University of Connecticut OpenCommons@UConn UCHC Graduate School Masters Theses 2003 - University of Connecticut Health Center Graduate 2010 School 2010 Adolescent Pregnancy Prevention in San Jose, Costa Rica : Assessment of an Educational Intervention Alexandra Devin Mainiero University of Connecticut Health Center Follow this and additional works at: https://opencommons.uconn.edu/uchcgs_masters Part of the Public Health Commons Recommended Citation Mainiero, Alexandra Devin, "Adolescent Pregnancy Prevention in San Jose, Costa Rica : Assessment of an Educational Intervention" (2010). UCHC Graduate School Masters Theses 2003 - 2010. 159. https://opencommons.uconn.edu/uchcgs_masters/159 Adolescent Pregnancy Prevention in San Jose, Costa Rica: Assessment of an Educational Intervention Alexandra Devin Mainiero B.A., Stanford University, 2005 A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health at the University of Connecticut 2010 APPROVAL PAGE Master of Public Health Thesis Adolescent Pregnancy Prevention in San Jose, Costa Rica: Assessment of an Education Intervention Presented by Alexandra Devin Mainiero, B.A. Major Advisor_____________________________________________________ Judy Lewis, M.Phil Associate Advisor__________________________________________________ Stephen L. Schensul, Ph.D. Associate Advisor__________________________________________________ Stacey L. Brown, Ph.D. University of Connecticut 2010 ii Acknowledgements I would like to thank a number of people for their contributions to this thesis: • Prof. Judy Lewis, my major advisor, who inspired me to pursue global health research and who guided me each step of the way throughout my MPH work, both personally and professionally. • Dr. Mario Tristan, Director of IHCAI, who works tirelessly to improve the health conditions of communities in Costa Rica and who welcomed me to his country, his foundation, and to his adolescent pregnancy prevention project. • Marcelo Abarca, Yuri Baidal, Alba Vargas, and Julia Antich, the outstanding Spanish instructors who gave me the confidence and ability to speak Spanish and helped with official study translations. • Diana Cordero and Pamela Valencia, my conscientious research assistants without whom this study would have no data to analyze. • Jeanette Flores Vivas who cared for me every day at IHCAI. • Margarita Chinchilla, Anabel Meza, and Lila Marin, my wonderful host mothers who welcomed me into their homes during my stay in Costa Rica. • Dr. Steven Schensul and Dr. Stacey Brown, my associate advisors, for bringing their unique perspectives to this project. • Barbara Case, for her helpfulness and unending patience with my repeated organizational questions over the last five years. iii Table of Contents Acknowledgements 1. Introduction…………………………………………………………………………...1 2. Background……………………………………………………………………..........3 Adolescent Pregnancy: The Problem…………………………………3 Global Epidemiology…………………………………………………....4 Risk and Protective Factors……………………………………………5 Pregnancy Prevention Programs……………………………………...5 Breaking the Cycle……………………………………………………...8 Plain Talk……………………………………………………………….10 Choose Life…………………………………………………………….11 Effects of the School Environment…………………………………..13 Costa Rica……………………………………………………………………...14 Land and People……………………………………………………….14 Political System………………………………………………………..16 Economy………………………………………………………………..16 Education……………………………………………………………….17 Health Care…………………………………………………………….19 IHCAI Foundation.……………………………………………………………21 Purral Region…………………………………………………………..22 Education Initiative…………………………………………………….23 3. Research Goal………………………………………………………………………25 4. Logic Model and Hypotheses……………………………………………………...26 Definitions.……..………………………………………………………………27 5. Methods……………………………………………………………………………..29 Study Population………………………………………………………………29 iv Recruitment…………………………………………………………………….30 Survey Instrument……………………………………………………………..32 Permissions and Approvals…………………………………………………..33 Statistical Methods…………………………………………………………….33 6. Results……………………………………………………………………………….36 7. Discussion…………………………………………………………………………...65 8. Study Limitations……………………………………………………………………84 9. Recommendations………………………………………………………………….86 10. Conclusions………………………………………………………………………..90 11. References…………………………………………………………………………92 Appendix A……………………………………………………………………………..95 v Introduction This thesis explores adolescent pregnancy in San Jose, Costa Rica and examines a school-based pregnancy prevention intervention. The relationships between school, gender and risk of adolescent pregnancy are also analyzed, and recommendations are made for effective pregnancy prevention programming. The Purral region of Guadalupe on the outskirts of San Jose, Costa Rica, suffers a higher rate of adolescent pregnancy compared to the rest