Walden University

COLLEGE OF EDUCATION

This is to certify that the doctoral study by

Lynette Collins

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.

Review Committee
Dr. Carol Philips, Committee Chairperson, Education Faculty
Dr. Esther Javetz, Committee Member, Education Faculty
Dr. Miranda Jennings, University Reviewer, Education Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University
2016
 Abstract

Knowledge, Attitudes, and Beliefs About Preconception Care Among American

Adolescent Females

by

Lynette A. Collins

BSN, Loyola University, 1992

MN, Louisiana State University Health Sciences Center, 1996

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Education

Walden University

August 2016
 Abstract

Despite an initiative to provide preconception care (PCC) and reproductive life planning

(RLP) for all women of childbearing age, many women, especially those with low

incomes, are not receiving it. As a result, there continues to be a high rate of infant

morbidity and mortality in this population. Furthermore, low income adolescent females

have not been adequately studied regarding this phenomenon. The purpose of this

phenomenological study was to explore low income adolescent females’ knowledge,

attitudes, and beliefs about PCC and RLP in order to serve them more effectively. Five

low income adolescent females, aged 18 to 21, were recruited through criterion sampling

and they each engaged in 2 individual in-depth interviews. The health belief model,

social cognitive theory, and adolescent affective and cognitive theory were the conceptual

frameworks used to develop the interview guide, conduct the interviews, analyze the

data, and formulate the recommendations for future studies. Moustakas’s

phenomenological interview process was used as a guiding framework to prepare and

conduct the interviews. Qualitative data were analyzed using Moustakas’s modified

version of the Stevick-Colaizzi-Keen method of analysis. Findings were that participants

(a) had no experiences with PCC or RLP, (b) lacked knowledge about preparing for

pregnancy, (c) had negative interactions with medical personnel, and (d) wanted more

information about PCC and RLP. Further research is recommended to examine current

PCC/RLP practices, conduct additional PCC studies of adolescents, and develop

culturally- and age-appropriate PCC programs. Findings from these studies could

improve both the lives of the adolescents and the health of their offspring.
Knowledge, Attitudes, and Beliefs About Preconception Care Among American

Adolescent Females

by

Lynette A. Collins

BSN, Loyola University, 1992

MN, Louisiana State University Health Sciences Center, 1996

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Education

Walden University

May 2015
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 Dedication

I would like to dedicate my doctoral study to the most important people in my

life, my family. Thank you to my supportive husband who has encouraged me through

this very long process. I also want to thank my children and grandchildren who have also

encouraged and been a source of joy between revisions.

 Acknowledgments

I would like to express my deep gratitude to my committee members for sharing

their knowledge and insight through this endeavor. I especially would like to thank my

Chairperson, Dr. Carol Philips, whose mentoring and guidance has helped me to

complete this doctoral study. I would also like to thank the participants who shared their

experiences and made this study complete.

 Table of Contents

Section 1: Introduction to the Study ....................................................................................1

Background ....................................................................................................................1

Problem Statement .........................................................................................................5

Nature of the Study ........................................................................................................6

Research Questions ........................................................................................................9

Purpose of the Study ......................................................................................................9

Conceptual Framework ................................................................................................10

Health Belief Model .............................................................................................. 10

Social Cognitive Theory ....................................................................................... 13

Adolescent Affective and Cognitive Theory ........................................................ 15

Utilization of Theories .......................................................................................... 17

Operational Definitions ................................................................................................18

Assumptions.................................................................................................................20

Limitations ...................................................................................................................20

Scope and Delimitations ..............................................................................................21

Significance of the Study .............................................................................................22

Social Change ..............................................................................................................22

Conclusion ...................................................................................................................23

Section 2: Literature Review .............................................................................................24

Introduction ..................................................................................................................24

Review of Related Research ........................................................................................24

i
 Medical Conditions Known to Affect Pregnancy ................................................. 25

Routine PCC in College Women .......................................................................... 27

Routine PCC in Childbearing Women .................................................................. 31

Routine PCC in Adolescent Women..................................................................... 32

Conceptual Frameworks ..............................................................................................35

Health Belief Model .............................................................................................. 35

Social Cognitive Theory ....................................................................................... 37

Adolescent Affective and Cognitive Theory ........................................................ 40

Qualitative Design .......................................................................................................43

Phenomenological Methodology .................................................................................44

Implications..................................................................................................................48

Summary ......................................................................................................................49

Section 3: Research Method ..............................................................................................51

Introduction ..................................................................................................................51

Qualitative Tradition ....................................................................................................51

Research Questions ......................................................................................................54

Contexts for the Study .................................................................................................54

Driftwood Housing Development ......................................................................... 55

Bayou Apartments ................................................................................................ 56

Measures for Ethical Protectio .....................................................................................57

Role of the Researcher .................................................................................................57

Researcher as Instrument ...................................................................................... 58

ii
 Researcher-Participant Relationship ..................................................................... 58

Relationship to Participants .................................................................................. 59

Researcher’s Interview Experience....................................................................... 59

Criteria for Selecting Participants ................................................................................60

Convenience Sampling ......................................................................................... 61

Snowball Sampling ............................................................................................... 61

Purposeful Sampling ............................................................................................. 62

Selection of Sampling Strategies .......................................................................... 62

Participant Selection ............................................................................................. 63

Data Collection Strategies............................................................................................64

Data Collection Steps ...................................................................................................65

Data Analysis Plan .......................................................................................................66

Horizontalization................................................................................................... 66

Textural Description ............................................................................................. 67

Structural Description ........................................................................................... 67

Textural-Structural Description ............................................................................ 68

Composite Textural-Structural Description .......................................................... 68

Reliability.....................................................................................................................70

Summary ......................................................................................................................70

Section 4: Results...............................................................................................................71

Introduction ..................................................................................................................71

Steps of Reviewing and Analyzing Data .....................................................................71

iii
Participant A ................................................................................................................72

Biographical Information ...................................................................................... 72

Textural-Structural Description of Participant A .................................................. 73

Participant B.................................................................................................................75

Biographical Information ...................................................................................... 75

Textural-Structural Description of Participant B .................................................. 75

Participant C.................................................................................................................78

Biographical Information ...................................................................................... 78

Textural-Structural Description of Participant C .................................................. 78

Participant D ................................................................................................................81

Biographical Information ...................................................................................... 81

Textural-Structural Description of Participant D .................................................. 81

Participant E .................................................................................................................84

Biographical Information ...................................................................................... 84

Textural-Structural Description of Participant E .................................................. 85

Composite Textural-Structural Description of Themes and Essences .........................88

Composite Description of Themes...............................................................................90

Negative Interactions with Medical Personnel ..................................................... 90

No Experiences with PCC .................................................................................... 91

No Experiences with RLP ..................................................................................... 92

Inaccurate Knowledge About the Relationship Between Unprotected Sex

and Pregnancy ........................................................................................... 92

iv
 Lack of Knowledge About Preparing for Pregnancy ............................................ 93

Miscommunication ............................................................................................... 93

Methods to Address Trustworthiness...........................................................................93

Summary ......................................................................................................................94

Section 5: Discussion, Conclusions, and Recommendations.............................................96

Overview ......................................................................................................................96

Research Questions ......................................................................................................97

Interpretation of Findings ............................................................................................97

Research Question 1 ............................................................................................. 97

Research Question 2 ........................................................................................... 103

Interpretation of Conceptual Framework ...................................................................106

Health Belief Model (HBM)……………………………………………...…….106

Social Cognitive Theory……..…………………………………………...…….108

Adolescent Affective and Cognitive Theory………………………...…...…….109

Implications for Social Change ..................................................................................110

Recommendations for Action ....................................................................................110

Recommendations for Further Study .........................................................................112

Reflections on the Research Experience ....................................................................113

Researcher Reflections........................................................................................ 113

Personal Biases ................................................................................................... 114

Changes Due to Findings of the Study ............................................................... 114

Conclusion .................................................................................................................115

v
References ........................................................................................................................116

Appendix A: Background Information Form ..................................................................130

Appendix B: Interview Guide ..........................................................................................134

Appendix C: Informed Consent (Aged 18 & Over).........................................................142

Appendix D: Participants’ Textural and Structural Descriptions of Participants ............146

vi
 List of Tables

Table 1. Housing Characteristics ...................................................................................... 55

Table 2. Supporting Statements ........................................................................................ 89

vii
 1
Section 1: Introduction to the Study

Background

The death rate for infants in the United States is high, despite the advanced level

of healthcare available. The mortality rate in the United States is 6.05 deaths per 1,000

live births, higher than in most developed countries (Hoyert & Xu, 2012). The mortality

rate for Black infants is more than two times higher than White infants in the United

States (Hoyert & Xu, 2012).

Several initiatives have been implemented to increase healthy pregnancies and

decrease infant morbidity and mortality. Despite these initiatives, such as increased

access to healthcare for high risk groups, increased awareness of prenatal care, and

increased access to Medicaid benefits, infant morbidity and mortality rates continue to be

a problem. Examination of some of the contributing factors (e.g. teen pregnancy,

unintended pregnancies, characteristics of adolescents, lack of prenatal care or late entry

into prenatal care) may help to understand the complex problems that contribute to infant

morbidity and mortality.

Teen pregnancy and childbearing is one factor that contributes to a high morbidity

and mortality rate (Centers for Disease Control and Prevention (CDC, 2016b; Fogel &

Woods, 2008; Hoffman & Maynard, 2008; Lowdermilk, Perry, Cashion, & Alden, 2016;

United States Department of Health & Human Services, 2006). This complex problem

has far-reaching educational, social, and economic costs that may affect many in the

country, particularly teen parents and their children (Fogel & Woods, 2008; Hoffman &

Maynard, 2008; Lowdermilk et al., 2016). Birth rates in the United States among women
 2
were 31.3 per 1,000 women in 2011 (Hamilton, Martin, & Ventura, 2012). Over 329,000

children were born to mothers aged 15 to 19 and over 3,900 children were born to

mothers aged 10 to 14 years of age in 2011 (Hamilton et al., 2012).

Women pregnant during the teen years are at higher risk for preterm labor, and

their babies are at higher risk for low birth weights and death (Burns, Dunn, Brady, Starr,

& Blosser, 2013; Lowdermilk et al., 2016; Hamilton, Martin, & Ventura, 2012). Children

of teenage mothers are more likely to have detrimental social and medical problems such

as chronic medical conditions, behavior problems, high dropout rates, and becoming teen

parents themselves (Hoffman & Maynard, 2008).

Unintended pregnancies continue to be a major factor in high infant morbidity and

mortality rates in the United States (Guttmacher Institute, 2015; Mosher, Jones, & Abma,

2012; U.S. Department of Health Resources and Services Administration, 2011).

According to the CDC (as cited in Mosher et al., 2012), approximately 37% of all

pregnancies in the US are unplanned. It is estimated that up to 82% of adolescent

pregnancies are unintended (U.S. Department of Health & Human Services, n.d.).

