meets the needs of young women in today's modern world. Today, where the accessibility to information is both a curse and a blessing, it is imperative that prevention programs are designed with a keen awareness of how to use opportunities at every level to address the impact social influences may have on a teenagers capability to adopt safer sex practices. In this regard,

HOPE has been developed to be that program.

11. References

Advocates for Youth. (2009, September). Comprehensive sex education: Research and results.

Retrieved from http://www.advocatesforyouth.org/publications/1487

Bonell, C. (2004). Why is teenage pregnancy conceptualized as a social problem? a review of

quantitative research from the USA and UK. JSTOR,6(3), 255-272. doi:

10.1080/13691050310001643025

Brown, J. (2002). Special issue: Promoting sexual health and responsible sexual behavior. Journal

of Sex Research, 39(1), doi: 10.1080/00224490209552118

CDC. Centers for Disease Control and Prevention, (2012). About teen pregnancy. Retrieved from

website: http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm Socio-Ecological Approach 12 CDC. Centers for Disease Control and Prevention, (2013).Teen birth rates drop, but disparities

persist. Retrieved from website: http://www.cdc.gov/features/dsTeenPregnancy/

Domenico, D., & Jones, K. (2007). Adolescent pregnancy in America: Causes and responses . The

Journal for Vocational Special Needs Education, 30(1), Retrieved from

http://files.eric.ed.gov/fulltext/EJ841380.pdf

Frost, J., & Forrest, J. (1995). Understanding the impact of effective teenage pregnancy prevention

programs. Family Planning Perspectives, 27(5), Retrieved from

http://sparky.guttmacher.org/pubs/journals/2718895.html

Leary, M., Tchividijian, L., & Kraxberger, B. (1994). Self-presentation can be hazardous to your

health: Impression management and health risk. Health Psychology, 13(6), 461-470. doi:

10.1037/0278-6133.13.6.461

Malone, P., & Rodriguez, M. (2011). Comprehensive sex education vs. abstinence-only-until-

marriage programs. Human Rights magazine , 38(2), Retrieved from

http://www.americanbar.org/publications/human_rights_magazine_home/human_rights_vol3

8_2011/human_rights_spring2011/comprehensive_sex_education_vs_abstinence_only_until_

marriage_programs.html

Merriam Webster's Dictionary. (2013). pregnancy. Retrieved from http://www.merriam-

webster.com/dictionary/pregnancy

PubMed Health. (2011). Adolescent pregnancy. Adolescent pregnancy, Retrieved from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002484/

Robinson, T. (2008). Applying the socio-ecological model to improving fruit and vegetable intake

among low-income African Americans. J Community Health,33, 395-406. doi:

10.1007/s10900-008-9109-5

Witte, K. (1997). Preventing teen pregnancy through persuasive communications: realities, myths,

and the hard-fact truths. Journal of Community Health, 22(2), 137-54. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/9149955 Socio-Ecological Approach 13 Vinovskis, M. (1988). An "epidemic" of adolescent pregnancy? some historical and policy

considerations. ERIC, 298. Retrieved from http://eric.ed.gov/?id=ED352430