of the country. In response to this problem, the International Health Central American Institute (IHCAI) implemented a sexual health education program in two local secondary schools in 2006. Very little information about the program is available. It is known that the program was initially evaluated through assessments of the participants’ knowledge before and after the educational sessions. There was no evaluation of the youth attitudes or behaviors, adolescent pregnancies, or long- term impact. The author worked with IHCAI in San Jose, Costa Rica to perform an assessment of the longer term effects of this sexual health education program. They developed a questionnaire to evaluate the knowledge, attitudes, and behaviors surrounding sexual health of youth in the Purral community. Researchers at IHCAI later used this survey to collect data from adolescents who had participated in the educational intervention and those who had not. This thesis analyzes the data collected by IHCAI to assess the effectiveness of the - 1 - educational intervention and the influence of other factors on the knowledge, attitudes, and behaviors of adolescents in the Purral region. The thesis begins with an overview of adolescent pregnancy, Costa Rica and the Purral region, and a description of the education intervention implemented by IHCAI. The research goal, logic model, and methods are then described. The results are reported, and the thesis then concludes with discussion of the results as well as study limitations and recommendations for future research and intervention. This thesis will be used to guide IHCAI’s continuation and expansion of adolescent pregnancy prevention programming. - 2 - Background Adolescent Pregnancy: The Problem Childbearing during adolescence is a major issue in public health because of its consequences for young women, their children, their families, and society as a whole. Worldwide, pregnancy and childbirth related deaths are the leading killers of females between the ages of 15 and 19 years.1 The physical process of pregnancy is more dangerous during adolescence than adulthood, with teenage mothers at an increased risk for preeclampsia as well as obstructed labor. 2 Prolonged labor can lead to death or permanent disability from obstetric fistula, and because adolescents are also less likely to have a skilled birth attendant present during delivery, the risk of these complications is further increased. 3 In addition, over 2.2 million adolescents undergo illegal and unsafe abortions each year which puts them at risk for infection, future fertility problems, and death. 4 Not only are the adolescents themselves at risk, but infants born to adolescent mothers have a higher risk for low birth weight, SIDS, accidents, and hospitalization in the first year of life.5 The social impact of childbearing during adolescence is also considerable, as these mothers are more likely to be single parents, to have greater numbers of children overall, and to earn less income and attain less education than women who delay childbearing until age 20 or later.6 Furthermore, adolescent mothers are at high risk for dysfunctional maternal-infant attachment, which puts the child at greater risk for long term psychological dysfunction.7 Carol Buvinic - 3 - found in her research in Chile, Barbados, Guatemala and Mexico that a dichotomy exists between poor and non-poor teenage mothers. Poor women who became pregnant during adolescence had lower income over their lifetime than poor women who delayed childbearing, yet no income difference exists for non-poor women regardless of when they first became pregnant. Adolescent pregnancy, therefore, serves to entrench poverty by limiting already poor women’s incomes. Furthermore, low socioeconomic status is a known risk factor for adolescent pregnancy,8 creating a vicious cycle. Global Epidemiology Worldwide, the average rate of births per 1000 females age 15-19 years is 65.9 This figure varies significantly depending upon region; see Table 1 below for a list of selected regions and countries. Table 1. Births per 1000 females age 15-19 years10 Sub-Saharan Africa 143 Middle East and Northern Africa 56 East/South Asia and Pacific 56 Latin America 78 Costa Rica 89 USA 60 Canada 24 Europe 25 - 4 - Risk and Protective Factors Many factors have proven to be associated with both increased and decreased rates of teen pregnancy. In a 2004 discussion paper on adolescent pregnancy, the World Health Organization described the following associations.11 Poverty is universally related to higher rates of adolescent pregnancy. In the United States this translates to greater incidence of teen pregnancy in minority populations, as they are more often poor. In many countries young age at marriage