Unintended pregnancies may place the woman at an increased risk of being in less than

optimal health. Furthermore, she may not know she has preexisting medical conditions

that could adversely affect her health or the health of the fetus (Guttmacher Institute,

2015; Mosher et al., 2012; U. S. Department of Health Resources and Services

Administration, 2011). Whether a pregnancy is unintended or planned but not discovered

until after a missed menstrual cycle, there remains a vulnerable time during which critical

growth and development of the fetus occurs. During this vulnerable time the fetus is at
 3
risk for detrimental effects from the mother’s unhealthy lifestyle behaviors such as drug

abuse, drinking alcohol, and poor diet.

Characteristics and tendencies that are common in adolescence may contribute to

a high infant morbidity and mortality rate for adolescents who become pregnant (CDC,

2016b; Lowdermilk et al., 2016). Adolescence is a dramatic period of cognitive, social,

physical, developmental, and emotional changes (Burns et al., 2013; Kendall, 2006;

Steinberg, 2013). Adolescents tend to engage in high risk behaviors such as substance

abuse, unprotected sexual activity, alcohol abuse, poor eating habits, and violent

behaviors (Hoffman & Maynard, 2008; Lowdermilk et al., 2016). Since adolescents tend

to rely on peers and the media for their source of health information they are often

uninformed or misinformed (Lowdermilk et al., 2016). All of these characteristics and

behavioral tendencies place the adolescent at higher risk for not seeking preconception

care, getting pregnant, and either not participating in prenatal care or late entry into

prenatal care.

Sexually active adolescents under 15 years of age are particularly at risk for

pregnancy due to the high number (46%) who do not use any contraception during their

initial episode of intercourse (Burns et al., 2013). Adolescents, who do become pregnant

and decide to have the baby, are more likely to initiate prenatal care late or receive no

prenatal care compared to older women who become pregnant (Ford et al., 2002;

Lowdermilk et al., 2016). Since adolescents tend not to recognize their own vulnerability,

they often need assistance navigating a complex social, emotional, and physical

environment and dealing with risk behaviors through preventative strategies that enhance
 4
healthy decision making and increase protective factors including building resources,

skills, strengths, coping skills, and problem solving skills. (Blum, McNeely, &

Nonnemaker, 2002; Nightengale & Fischoff, 2002).

Many believe that two of the major factors that contribute to a high infant

morbidity and mortality rate are lack preconception care (PCC) and late entry into

prenatal care (Howse, 2008; Johnson, Atrash, & Johnson, 2008; Posner, Johnson, Parker,

Atrash, & Bierman, 2006). Providing PCC is one strategy to improve preconception

health and decrease infant morbidity and mortality. PCC is not a new concept but has

primarily only been targeted at populations with chronic health conditions and women

with known detrimental lifestyle behaviors such as alcohol abuse and drug abuse

(Sanders, 2009).

The CDC, in 2006, released a set of 10 recommendations and four goals for

implementing PCC beyond the usual target group and recommended providing PCC for

all women of childbearing age. Expanding the population is especially important since

many women do not perceive themselves to have detrimental behavioral issues that

would warrant seeking PCC (CDC, 2006; Delgado, 2008; Elisinga et al., 2008;

Hillemeier, Weisman, Chase, Dyer, & Shaffer, 2008; Lowdermilk et al., 2016).

One way to mitigate these problems is through PCC, a comprehensive “set of

interventions that aim to identify and modify biomedical, behavioral, and social risks to a

woman’s health or pregnancy outcome through prevention and management” (CDC,

2006). An essential part of PCC is having a woman develop a reproductive life plan

(RLP). Setting personal goals about having (or not having) children and being informed
 5
of how to successfully fulfill those goals is an important part of an RLP. For an RLP to

be successful and sustainable the woman needs appropriate information to make and

implement choices. A woman’s RLP is an evolving plan that changes as the woman

desires change.

Based on the unique characteristics of adolescents, a PCC program for

adolescents should be developed that addresses their particular educational, social, and

medical needs (Bearinger, Sieving, Ferguson, & Sharma, 2007; Daley, Sadler, Leventhal,

& Cromwell, 2004; Tylee, Haller, Graham, Churchill, & Sanci, 2007). In order to

develop an effective, culturally-appropriate PCC program targeted for adolescent women,

researchers must identify the reasons why some adolescent women choose to seek PCC

and some choose not to seek PCC. I conducted a qualitative research study to investigate

the reasons why adolescents do or do not seek PCC.

This study fulfills Walden University’s mission for achieving teacher leadership

and social change by helping to understand perceptions of PCC from the perspective of

adolescents. The findings from this study have the potential to increase the body of

knowledge about PCC, give voice to a vulnerable population on the subject, and give

guidance to developing effective PCC programs for adolescents.

Problem Statement

The problem addressed in this study is that many women are not receiving

preconception care prior to pregnancy (CDC, 2006; Hillemeier et al., 2008; Maryland

PRAMS: Pregnancy Risk Assessment Monitoring System, 2013; Wilensky & Proser,

2008). As a result, many women are not prepared for pregnancy prior to conception, a
 6
situation that contributes to high rates of unintended pregnancies, infant morbidity and

mortality, and preventable birth defects (CDC, 2016b; Howse, 2008; Johnson, Atrash, &

Johnson, 2008; Maryland PRAMS: Pregnancy Risk Assessment Monitoring System,

2013; Posner et al., 2006). Because adolescents are at a higher risk for unintended

pregnancies, delayed or lack of prenatal care, and maternal and fetal morbidity and

mortality providing adequate PCC for this age group is essential (Lowdermilk et al.,

2016; U.S. Department Of Health & Human Services, 2013). It is important to identify

and consider the unique needs of adolescents to be able to provide adequate PCC services

to them (Bearinger et al., 2007; Daley et al., 2004; Tylee et al., 2007). It would be helpful

to understand the adolescents’ perspectives to successfully design and implement an

effective, culturally-appropriate PCC program for this age group.

Nature of the Study

I explored adolescent females’ knowledge of, attitudes, and beliefs about

preconception care. A qualitative phenomenological approach was chosen because it

“identifies the essence of human experiences about a phenomenon as described by

participants” (Creswell, 2014, p. 13). Moustakas (1994) explained, “phenomenology

seeks meanings from appearances and arrives at essences through intuition and reflection

on conscious acts of experience, leading to ideas, concepts, judgments, and

understandings” (p. 58). This approach allowed full exploration of the phenomenon.

I collected data through multiple in-depth phenomenological interviews with each

of the five participants. I conducted two to three interviews with each participant

depending on the amount of information gathered at each interview. I recruited

 7
participants from a low income housing development and low income apartment

complex. I recruited participants until saturation was achieved. Saturation was considered

achieved when the information collected from participants became repetitive and

validated the data I had previously collected (Streubert & Carpenter, 2010). I utilized

Moustakas’ (1994) phenomenological interview process as the guiding framework to

prepare and conduct the interviews. Interview questions (Appendix A) were prepared

prior to the interviews.

Interview questions were open-ended and designed to capture the participant’s

attitudes, beliefs, and knowledge about PCC and RLP. All interviews were conducted in

person, audio-taped with two recorders, and then transcribed verbatim. After the tapes

were transcribed, I reviewed them for accuracy and corrected any inaccuracies. I also

recorded personal impressions and observations in a journal immediately following each

interview, in addition, I used a journal throughout the process to identify and address

researcher bias.

I analyzed each of the participant’s transcribed interviews using Moustakas’s

(1994) modified version of the Stevick-Colaizzi-Keen method of analysis. The first step

included reflecting on my own personal experiences with PCC in a journal. My goal was

to identify and put aside any judgments, biases, typical understandings of PCC in order to

have a fresh open view during analysis of the interviews. Writing out, reviewing, and

labeling my previous experiences of preconception care, then reviewing them prior to

analyzing the interviews regularly helped me achieve a less biased perspective.

 8
The second analytical step involved organizing the content of the verbatim

transcripts (Moustakas, 1994). I considered each statement and put it in context of its

significance to the experience. This process, known as horizonalization, was done by

grouping statements, phrases, and sentences together into different groups that

represented different aspects of the phenomenon. I also had a peer review the transcribed

statements to verify that the data was accurate and grouped correctly. Overlapping

repetitive or vague statements were then eliminated leaving only invariant constituents. It

was important to glean rich detail from participants rather than generalizations such as

good or bad experiences.

I placed each relevant statement on a separate paper and then into common

categories. All of the categories were then reviewed to identify and group clusters of

statements with common themes. I also had a peer review the category themes to verify

that the data were appropriately categorized. Each of the themes was then synthesized to

formulate a rich description of the experience. The textural description included verbatim

examples.

I then used reflection and imaginative variation to develop a structural

description. Imaginative variation means “to seek possible meanings through the

utilization of imagination, varying the frames of reference, employing polarities and

reversals, and approaching the phenomenon from divergent perspectives, different

positions, roles, or functions” (Moustakas, 1994, p. 97-98). Structural description helped

to identify factors or influences that may have led to an individual participant’s

experience (e.g., participants who had Medicaid may have had more access to healthcare
 9
than those without Medicaid). Imaginative variation required that I reexamine the textural

and structural description in terms of what other meanings or influences could affect the

data and identify the invariant structural themes that represented the true phenomenon.

I then developed a textural-structural description for each participant that

described the meaning and experience of PCC. I completed this step for each of the

participants. In the final step I synthesized all of the descriptions into a composite of all

of the participants. This synthesized description represents the combined lived experience

of PCC for adolescent participants.

Research Questions

1. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding preconception care?

2. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding participating in a reproductive life

plan?

Purpose of the Study

The purpose of this phenomenological study was to understand preconception

care and reproductive life planning from the perspective of adolescent females. I sought

to identify barriers to seeking preconception care and reproductive life planning. PCC

was defined as “a set of interventions that aim to identify and modify biomedical,

behavioral, and social risks to a woman’s health or pregnancy outcome through

prevention and management” (CDC, 2006).

 10
Conceptual Framework

The conceptual framework of this qualitative study consisted of three

components: the health belief model (HBM), social cognitive theory (Bandura 1978,

1986, 1997), and adolescent affective and cognitive theory (Brown, 1990; Ginsburg &

Opper, 1988; Steinberg, 2005, 20013; Wadsworth, 1971; Zelazo, Chandler, & Crone,

2010).

Health Belief Model

The HBM is the first component of this study’s theoretical framework because it

emphasizes how and why people adopt or reject health-related behaviors. The HBM has

been widely used in research to “explain change and maintenance of health-related

behaviors and as a guiding framework for health behavior interventions” (Champion &

Skinner, 2008, p. 45). The theory was developed in the 1950s and originated from

classical stimulus response theory (Watson, 1925) and cognitive theory (Lewin, 1951;

Rosenstock, Stretcher, & Becker, 1988; Tolman 1932). Important contributors to the

HBM include Bandura (1997), Becker (1974), Hochbaum (1958), and Rosenstock

(1974). Stimulus response theory posits that reinforcement determines the frequency with

which an individual will engage in a behavior, but the quicker the reinforcement

following the behavior, the more likely the behavior would be repeated.

The HBM is based on the understanding that a person will participate in behaviors

that will prevent a detrimental health outcome if they believe it will successfully work.

Key factors influencing the HBM that were utilized to guide the collection and
 11
interpretation of data during the study included perceived susceptibility, perceived

severity, perceived benefits, perceived barriers, cues to action, and self-efficacy.

Perceived susceptibility, the first key factor of the HBM, is concerned with

whether an individual believes they will contract a particular condition. Perceived

susceptibility, for this study, was whether participants believed they were at risk for

getting pregnant or needed to plan ahead for healthy pregnancies. Interview questions

were developed to determine perceived susceptibility by questioning as to whether they

have ever had sex, if they ever had unprotected sex, if they have taken a home pregnancy

test, whether they used contraception each time they had sex, and whether they thought

they would be pregnant in the next 2 years.

Perceived severity, another key factor of HBM, is concerned with whether an

individual believes a condition has associated serious effects or consequences. Perceived

severity in this study referred to whether participants believed that being pregnant was a

serious condition that could have serious effects or consequences. Interview questions

were developed to determine participants’ perceived severity by asking questions such as

whether they knew any medical conditions or lifestyle behaviors that could negatively

affect a pregnancy or a baby.

Perceived benefits, an HBM key factor, is concerned with whether an individual

believes that actions could be taken to decrease or prevent risks or lessen serious effects

of a condition. Perceived benefits for this study were whether participants believed

participating in PCC could help prevent risks or lessen detrimental effects of pregnancy.

Interview questions were developed to determine participants’ perceived benefits by

 12
asking questions such as whether they planned to do anything to prepare for a pregnancy

or did they know any lifestyle behaviors that should be adopted prior to pregnancy that

would have a positive effect for the woman or fetus.

Perceived barriers, a fourth HBM factor, is concerned with whether an individual

believes there are physical or psychological reasons present that would prevent them

from engaging in a behavior. In this study, perceived barriers were defined as whether the

participants believed there are physical, financial, psychological, medical, or family

barriers present that would prevent them from engaging in PCC. Interview questions

were developed to determine participants’ perceived barriers by asking questions about

the last time they went to a doctor and how they got there, who went with them, and how

they paid for it.

Cues to action, an HBM factor, is concerned with how an individual would

actualize a changed behavior. In this study, cues to action were defined as the

participant’s ability to verbalize how to participate in PCC. Interview questions to

ascertain the participants’ ability to participate in PCC included asking the participants to

describe where and how they could receive PCC.

Self-efficacy, the last of the six HBM key factors, is concerned with whether

individuals believe they can successfully execute the desired changed behavior. I defined

self-efficacy as the participants’ belief that they can successfully participate in PCC.

Interview questions to determine the participants’ belief that they will participate in PCC

included inquiring as to when was the best time for a woman to seek PCC, whether the
 13
participant planned to make an appointment for PCC, and if the participant intended to

engage in PCC prior to a pregnancy.

Social Cognitive Theory

Social Cognitive Theory (SCT) is the second component of this study’s

theoretical framework because it emphasizes how a person’s behavior and thought

processes influence future behavior. SCT was built on the theory and research of Miller

and Dollard (1941), Rotter (1945), Vygotsky (1978), Bandura (1986), and Lave (1988).

They all postulated theories that emphasize the central role of social learning. Initially

Bandura (1986) called his theory observational learning or social learning theory. As

concepts from cognitive psychology were integrated into the theory, Bandura (1986)

renamed it SCT. One of Bandura’s (1997) most recent and important expansions of SCT

is the inclusion of self-efficacy.

SCT is based on the understanding that human behavior is influenced by many

factors including environmental, personal, and behavioral experiences (Bandura, 1986).

These experiences influence all types of learning including learned health behaviors. It

also recognizes that people are capable of reshaping their own physical and social

environments to change their health behaviors (Bandura, 1986). Three key concepts of

SCT that were utilized to guide the collection and interpretation of data during the study

included reciprocal determinism, observational learning, and facilitation.

Reciprocal determinism, a key concept of SCT, is concerned with understanding

the influence of social, personal, and environmental factors on individual and group

behaviors (Bandura, 1978). In this study, reciprocal determinism was defined as

 14
understanding the influence of social, personal, and environmental factors on a

participant’s knowledge and participation in PCC. Interview questions to identify social,

personal, and environmental factors included inquiries as to whether the participants or

anyone they knew undertook PCC; whether the participants talked to anyone about what

to do to plan a pregnancy or prevent a pregnancy; and their views on how their mothers

would respond if told the participants wanted to talk to someone about how to prepare for

a pregnancy or how to prevent a pregnancy.

Observational learning, an SCT key concept, is concerned with the multiple ways

we learn about performing new behaviors including from peers, formal classes,

multimedia, and the like (Bandura, 1986). I defined observational learning as influences

from multiple sources that form knowledge about PCC and pregnancy. Interview

questions were developed to identify the participant’s knowledge of PCC and pregnancy

as well as the sources of information that helped to form the knowledge and beliefs.

Interview questions included direct questions about what the participants have learned

about PCC, RLP, and pregnancy and where they learned it.

Facilitation, another SCT key concept, is concerned with provision of support to

enable an individual to implement a new behavior (Bandura, 1986). I focused on having

the participants identify resources, tools, and changes that they think would help educate

and enable other adolescents to participate in PCC. Interview questions included asking

from whom would be the best person to receive such information, what age would be best

to start PCC, and what is the best way to deliver the information about PCC.
 15
Adolescent Affective and Cognitive Theory

Adolescent affective and cognitive theory (AACT) is a third component of this

study’s theoretical framework because it may help explain why adolescents make the

decision to seek PCC or not to seek PCC. I also used AACT to help understand how

adolescents’ form and acquire knowledge about PCC (Ginsburg & Opper, 1988;

Wadsworth, 1971). It also helped explain varied perceptions and attitudes of PCC and

RLP. AACT was built on the theory and research of Piaget (Wadsworth, 1971; Zelazo et

al., 2010). The theory has been widely used in psychology and educational research of

children to help “understand how and why children behave as they do” (Wadsworth,

1996, p. IX). Initially, Piaget turned his attention from biology and epistemology to

psychology in 1919. Piaget’s work was influenced by the work of psychoanalysts Freud

and Jung and initially guided by psychologist Binet (Ginsburg & Opper, 1988;

Wadsworth, 1971). Piaget’s cognitive theory developed over 60 years and was based on

extensive studies of children. AACT posits that intellectual development is accomplished

with a combination of cognitive, affective, and social aspects (Wadsworth, 1971).

AACT is based on belief that brain development of emotional, behavioral, and

cognitive systems mature at different rates and are influenced by many factors including

social, biological, and cultural factors (Casey & Jones, 2010; Piaget, 1970; Steinberg,

2005). These researchers believed that different parts of the brain may mature at differing

rates during development. Although early, middle, and late adolescence can be defined

by age, these strategies do not indicate whether the adolescent’s brain has matured

equivalently to their biological age (Casey & Jones, 2010; Piaget, 1970). An adolescent’s
 16
chronological age may not be correlated with the brain’s maturity. This study drew on

Piaget’s third and fourth states of cognitive and affective development: concrete

operations and formal operations to help understand why adolescents make the decision

to seek PCC or not to seek PCC and understand how adolescents’ form and acquire

knowledge about PCC. Key concepts also included defining the affective and cognitive

components of AACT.

Concrete operations, the third stage of Piaget’s AACT, is characterized by an

individual’s ability to think and solve problems in a concrete manner (Ginsburg & Opper,

1988; Piaget, 1970; Wadsworth, 1996). This stage is generally accomplished in the 7 to

11 year old age group. Characteristics of this stage include advancing from the

preoperational stage of being able to solve problems only through representation to being

able to determine logical solutions to problems. This is accomplished through maturity of

affective and cognitive domains of the individual. Individuals are not able to progress to

the next stage until they have accomplished this stage (Ginsburg & Opper, 1988; Piaget,

1970; Wadsworth, 1996).

Formal operations, the fourth stage in Piaget’s AACT, is characterized by an

individual’s ability to successfully solve real or perceived problems (Ginsburg & Opper,

1988; Piaget, 1970; Wadsworth, 1996). This stage is generally accomplished in the 11 to

15 year old age group but may not be accomplished well into adulthood. An individual

may only advance to this stage if they have completed the previous stage. This stage is

accomplished through the highest level of maturity of both the affective and cognitive

domains of an individual (Ginsburg & Opper, 1988; Piaget, 1970; Wadsworth, 1996).
 17
The affective component of AACT addressed the feelings and emotional aspect of

an individual’s experience with a phenomenon (Wadsworth, 1971). Interview questions

were developed to collect information about the affective component, which included

prompting the participant to describe in detail what their medical experiences have been,

asking them to describe their feelings about past experiences, inquiring as to whether they

feel PCC is important, and questioning what they believed were barriers to getting PCC.

The affective component of AACT complemented the cognitive component, which

addressed what individuals, believed they knew of a topic and what they were capable of

doing (Wadsworth, 1971).

Interview questions were developed to collect information about the cognitive

component as well. These questions included prompting the participants to share what

knowledge and beliefs they had about PCC and what barriers they experienced in seeking

medical care. The AACT component was also utilized during data analysis to help

understand why adolescents’ knowledge, attitudes, and beliefs regarding PCC and RLP

varied widely. This component also helped explained why adolescents in the same age

group varied in their ability to seek and participate in PCC.

Utilization of Theories

The HBM, SCT, and AACT provided comprehensive and well-supported

conceptual frameworks for understanding positive and negative factors that influence

adolescents’ participation in PCC. The HBM, SCT, and AACT were essential to every

part of the study including formulation of the interview guide, analysis, and

recommendations for future studies.

 18
Operational Definitions

Adolescent: Children between 12 and 20 years of age. Adolescence is

characterized as a period of rapid psychological, social, physical, and secondary sexual

characteristics growth and development (Kliegman, Behrman, Jenson, & Stanton, 2015).

Adverse birth outcomes: Births that occur without optimal health or physical

outcomes including fetal distress, infant deaths, low birth weight, premature births, and

birth defects (Dunlop, Jack, & Frey, 2007, p. 81).

Behavioral health issues: Detrimental behaviors associated with maternal or fetal

complications. Examples include cigarette smoking, alcohol use, and drug abuse

(Sanders, 2009).

Bracketing: A process where the researcher places the research in brackets and

extraneous factors are removed so that the research process is focused only on the

phenomenon and research questions (Moustakas, 1994, p. 97).

Chronic health conditions: Medical conditions diagnosed prior to pregnancy that

could adversely affect maternal fetal outcomes. These include diabetes, hypertension,

cardiac disease, HIV, and endocrine and autoimmune diseases (Aaron & Criniti, 2007;

Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Lampe, 2006).

Early Adolescence: Children 15 to 17 years of age (Burns et al., 2013).

Facilitation: “Providing tools, resources, or environmental changes that make

new behaviors easier to perform” (McAlister, Perry, & Parcel, 2008, p. 171).

Late Adolescence: Children 18 to 21 years of age (Burns et al., 2013).

 19
Late entry into prenatal care: When a pregnant women’s first prenatal visit

occurs after the 12th week of gestation (Lowdermilk et al., 2016).

Low birth weight (LBW): An infant birth weight of less than 2,500 grams

(Lowdermilk et al., 2016).

Middle Adolescence: Children 15 to 17 years of age (Burns et al., 2013).

Modified Stevick-Colaizzi-Keen Method: A method of organizing and analyzing

phenomenological data. Moustakas modified the original method developed by Stevick,

Colaizzi, and Keen (Moustakas, 1994).

Neural tube defect: Improper development of the brain and/or spinal cord during

pregnancy (Lowdermilk et al., 2016). Folic acid deficiency is one of the known causes of

neural tube defects occurring during pregnancy.

Observational learning: Learning new ways to do things through observation,

such as interaction with peers or multimedia sources (McAlister et al., 2008, p. 171).

Preconception Care (PCC): “A set of interventions that aim to identify and

modify biomedical, behavioral, and social risks to a woman’s health or pregnancy

outcome through prevention and management” (CDC, 2006).

Pregnancy Trimesters: The three periods of a human pregnancy. The first

trimester of pregnancy is comprised of weeks 1 to 12. The second trimester of pregnancy

includes weeks 13 to 24. The third trimester of pregnancy spans week 25 until the baby is

born, usually at 40 weeks (Lowdermilk et al., 2016).

 20
Reciprocal determinism: How environmental factors may influence individuals

and groups and individuals and groups can also influence their environments by

regulating their behavior. (McAlister et al., 2008)

Reproductive Life Plan (RLP): “A set of personal goals about having (or not

having) children. It also states how to achieve those goals. Everyone needs to make a

reproductive plan based on personal values and resources” (CDC, 2014).

Self-efficacy: “A person’s beliefs about her capacity to influence the quality of

functioning and the events that affect her life” (McAlister et al., 2008, p. 172).

Assumptions

I assumed that participants interviewed for the study were honest and accurately

portrayed their knowledge, attitudes, and beliefs about preconception care and

reproductive life planning (Creswell, 2013; Moustakas, 1994). I assumed that all

participants had experienced the phenomenon and answered all questions openly and

honestly (Creswell, 2013; Moustakas, 1994). I also assumed that data gleaned from the

interviews was comprehensive and reflected the phenomenon accurately. It is assumed

that the three conceptual frameworks selected were suitable to guide and analyze this

study (Creswell, 2013). I assumed the data were interpreted and analyzed to accurately

reflect the data collected.

Limitations

Limitations of a study refer to the factors that may affect the findings of the study

or how the findings are applied or interpreted (Baltimore County Schools, n.d.; Baron,

n.d.; Creswell, 2013; Marshall & Rossman, 2015; Northern Arizona University, n.d.;
 21
Patton, 2014). Limitations of this study included sampling size, limited variation in racial

representation, no variability in socioeconomic status represented, and only female

participants. Due to the small sample size with female participants being from a one

racial-cultural low socioecomic status group the generalizability of the findings is

decreased. In addition, my own bias as a medical provider may have influenced my

interviewing techniques and interpretation of interviews.

As a nurse practitioner who provides prenatal care and healthcare to teens and

women I hold the bias that every childbearing woman needs to receive preconception

counseling. My professional experiences of seeing infants with preventable birth defects

and poor maternal outcomes due to late or no prenatal care also inspired me to do this

study. I employed the strategies of self-reflection, member checking, and using full rich

descriptions to convey the findings, as recommended by Creswell (2014), in order to

avoid researcher bias and bolster the validity of the study. I also maintained a journal

throughout the study to help with self-reflection. There are also possible interview data

limitations that are a result of distortions of participants’ responses due to a labile

emotional state of the participant during the interview such as anger, sadness, or anxiety

(Patton, 2014). Another possible limitation may be that the participants who were

selected may not have entirely represented or related the phenomenon adequately (Patton,

2014).

Scope and Delimitations

The delimitations of a study are characteristics limiting the scope of the inquiry.

These characteristics are determined by the decisions that were made throughout the
 22
development of the proposal. (Baltimore County Schools, n.d.; Creswell, 2013; Marshall

& Rossman, 2015; Patton, 2014). This qualitative study was delimited by the selection of

participants from one city in the southern part of the United States. Additional

delimitations of this study included recruiting participants from a one housing community

and adjacent apartment complex located in an economically depressed area and the

majority of participants represented by one racial group, Black women. The use of

multiple in-depth interviews instead of surveys limited the number of participants’ views

collectively used for interpretation.

Significance of the Study

This study may be significant for medical providers, educators, and policy makers

for multiple reasons. First, this study will contribute to the body of knowledge on PCC. It

will provide insights into adolescent females’ knowledge, beliefs, and attitudes regarding

PCC and RLP. Both positive factors that promote entry to PCC and barriers that may

prevent adolescents from seeking PCC were identified. This study may make medical

providers more aware of the educational needs of pregnant adolescents. Second, this

study may encourage nurses, nurse practitioners, and physicians to make changes to PCC

services delivered to adolescents in their practices. Finally, this study will be significant

by laying the foundation for further study and ultimately development of an age-

appropriate PCC program for adolescents.

Social Change

An important goal of this study was to effect a positive social change, an

“improvement of human and social conditions.” (Walden University, 2010, para 4) A

 23
goal of this study was to provide improved PCC services for adolescents. Identification of

knowledge deficits of adolescent women regarding PCC may assist medical providers,

educators, and policy makers to develop and implement PCC services to address these

needs. This study may also contribute to social change by describing adolescent

experiences and gaining information about barriers, beliefs, attitudes and factors that may

be helpful in identifying new and effective ways to deliver PCC services to adolescents.

These newly designed PCC programs may ultimately reduce poor maternal and fetal

outcomes.

Conclusion

Providing PCC to adolescents is one way to decrease teen pregnancy, increase

knowledge about contraception, and increase participation in prenatal care. Before

developing and implementing a PCC model for adolescents, we need to know more about

what barriers must be overcome in order to be successful. This phenomenological study

will help identify these barriers. An introduction to the phenomenon and need for study

was presented in Section One. A review of literature that explores research documenting

PCC and RLP will be provided in Section 2. Section 3 is an explanation of the qualitative

research design methodology including research questions, description of the

participants, and role of the researcher. Section 4 is the research findings. The summary,

conclusions, recommendations for further research, and researcher reflections will be

presented in Section 5.
 24
Section 2: Literature Review

Introduction

Section 2 is a review of research about the subject of the study, PCC, and

conceptual frameworks used for this study, and examines similar studies that, like this

one, uses phenomenological methodology. Due to the limited number of studies

published on routine PCC in adolescent women, the review draws on literature about

adults and includes both routine care and care for women with known medical diseases.

Research for this literature review began using four strategies: review of relevant

book chapters, online journal searches, Cochrane Review searches, and seminal

published manuscripts and relevant dissertations. Both electronic and print sources were

employed. Multiple electronic databases were used in the literature review including

ProQuest, ERIC, SAGE, Cochrane Review, and Walden University Dissertations and

Theses. The following key words were used to help identify potential resources:

preconception care, preconception health, pregnancy + adolescents, pregnancy +

adolescence, pregnancy planning, health promotion + adolescence, health promotion +

adolescents, and reproductive life planning. Identification of relevant resources also

helped to identify more relevant resources, a process that expanded the literature review.

Review of Related Research

PCC has evolved from trying to prevent poor outcomes in high risk women who

have diseases known to likely cause birth defects such as diabetes, to providing the

benefits of preconception care for all women of child bearing age. In this section, I

reviewed the current state of research on preconception care in these four situations: (a)
 25
women with diabetes, (b) routine care for college aged women, (c) routine care for

childbearing women, and (d) routine care for adolescent women.

Medical Conditions Known to Affect Pregnancy

Preconception care for women with pregestational diabetes has been studied for

decades to try to identify ways to decrease poor maternal and fetal outcomes due to

maternal hyperglycemia (Lu, 2007; Wahabi, Alzeidan, Bawazeer, Alansari, & Esmaeil,

2010). Multiple studies dating from Fuhrmann’s 1986 study to Galindo, Burguillo,

Azriel, and Fuente’s 2006 study have supported that preconception care in women with

Insulin-Dependent Diabetes Mellitus (IDDM) has significantly reduced the frequency of

congenital malformations. These extensive studies have helped establish the need for

childbearing women with IDDM to receive PCC so that they achieve good glycemic

control prior to attempting a pregnancy and throughout the pregnancy (Fuhrmann, 1986).

Researchers in this area have moved from focusing on whether or not PCC should

be implemented to defining what type of insulin will achieve the best glycemic control in

women with diabetes during PCC (Mathiesen et al., 2007; Temple, Aldridge, & Murphy,

2006). This section will include examples of research studies, including the most recent,

that have examined the effect of providing PCC to women with IDDM to decrease the

incidence of poor maternal or fetal outcomes. Due to the large number of studies

examining PCC versus no PCC in childbearing women with IDDM, selection criteria

were employed. I selected three studies based on their having a large cohort, control and

self monitoring of blood glucose, and a clear description of the participants and PCC

intervention. One additional study will be reviewed as an example of the most recent
 26
research being done on childbearing women with IDDM and the direction current studies

are evolving.

A landmark study, conducted by Fuhrmann (1986), is one of the earliest and

largest retrospective studies examining the effect of good glycemic control through PCC

in childbearing women with IDDM compared to childbearing women with IDDM

without PCC. One strength of this study was that the PCC intervention was well

described and could be easily replicated. Of the 620 participants 184 received PCC and

436 did not receive the PCC intervention. Findings from this study indicated a

significantly lower rate of congenital malformations in the PCC group than the group

without PCC. One criticism of this study is the lack of consideration of possible

confounding variables to explain the differences in the findings.

Steel, Johnstone, Hepburn, and Smith (1991) examined the incidence of

congenital malformations in women who received PCC aimed at good glycemic control

before and during a pregnancy in childbearing women with IDDM compared to

childbearing women with IDDM who do not receive PCC. Of the 239 participants 143

received PCC and 96 participants did not. The PCC used was the same intervention as

Fuhrmann’s (1986) study and included contraception education. Steel et al. found a

significant decrease in the number of congenital defects in the group who received PCC

compared to the group that did not receive PCC.

Temple et al. (2006) examined the incidence of congenital malformations in

childbearing women with IDDM who received PCC to childbearing women with IDDM

who did not receive PCC. Although the main PCC intervention was glycemic control it
 27
also included other confounding factors such as smoking and folic acid supplementation.

There were 290 participants, 110 received the PCC intervention and 180 received no

PCC. Findings were that participants who participated in PCC had a significant decreased

incidence of congenital malformations, spontaneous abortions, and preterm deliveries

than the group with no PCC. A logistic regression analysis was used to examine the

association between PCC and the outcomes.

Mathiesen et al. (2007) provided an example of how research of PCC in women

with IDDM has moved away from whether or not they would benefit from PCC using

tight glycemic control to examining which type of insulin should be used in PCC to

achieve the best glycemic control. This randomized study had 322 participants; 157 used

insulin aspart and 165 used regular human insulin as meal time insulin. The objective of

this study was to assess the two types of insulin in women with IDDM with regards to

their safety and efficacy. Although the findings were not statistically significant, they did

find a lower risk of severe nocturnal hypoglycemia when using insulin aspart. They also

found both types of insulin were equally safe and effective during preconception and

pregnancy.

Routine PCC in College Women

This section includes examples of research studies from the literature examining

the efficacy of PCC in college aged women. Both of these research studies focused on

PCC in undergraduate students. I selected these two studies based on their having a large

cohort, a clear description of the participants, the process, and the findings.
 28
The Colorado Undergraduate PCC study (Corbett, 2011) evaluated undergraduate

students’ knowledge and attitudes of PCC health and wellness. This quantitative research

study used a convenience sample of 203 female undergraduate students enrolled in an

introductory psychology course at a university in the Western U.S. The majority of

participants were White, families earned over $30,000 per year, and the students were in

their first 2 years of college. Exclusion criteria included participants could not have

received prenatal care prior to the study or given birth to a child. The information,

motivation, and behavioral skills (IBM) model for preventative health was the guiding

theoretical framework for her study.

The Colorado undergraduate PCC study (Corbett, 2011) utilized a background

information form, a modified reproductive health attitudes and behaviors (RHAB)

questionnaire, and the reproductive health knowledge scale for women (RHKS-W) as the

three instruments to evaluate the participants’ degree of knowledge, motivation, and

ability to maximize preconception health. The background information form, a 40-item

form, was constructed to gather participant demographic information, assess knowledge

about PCC and risk factors that would dictate increased need for PCC, and identify

perceptions of where to receive information on PCC and pregnancy prevention. The

background information form also assessed participants’ knowledge, motivation, and

behaviors regarding PCC and pregnancy prevention.

The RHAB was initially developed to assess reproductive health issues in

adolescent females with diabetes (Charron-Prochownik et al., 2006). The RHAB

questionnaire was modified by the researcher to exclude questions about diabetes. The
 29
RHAB incorporates constructs from SCT, the HBM, and the theory of reasoned action

(TRA). The modified RHAB questionnaire, a 52-item Likert scale was used to assess

reproductive issues in undergraduate women. The RHKS-W, the third instrument, was

developed by the researcher and used to gather information regarding the extent

participants were informed on issues related to pregnancy prevention and PCC. Half of

the items on the RHKS-W assessed PCC and half assessed pregnancy prevention.

The eight research questions were addressed using five steps of data analysis to

evaluate all eight research questions (Corbett, 2011). Analysis included multiple

approaches including frequency and descriptive statistics, classical item analysis,

exploratory factor analysis, statistical analysis, and comparative and inferential statistical

methods.

Corbett (2011) demonstrated significant knowledge deficits in regard to PCC.

Although the participants had an overall increased understanding of pregnancy

prevention, they still engaged in several health-risk behaviors that could result in

pregnancy. One concern in replicating this study with adolescents is the length and

difficulty of the questionnaire. College students usually have a higher grade vocabulary

and reading ability than adolescents. One shortcoming of this study was that the

participants were highly motivated to complete the lengthy questionnaires by receiving

academic credit to complete the study. A major implication from the findings of this

study is the need to expand PCC and develop new strategies to meet the needs of

different populations.
 30
The University of Miami undergraduate PCC study by Delgado (2008) examined

undergraduate students’ awareness of PCC and whether there were differences between

the awareness of males and females. Delgado used a convenience sample of 241 male

and female undergraduate students enrolled in an introductory psychology course at the

University of Miami. The majority of participants were White, aged 18 to 24 years old,

did not have children but previously had a course that had information on pregnancy and/

or child development. A 20-item self-scoring questionnaire with multiple choice and

checklists was used to gather data on students’ awareness of preconception health and

pregnancy. Both positive and detrimental health behaviors were included in the

questionnaire.

The key finding was that students had a low to moderate level of PCC and

pregnancy awareness. A significant percentage of female participants had a higher

awareness of pregnancy and PCC than the male participants. Overall the majority of

participants scored low to moderately aware of PCC. Within the scores the majority of

participants scored low with regard to different aspects of PCC including folic acid use,

fetal development, and proper spacing between pregnancies. Participants who had

previously taken a course with child development or pregnancy content tended to score

better than those participants who had not had a course. The majority of participants

(87%) also reported they took that previous course in high school. Implications of this

finding are that although participants with a previous course did score better some still

scored low to moderate awareness in multiple areas, thus further education is needed.

Several important implications emerged from the findings of this study including that
 31
new PCC strategies need to be developed and expanded to meet the educational needs of

both males and females.

Routine PCC in Childbearing Women

This section includes an example of research studies from the literature examining

the efficacy of routine PCC in childbearing women. The research study selected focused

on routine PCC in a vulnerable population of Hispanic women of low socioeconomic

status. I selected this study based on it having a large cohort, a clear description of the

participants, and the overall purpose and findings of the study.

Coonrod, Bruce, Malcolm, Drachman, and Frey (2009) evaluated knowledge and

attitudes regarding PCC in a public health clinic in Phoenix, Arizona. Coonrod et al.

employed a cross-sectional survey with a convenience sample of 305 women of

childbearing age. The majority of participants were Hispanic, low socioeconomic status,

had a high school education or less, and either were currently pregnant or previously

pregnant. Participants ranged in age from 18 to 45 with the majority (45%) in the 26 to 35

year old age range.

A self-administered five point Likert scale questionnaire was used to identify

knowledge, attitude, and interests/preferences regarding PCC in the Arizona Mexican-

American PCC study (Coonrod et al., 2009). The majority of preconception knowledge

questions focused on detrimental behaviors that could affect pregnancy. Prior to the study

a pilot study was completed using the questionnaire, in English and Spanish, to establish

readability.
 32
Multiple findings from the Arizona Mexican-American PCC study (Coonrod et

al., 2009) validated the need to provide routine PCC to adolescent women. Coonrod et al.

demonstrated that the younger the age of the woman the less knowledgeable she was

regarding positive and negative health behaviors affecting pregnancy. This finding is

even more significant if one considers that the over 88 % of participants were either

currently pregnant or were previously pregnant. Since adolescents were the younger

participants in this study that means it found that the majority of adolescents were less

knowledgeable regarding positive and negative health behaviors affecting pregnancy. It

could also be inferred that even younger adolescents aged 13 to 17 would be either

equally knowledgeable or even less knowledgeable regarding positive and negative

health behaviors affecting pregnancy due to their age. The study also found that the

majority of participants (77 %) were interested in PCC and identified the primary care

provider as the preferred person to provide PCC. Important implications of this study

were that adolescents are in need of routine PCC and would be receptive to receiving it

from their primary care provider.

Routine PCC in Adolescent Women

This section includes examples of research studies from the literature examining

the efficacy of routine PCC in adolescent women. The first research study focused on

identifying positive and detrimental health-risk behaviors adolescents were engaging in

during their pregnancy. The second research study focused on PCC in adolescent women.

These two studies based on their having a large cohort of adolescent women of low

socioeconomic status, a clear description of the participants, and the focus of the studies.
 33
The Midwestern pregnant adolescent health-risk behaviors study conducted by

Kaiser and Hays (2005) was to evaluate the frequency of health risk behaviors in first-

time pregnant adolescents. This nonrandom convenience sample consisted of 145 first-

time pregnant adolescents aged 15 to 18 years old and represented 47 sites in seven

Midwestern cities. The majority of participants were of low socioeconomic status.

Ethnically the participants represented a diverse population with over 1/2 White,

approximately 1/3 Black, and approximately 1/10 Hispanic.

Kaiser and Hays (2005) used a questionnaire to identify the frequency of

detrimental and positive health-risk behaviors participants were engaging in during this

pregnancy. The questions focused on smoking cigarettes, alcohol use, illegal street drug

use, sexual activity, condom use, prenatal visits attended, and if she had attended

childbirth, parenting, or breastfeeding classes.

Kaiser and Hays (2005) found that adolescents are engaging in detrimental health-

risk behaviors during pregnancy at higher rates more than previously documented

through surveys on birth certificates. Another important finding in this study was that the

majority of participants quit engaging in detrimental health-risk behaviors once they

knew they were pregnant. These findings help establish the need to provide adolescents

with routine PCC. One shortcoming of this study was not identifying if the participants

knew or how they knew which health-risk behaviors were detrimental or positive during

a pregnancy. Another shortcoming of this study is that not all detrimental and positive

health-risk behaviors in PCC were addressed. An important implication of this study is

that we need further research to better understand adolescents’ knowledge, attitudes, and
 34
beliefs about health-risk behaviors that affect pregnancy to identify better ways to

educate this vulnerable population.

In the New York urban PCC study, Heavey (2010) examined outpatient medical

charts of pregnant adolescent females to determine if they had a previous clinic

appointment prior to pregnancy where PCC could have been provided. Heavey also

reviewed the medical charts to identify PCC Health risk behaviors and interventions prior

to pregnancy and at the clinic visit where they had a positive pregnancy test. A

retrospective chart review identified 81 participants between the ages of 14 to 19, had a

positive pregnancy test, and completed the normal nurse-assisted health information

questions. The nurse-assisted questions were completed on the day of a positive

pregnancy test and included whether this pregnancy was desired. The participants were

drawn from a public health clinic in upstate New York that offers family planning and

primary care. The majority of participants were low socioeconomic Black adolescents

who were not attending school.

Multiple findings from the Heavey (2010) study emerged that helps give direction

to adolescent PCC. Significant finding of Heavey’s study included establishing a need for

routine PCC and that opportunities to provide PCC did occur for the majority of

adolescents during healthcare visits before pregnancy occurred. In addition, findings

emerged that adolescents have unique needs that would benefit from PCC designed to

meet their needs. This study found that routine PCC could help address adolescents’

multiple risk factors at the time they are identified instead of waiting until they are

pregnant. It also found that PCC knowledge deficits could be addressed in healthcare
 35
visits prior to a pregnancy to encourage healthy behaviors before conception and early in

their pregnancy. The fact that the majority of adolescents who were pregnant stated they

did not desire a pregnancy, emphasized the need to provide PCC to all adolescents at

every healthcare visit.

Conceptual Frameworks

Conceptual models and theories can provide guidance in many aspects of a

qualitative study. Guidance can include helping a researcher determine what information

needs to be learned to effectively develop and organize an intervention program, help

formulate questionnaires, and explain or interpret behavior (Glanz, Rimer, & Viswanath,

2008; Patton, 2014). In this section, I examined the several examples of current research

using each of the three conceptual frameworks used for this study. The studies were

selected to match as closely to the characteristics and topic of my study.

Health Belief Model

The HBM has been used as a guiding conceptual framework extensively in health

behavior research for over 60 years (Glanz et al., 2008). It has served many purposes

including helping “explain health behavior change and maintenance of health-related

behaviors and as a guiding framework for interventions” (Glanz et al., 2008, p. 45). The

theory was developed in the 1950s and originated from classical stimulus response theory

(Watson, 1925) and cognitive theory (Lewin, 1951; Rosenstock, Stretcher, & Becker,

1988; Tolman 1932). Important contributors to the HBM include Bandura (1997), Becker

(1974), Hochbaum (1958), and Rosenstock (1974). Stimulus response theory posits that

reinforcement determine the frequency with which an individual will engage in a

 36
behavior but the quicker the reinforcement following the behavior the more likely the

behavior would be repeated.

A literature review of PCC using the HBM as a conceptual framework resulted in

two studies available for review (Quillin, Silberg, Board, Pratt, & Bodurtha, 2000; Wang,

Charron-Prochownik, Sereika, Siminerio, & Kim, 2006). In this section, I examined two

studies that used the HBM to guide their research studies. The first study was selected

because the study used the HBM as a guiding conceptual framework, the topic was PCC,

and the majority of the female sample was aged 17 to 24 (Quillin et al., 2000). The

second study was selected because both the HBM and SCT were used as conceptual

frameworks, the topic was PCC, and the sample were adolescents which closely aligns

my study (Wang et al., 2006).

Quillin et al. (2000) used an exploratory approach to examine college-aged

women’s vitamin consumption, knowledge of the cause of neural tube defects as related

to preconception deficient folic acid, and related behavioral factors. Participants were

recruited by posting flyers and class announcements at a Virginia college. All 71

participants were females aged 17 to 50 years of age with the majority aged 17 to 24

(94%). No details regarding participants race, socioeconomic status, or marital status was

reported. All the participants were enrolled in an undergraduate psychology course at the

time of the study.

Quillin et al. (2000) used a pretest, intervention, post-test method to collect data.

Both the HBM and the Fetal Health Locus of Control Scale (FHLCS) were used as

conceptual frameworks to guide the study. The HBM was used in constructing the
 37
pretest, posttest, and during analysis. During analysis the HBM was used to help analyze

participant behaviors and perceptions. The main constructs from the HBM used for this

study were perceived susceptibility, perceived seriousness, perceived benefit, and

perceived barriers. Quillin et al. clearly stated that the HBM was modified during

analysis to combine perceived seriousness and perceived susceptibility into a new

construct called perceived threat. An advantage of reviewing this study was the written

sample test questions with the correlating HBM constructs presented to readers. Although

Quillin et al. did not support the use of an educational intervention to increase folic acid

consumption it was beneficial in identifying a lack of knowledge of preconception care.

In addition, this study clearly described how the HBM and FHLCS was utilized and

supported this study.

Wang, Charron-Prochownik, Sereika, Siminerio, and Kim (2006) used an

exploratory case-control design, using cross-sectional data, to compare the ability of three

theories to predict reproductive health decision-making in adolescents with Type 1

diabetes. Another objective of this study was to combine the strongest predictors of the

theories to develop a composite model. This study will be further discussed under SCT

since it uses both the HBM and SCT as guiding conceptual frameworks.

Social Cognitive Theory

SCT has been used as a guiding conceptual framework extensively in health

behavior research for over 30 years (Glanz, Rimer, & Viswanath, 2008). It can serve

many purposes including “understanding the factors that influence human behavior and

the processes through which learning occurs, offering insight into a wide variety of
 38
health-related issues” (Glanz et al., 2008, p. 175). SCT was built on the theory and

research of Miller and Dollard (1941), Rotter (1945). Vygotsky (1978), Bandura (1986),

and Lave (1988) postulated theories that all emphasize the central role of social learning.

Initially, Bandura (1986) called his theory observational learning or social learning

theory. As concepts from cognitive psychology were integrated into the theory Bandura

(1986) renamed it SCT. One of Bandura’s (1997) most recent and important expansions

of SCT is the inclusion of self-efficacy. A literature review of PCC using SCT as a

conceptual framework resulted in one study available for review (Wang et al., 2006).

In this section, I examined two studies that use SCT to guide their research

studies. The first study was selected because both the HBM and SCT were used as

conceptual frameworks, the topic was PCC, and the sample were adolescents which

closely aligns my study (Wang et al., 2006). The second study was selected because the

study used SCT as a guiding conceptual framework, evaluated knowledge of a health

related behavior, the sample of adolescents aged 14 to 19 years of age was similar to the

targeted age group in my study, and had varied racial representation.

Wang et al. (2006) used an exploratory case-control design, using cross-sectional

data, to compare the ability of three theories to predict reproductive health decision-

making in adolescents with Type 1 diabetes. Another objective of this study was to

combine the strongest predictors of the theories to develop a composite model. The data

for this study were derived from another study where all 87 participants were single

females aged 17 to 21. The majority were White (87%), attending high school (66.7%),

and Roman Catholic (52%).

 39
Wang et al. (2006) used 1-hour telephone interviews to the complete the RHAB

questionnaire for this study. The RHAB was formulated using the HBM, SCT, and TRA.

Although the actual questionnaire or sample questions were not provided the study cited

where the entire questionnaire could be located. Five constructs from the HBM were used

in the RHAB including susceptibility, severity, benefits, barriers, and cues to action. Self-

efficacy was the construct used from SCT in the RHAB questionnaire. Two constructs

from the TRA were used in the RHAB including personal attitudes and subjective norms.

Findings from the Pittsburgh Adolescent Diabetic PCC study supported that the

constructs from the HBM and SCT were the strongest predictors of adolescents’

reproductive health decision-making in adolescents with type 1 diabetes. In addition, cues

to action, perceived barriers, and self-efficacy were the best predictors of the adolescents’

planned use of birth control. The findings of this study support the use of both the HBM

and SCT in my study of PCC in adolescents.

In an adolescent over-the-counter (OTC) pain medication study by Rogers &

King (2013), the researchers used and randomized pretest, intervention, post-test design

to determine if an intervention based on SCT could increase students’ knowledge and

beliefs to more effectively use pain medications. All 203 participants were recruited from

10 classrooms from one rural high school. Participants were both male and female ranged

in age from 14 to 19, currently enrolled as a student in the high school, and represented a

wide range of ethnicity.

Rogers and King (2013) used a randomized pretest, intervention, posttest design.

The SCT constructs of self-efficacy, outcome expectations, behavioral capabilities, and

 40
situational perception were used in this study to develop the intervention and the

instrument used in the pretest and post-test. Rogers and King performed a pretest on the

instrument which resulted in modification of the tool. An expert panel was used to review

the original instrument and the modified instrument. Examples of the instrument were not

available to the reader.

Rogers and King’s (2013) findings were mixed. There were significant increases

in the intervention group for outcome expectations and behavioral capabilities compared

to the control group participants. Rogers and King did not find significant changes in

self-efficacy, situational perception, or outcome expectancies. An important finding was

that prior to the intervention students thought they possessed the skills and knowledge

needed to medicate and self-administer OTC medications. Participants also falsely

believed they knew the positive and negative side effects of OTC medications.

Adolescent Affective and Cognitive Theory

Affective and cognitive theory has been used as a guiding conceptual framework

extensively in psychology and education research for over 60 years (Wadsworth, 1996).

It can serve many purposes including helping understand how adolescents’ form and

acquire knowledge (Ginsburg & Opper; Wadsworth, 1996). AACT is an evolving theory.

AACT was built on the theory and research of Piaget (Wadsworth, 1971; Zelazo,

Chandler, & Crone, 2010). The theory has been widely used in psychology and

educational research of children to help “understand how and why children behave as

they do” (Wadsworth, 1996, p. IX). Piaget’s work was influenced by the work of

psychoanalysts Freud and Jung and initially guided by psychologist Alfred Binet
 41
(Ginsburg & Opper, 1988; Wadsworth, 1971). Piaget’s theory of cognitive theory

developed over 60 years based on extensive studies of children.

AACT posits that intellectual development is accomplished with a combination of

cognitive, affective, and social aspects (Wadsworth, 1971). A literature review using

Piaget’s ACT as a conceptual framework resulted in two studies available for review

(Drust, 2013; Shaw, 2012). In this section, I examined two studies that used ACT to

guide their research studies. The first study was selected because the study used ACT as a

guiding conceptual framework, examined perceptions, and it used a qualitative approach

(Drust, 2013). The second study was selected because ACT was used as the conceptual

framework, utilized a qualitative approach, and the participants were Hispanic,

representing a disenfranchised group (Shaw, 2012).

Drust (2013) used a qualitative case study approach to explore how the use of a

math coach to provide professional development affected the teachers’ instructional

practices. Purposeful sampling was used to recruit 12 participants from one school. No

details regarding participants’ race, socioeconomic status, sex, or marital status were

reported. All participants were required to be enrolled in the yearlong math coaching

professional development program.

Drust (2013) used questionnaires, interviews, and archival data to collect data.

Both Piaget’s affective and cognitive theory and Knowles’ andragogy theory were used

as conceptual frameworks to guide the study. Piaget’s affective and cognitive theory was

used to help understand the participants’ learning processes. Schema, cognitive

 42
disequilibrium, and constructivism were three constructs from Piaget’s affective and

cognitive theory used in this study.

Although Drust (2013) discussed the use of Piaget’s affective and cognitive

theory it did not demonstrate or detail how the theory was used in the study. Review of

this study did give me the opportunity to learn how Knowles’s andragogy theory and

Piaget’s affective and cognitive theory could be used in combination as a conceptual

framework. This review also afforded me the opportunity to identify stronger ways to

demonstrate and cite more directly how I will use AACT in my own study.

The Hispanic Parental Involvement Study used a qualitative approach to explore

the quality of their children’s schools involvement opportunities and support systems and

to find new ways to engage Hispanic families in academic and engagement programs

(Shaw, 2012). Thirty families of Hispanic students were recruited from one school to

participate in this study. Only 13 families completed the questionnaire and only nine

participated in the focus group.

The Hispanic Parental Involvement Study used questionnaires, focus groups, and

field notes to collect data (Shaw, 2012). Vygotsky’s zone (1978) of proximal

development theory, Moll’s Funds of knowledge theory, and Piaget’s ACT were used as

conceptual frameworks to guide the study. All three theories were explained in detail and

related the relevance to this study. Key constructs of ACT included concrete operations

and formal operations. Piaget’s ACT was used as a way to understand the participants’

stage of cognitive development and gain insights of how to improve conditions to

promote the parents’ movement to formal operations stage. Facilitating movement along
 43
the stages of cognitive development was found to assist families in helping their child

with homework.

Findings from the Hispanic parental involvement study (Shaw, 2012) supported

the use of the three theories used to guide this study. This study provided detailed

discussion of how the theories were used and how the findings were interpreted and

supported by the theories. Since this study used concrete and formal operations stages of

cognitive development, just as my study will, it was beneficial to see how this study

applied the theory and used it in analyzing the data.

Qualitative Design

There are three important keys to selecting an appropriate research design:

understanding the nature of the problem, understanding what research has been done in

the past, and knowing the population you are targeting (Creswell, 2014). Qualitative and

quantitative research designs have very different approaches and methods. When the

nature of the problem is to explore and understand the meaning of a problem of one or a

group of individuals, then qualitative research will best serve the research study

(Creswell, 2014). If the nature of the problem is to examine variables to test objective

theories, then quantitative research would best serve your research study (Creswell,

2014). Mixed methods researchers employ both quantitative and qualitative methods

when combining both methods would yield a clearer understanding of the problem

(Creswell, 2014). Qualitative research would be the best suited for the study on routine

adolescent PCC due to the nature of the problem, lack of research on the subject, and

working with a vulnerable adolescent population. The use of a quantitative approach

 44
would not yield a thick detailed rich description that a qualitative research design would

provide on the subject.

Narrative research, phenomenology, grounded theory, ethnography, and case

studies are five common types of qualitative research approaches available (Creswell,

2013). Each approach has distinct different focuses, units of analysis, data collection

forms, data analysis strategies, and type of report generated from the data (Creswell,

2013). One needs to evaluate all of these characteristics to determine the best approach to

investigate the phenomenon selected. After examining the five qualitative approaches and

their individual characteristics phenomenology would best serve as the research approach

to explore adolescent PCC.

Phenomenological Methodology

A phenomenological method to collect data has been used by many to help

illuminate the lived experience of a topic. Due to the limited number of studies on PCC

and use of adolescent participants phenomenology would best serve as the research

methodology. Studies done gathering information about adolescents’ knowledge,

experiences, perceptions, and attitudes of PCC could lay the foundations to explore other

methodology such as mixed method and quantitative. A literature review of PCC using a

phenomenological method resulted in no studies available for review.

In this section, I examined three studies that use a phenomenological design that

used the modified Stevick-Colaizzi-Keen method (Moustakas, 1994) to interview and

analyze the data and studied a phenomenon that included adolescent participants. The

first study was selected because the researcher used all adolescents and provided a
 45
detailed description of how the modified Stevick-Colaizzi-Keen method was used to

analyze the data (Kerr, 2008). The second study was selected because it also provided a

detailed description of how the modified Stevick-Colaizzi-Keen method was used to

analyze the data and participants were younger adolescents aged 16 to 19 (Schulz, 2006).

The third study was selected because it included five adolescent participants ages 13 to

16 years old, similar to the age group targeted in my study (Gueye, 2012).

Kerr (2008) used a phenomenological approach to understand the experiences of

male adolescents of divorced parents and the relationship they had with their father who

were not granted custody. Participants were recruited by posting flyers at a Midwestern

University. Eight male participants, aged 19 to 23, were recruited to participate in the

study. Over 62 % were White, about 32% were Black, and only one participant was

multiracial. All of the participants were enrolled in college at the time of the study.

Kerr (2008) used a semistructured interview protocol, developed for this study,

with open-ended questions to facilitate collection of data. An initial interview was

conducted to gather data and then a follow-up interview was scheduled to review their

responses, researcher interpretation, and themes identified. The analysis process was

clearly presented including full transcripts of interviews, listing of common themes, an

accounting of common themes by each participant, and included additional themes

identified by a single participant.

Kerr (2008) found multiple common themes shared by the participants. The use of

phenomenology helped to give voice to adolescents to open up about a difficult topic. In

addition, findings validated that although common themes could be identified on the
 46
topic that the participants did have individual unique experiences that a survey may not

have yielded. The study design was successful in gathering the unique experiences of a

vulnerable population, adolescents.

Schulz (2006) used a phenomenological approach to understand the perceptions

and experiences of adolescent males who attributed their inability to complete high

school to feeling alienated from the educational system. Five participants aged 16 to 19

years old were recruited to participate in the study. The purpose of the study was to

discover the essence of alienation from the perspective of the participants.

Schulz (2006) used a series of three semistructured interviews with each

participant. The last interview included having the participant reflect on the meaning of

his experiences of the phenomenon. The modified Stevick-Colaizzi-Keen method was

identified as the process used to analyze the data collected. In addition, the method was

explained in step-by-step detail that resulted in identifying common themes among the

participants. Schulz accurately followed all five steps outlined in the modified Stevick-

Colaizzi-Keen method of analysis including horizonalization, textural description,

structural description, textural-structural description and lastly the composite textural-

structural description. The last step in the analysis involved the formation of one

description of the experience that represented the experience of all five participants.

Schulz (2006) through the use of phenomenology was able to discover the essence

of the topic of the five participants. The essence was identified as an interrelationship

among disappointment, trust, peer acceptance, and fear of failure. The use of

phenomenology helped to give voice to these adolescent participants, a group considered

 47
vulnerable, to open up about a difficult topic. The use of a survey would not have been

applicable in this study due to lack of research on the topic. In addition, findings

validated that although common themes could be identified on this topic but the

participants did have individual unique experiences that a survey may not have yielded.

The study design was successful in gathering the unique experiences of a vulnerable

population, adolescents.

Gueye (2012) used a phenomenological approach to explore the mentoring

experiences from the perspective of adult mentors and adolescent females who were

mentored. A total of 17 participants were recruited including five adolescent girls in

Grades 7 to 9. A purposeful sampling method was used to identify participants for this

study. Participants included mentors aged 39 to 58, mentees aged 13 to 16. The

participants’ ethnicity or socioeconomic status was not included in the study.

An interview protocol was developed and used to collect data from the

participants in the Perceptions of mentoring relationships study (Gueye, 2012). Prior to

conducting the interviews the researcher underwent a bracketing interview using a

licensed mental health psychologist to help identify and set aside any personal

experiences that may cloud her view and help her keep a fresh perspective of the

phenomenon under investigation. One interview session was used to collect the data from

participants. The modified Stevick-Colaizzi-Keen method was identified as the process

used to analyze the data collected. In addition analysis also included using graduate

students performing axial coding to help interpret and open code the data to identify
 48
recurring themes. Although all five steps of the modified Stevick-Colaizzi-Keen method

were reported as being used they were not provide in explicit detail or labeled as such.

Gueye (2012) found multiple common themes shared by both mentors and

mentees. The use of a phenomenological approach to explore the mentoring experience

helped identify that both mentors and mentees use multiple strategies to nurture and

maintain the relationship. The selected study design was successful in gathering the

unique experiences of a group with a wide age range from 13 to 58 years of age.

Implications

This study provides implications for nursing practice, advanced nursing practice,

education, and medical practice with considerations for future research. In addition to the

CDC (2006) mandating that routine PCC be provided, various researchers and scholars

have recommended that new strategies need to be developed and expanded to provide

PCC for all women of childbearing women (Howse, 2008; Johnson, Atrash, & Johnson,

2008; Posner, Johnson, Parker, Atrash, & Bierman, 2006). Due to the wide range of ages

and varied needs within the group of women of childbearing age more than one approach

to PCC should be developed. The educational, emotional, developmental, physical, and

psychosocial needs of an adolescent are not necessarily the needs of a young or middle

adult. Based on the unique characteristics of adolescents, a PCC program for adolescents

should be developed that addresses their particular educational, social, and medical needs

(Bearinger et al., 2007; Daley et al. 2004; Tylee et al., 2007). This research study will add

to the body of knowledge regarding the knowledge, attitudes, and beliefs about PCC, in
 49
low income Black adolescents, to assist in developing appropriate culturally sensitive

PCC programs for adolescents.

Summary

Researchers have consistently has recommended that PCC needs to be provided to

all women of childbearing age and should be tailored to their unique educational,

emotional, developmental, physical, and psychosocial needs of the individual (Bearinger

et al., 2007; Daley et al., 2004; Tylee et al., 2007). Among the themes that emerged from

the literature review, were PCC knowledge deficits exist that are not being met (Corbett,

2011; Coonrod et al., 2009; Delgado, 2008; Heavey, 2010; Kaiser & Hays, 2005) the

younger the participant the less knowledgeable they were regarding positive and negative

health behaviors that affect pregnancy (Coonrod et al., 2009), participants are interested

in receiving PCC (Coonrod et al., 2009), there are opportunities to provide PCC that are

not being utilized (Heavey, 2013), new strategies need to be developed and expanded in

delivering PCC for all women of childbearing women (Corbett, 2011; Delgado, 2008),

and that further research needs to be done to better understand the PCC needs of

adolescents (Corbett, 2011; Coonrod et al., 2009; Delgado, 2008; Heavey, 2010; Kaiser

& Hays, 2005).

The purpose of this phenomenological study will be to understand preconception

care from the perspective of adolescent females. I will also seek to identify barriers to

seeking preconception care.

To understand preconception care from the perspective of adolescent females, a

qualitative phenomenological approach was used to gather information. Interviews were

 50
used to collect data since it is the most common method of collecting data in

phenomenological research. In addition in-depth interviews allowed multiple

opportunities for clarification and better understanding of the meaning of the data

collected from the adolescent participants. The modified Stevick-Colaizzi-Keen method

was used to conduct interviews and analyze the data (Moustakas, 1994). Section 3 is an

explanation of the methodology and selection of research design, data collection, and data

analysis methods employed to conduct this study.

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Section 3: Research Method

Introduction

The purpose of this phenomenological study was to understand preconception

care from the perspective of adolescent females. I sought to identify barriers to seeking

preconception care. I investigated (a) adolescent females’ knowledge, attitudes, and

beliefs regarding preconception care; and (b) adolescent females’ knowledge regarding

participating in a reproductive life plan. I used a qualitative phenomenological approach

to gather information from adolescents about PCC, conducted two in-depth

phenomenological interviews with each of the five participants. This study provides

insight as to why adolescents seek or, more importantly, do not seek PCC. This section is

a description of the qualitative method, research questions, contexts for the study,

measures for ethical protection, role of the researcher, criteria for selecting participants,

data collection strategies, data analysis plan, and strategies to ensure reliability.

Qualitative Tradition

One of the most important tasks in preparing for a research study is to determine

which research design should be utilized to study the topic. Creswell (2014) identified

quantitative, qualitative, and mixed methods as three types of research designs. The

nature of the research problem, target population, procedures of inquiry, and specific

methods of data collection, analysis, and interpretation are some of the factors which

should be considered when selecting a research design.

To evaluate objective theories using quantitative research, the variables of a

phenomenon need to be known (Creswell, 2009; Denzin & Lincoln, 2011). Considering
 52
that important variables on PCC have yet to be identified due to lack of research on the

subject, a quantitative design would not be applicable for this study. A qualitative method

is well suited for an exploratory study aimed at examining and understanding the

meaning of an experience (Creswell, 2009). Studies are usually considered exploratory if

there is a lack of published research on the topic or on the topic with a particular target

population, and when the researcher’s objective is trying to understand the subject by

listening to the participants’ experiences (Creswell, 2013; Marshall & Rossman 2015;

Patton, 2014). Since the majority of researchers on PCC have addressed PCC in women

with known chronic illnesses rather than healthy women, this study qualifies as an

exploratory study. In addition, adolescents have not been a target population of PCC

research published in the literature.

Use of a qualitative research design is justified because the proposed study is an

exploratory study, will use in-depth interviews to understand adolescent females’

experiences of PCC, and little research has been done on this topic or with this

population. “Mixed methods research is an approach to inquiry that combines or

associates both qualitative and quantitative forms” (Creswell, 2013, p. 4). Since a

quantitative approach is not applicable, neither is a mixed method approach for this

study.

Ethnography, grounded theory, case studies, phenomenological research, and

narrative research are five types of qualitative strategies of inquiry to research a topic

(Creswell, 2013; Denzin and Lincoln, 2011). Each of these five strategies is designed to

put forth different kinds of questions and use different analytic tools to answer those
 53
questions (Polkinghorne, 2005). “Phenomenology is a complex system of ideas

associated with the works of Husserl, Heideggar, Sartre, Merleau-Ponty, and Alfred

Schutz” (Denzin & Lincoln, 2011, p. 27). The hallmark of phenomenology is capturing

the lived experience or essence of several participants (Creswell, 2013; Denscombe,

2014; Hatch, 2002). The basic purpose of a phenomenological approach is to develop a

composite description of the lived experience and uncover a universal essence that

represents the participants’ experiences. Both the purpose and hallmark of

phenomenology support using this strategy as the best approach to explore PCC attitudes

and beliefs with this target population and to allow for adolescents’ voices and

experiences to be heard.

There are many forms of phenomenology to guide a researcher during a study.

Denscombe (2014) identified two types of phenomenology as the European and North

American versions. The North American version is “less concerned with revealing the

essence of experience, and more concerned with describing the ways in which humans

give meaning to their experiences” (Denscombe, 2014, p. 101). The European version of

phenomenology is concerned with “investigating the essence of human experience”

(Denscombe, 2014, p. 100). The purpose of European phenomenology is to get a rich

description of all the important qualities of the participants’ experiences on the topic. The

aim of transcendental phenomenology, a type of European phenomenology, is focused on

“discovering underlying, fundamental aspects of experience- features that are universal

and that lie at the very heart of human experience” (Denscombe, 2014, p. 100)

Transcendental phenomenology is consistent with the aims of my study to explore PCC

 54
and for adolescents’ voices and experiences to be heard. I used transcendental

phenomenology as the qualitative research design to execute this study of PCC.

Research Questions

1. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding preconception care?

2. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding participating in a reproductive life

plan?

From each of the central research questions, additional sub questions emerged that were

used to help narrow the focus and understand more fully the knowledge, attitudes, and

beliefs about preconception care.

Contexts for the Study

The context for this study was a public housing development and an apartment

located in a large metropolitan city in southeastern U. S. The population for this study

was adolescents who lived in a housing development and an apartment complex.

 55
Table 1

Housing Characteristics

Characteristic Driftwood Housing Development Bayou Apartments

Type of Housing Single Family Housing Apartments
Number of Units 160 450
Number of Bedrooms 2, 3, & 4 1, 2, & 3
Monthly Rent $918 to $1341 $529 to $750
Accepts Section 8 Yes Yes
Paid Utilities Included No Yes
Central Air & Heat Yes Yes
Washer/Dryer in Unit Yes No
24 Hour On-Site Manager Yes No
Swimming Pool No Yes
Playground Yes Yes
Community Center Yes Yes

Driftwood Housing Development

Driftwood Housing Development (pseudonym), a low-income housing

development located in a suburb of a metropolitan city in southeastern U.S., was used to

recruit participants for this study. The 160 single family rental houses were built in the

last five years. The residents included traditional, single-parent, and multigenerational

families. The majority of residents are African-American. The development has a

community center, strictly enforced rules for residents, a curfew, and a manager living

on-site. The community center has meeting rooms and a computer room for residents to

use. There are plans to open an on-site daycare center in the next few months. Rent

ranges from $918.00 to $1341.00 per month plus utilities. Residents may use government

assistance, Section 8, to assist with the monthly rent.

Each house is furnished with all major appliances including a washer and dryer.

The entire housing development is clean, and well maintained, the houses are all modern,
 56
attractive and colorful. The bus stop for all Driftwood school students is located in front

of the community center. The housing development is not located near health care centers

or hospitals. One public bus line services the area but service is very infrequent. There is

a high crime rate in the area surrounding the housing development.

Bayou Apartments

Bayou Apartments (pseudonym), a low-income apartment complex, was also one

of the sites used to recruit participants for the study. The apartment complex is located in

the same neighborhood as the housing development. There are 450 one, two, and three

bedroom apartments in the complex. The residents include traditional, single-parent, and

multi-generational families. The majority of residents are African-American. Rent ranges

from $529.00 to $750.00 per month not including utilities. Residents may use

government assistance, Section 8, to assist with the monthly rent if they qualify.

Each apartment is furnished with all major appliances including central air and

heat. A manager is on-site only during daytime business hours. The complex has a

community center, laundry facility, and swimming pool. The school buses load and

unload high school students in front of the community center. The apartment complex is

older, maintained, but not attractive. The apartment complex is located within a few

blocks of the housing development. The apartment complex is not centrally located near

health care centers or hospitals. One public bus line services the area but service is very

infrequent. There is a high crime rate in the area surrounding the apartment complex.
 57
Measures for Ethical Protection

“A ‘good’ qualitative study is one that has been conducted in an ethical manner”

(Merriam, 2002, p. 29). Informed consent, anonymity, and confidentiality are some of the

most important ethical issues to address in qualitative research. First, I received approval

from Walden University’s Internal Review Board to perform the study. I obtained

permission from the managers of the housing development and apartment complex to

recruit and interview the participants.

Informed consent forms were prepared using language that was age appropriate

for the participants. Participants received a written description of the study that included

contact information for me and my faculty chairperson. A signed informed consent form

was obtained from each participant (Appendices B, C, and D).

I employed multiple strategies to protect the participants’ anonymity and

confidentiality. I used pseudonyms for the housing development, apartment complex, and

all participants to ensure confidentiality. In addition to each of the participants being

assigned a pseudonym they also had a code number assigned to them for anonymity.

Identifying information that links the participant with their name and demographic

information is stored in a locked file cabinet in my home and in a password protected

computer file.

Role of the Researcher

“Thinking through and describing the anticipated relationships between researcher

and participants is a vital part of designing a qualitative project” (Hatch, 2002, p. 51).

Understanding a qualitative researcher’s role as the key data collection instrument,

 58
establishing a researcher-participant relationship, and identifying methods to help build

and maintaining researcher-participant relationships should be developed prior to

interviewing participants. Defining the researcher’s relationship to the participants and

identifying strengths and weaknesses of interviewing techniques will also help to

establish, build, and maintain researcher-participant relationships.

Researcher as Instrument

A researcher acts as the main instrument to collect data from the participants in a

qualitative study (Borbasi, Jackson, & Wilkes, 2005; Creswell, 2013). The use of the four

senses of sight, hearing, smell, and touch were utilized during interviews. Active

listening, good interviewing skills, participant observation, and interpretation on multiple

levels needed to be used during interviews to accurately capture the data (Borbasi,

Jackson, & Wilkes, 2005). I used these skills that I, as a nurse and nurse practitioner,

have been trained and have actively utilized these for over 30 years.

Researcher-Participant Relationship

In a phenomenological study, it is essential to develop a researcher-participant

relationship to encourage participants to openly share their experiences. It is important to

present one’s self in a nonthreatening role that is generally acceptable to participants such

as a student, faculty, or author (Rubin & Rubin, 2005). I developed relationships by

recruiting participants in person in the rental offices, community center, and at the bus

stops at each site. I briefly introduced myself as a student completing a formal paper for

school, explained the proposed study, and what their role as participant involved. I shared

with participants that I am trying to gather information to understand what their

 59
experiences with PCC have been. Those interested in participating were invited into a

private room, in the community center or rental office, to further discuss the study. I

continued to foster an open and trusting relationship throughout each of the multiple

interviews. At the conclusion of each interview I thanked each participant for their time

and help with the study. I gave a ten dollar gift card to each participant as a thank you gift

for participating.

Relationship to Participants

My relationship to participants in this study was as researcher collecting data. My

role was not as a nurse, nurse practitioner, medical provider, counselor, teacher, or friend.

During this study my relationship to the participants included not having any previous or

current personal or professional relationship with them. I have never been employed by

the housing development or apartment complex. I do not personally know any of the

employees or residents of the housing development. In the past few months I initiated

contact with both facilities to introduce myself and discuss the possibility of recruiting

participants for my study. Both facilities agreed to allow me to recruit participants for my

study at their facilities.

Researcher’s Interview Experience

Evaluation of one’s interviewing techniques and experiences may help identify

ways to improve interview skills and data collection during a qualitative study. As a

registered nurse for over 30 years and a nurse practitioner for over 15 years, interviewing

is a skill I depend on in every interaction with patients daily. Due to their clinical

experience, nurses tend to have a greater ability to successfully actualize the researcher
 60
role of interviewing, establishing and maintaining a researcher-participant role than other

social researchers (Borbasi, Jackson, & Wilkes, 2005).

Although I possess strong interview skills, I also have several weaknesses that

need to be addressed. My normal roles as caretaker, teacher, and counselor had to be

eliminated during my interactions with participants. Nurse practitioners tend to control

the information gathered and pace during medical interviews whereas the control shifted

more to the participant with a more relaxed pace. Also many of the questions during a

medical interview are completed with simple yes or no answers, whereas, during this

study rich detailed answers were encouraged. To address these weaknesses, I reviewed a

reminder list of 11 common pitfalls prior to every interview (Pope & Mays, 2006). I also

carefully listened after each interview using Whyte’s (1986) directiveness scale for

analyzing interviewing techniques and Patton’s (2014) scale to evaluate if control of the

interview by the researcher was successfully achieved. Based on what I learned, I made

positive changes needed to improve my interviewing skills.

Criteria for Selecting Participants

Selection of a sampling strategy should be guided by the purpose of a research

study (Pope & Mays, 2006). Qualitative research sampling methods differ from

quantitative because they are not usually random or designed to produce results

generalizable to an entire population (Gall, Gall, & Borg, 2014; Polkinghorne, 2005;

Pope & Mays, 2006). It is important to choose participants that have the richest

experiences of the phenomenon to be able to gather data to better form a clearer

understanding of the phenomenon (Merriam, 2002). Convenience, snowballing and

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purposeful sampling are all appropriate strategies to select participants for qualitative

phenomenological research studies. Each sampling strategy has advantages and

disadvantages that may affect a study. Evaluation of the disadvantages and advantages of

each sampling method helped determine which strategy was best suited to select

participants for this study.

Convenience Sampling

Convenience sampling is a sampling strategy where the main selection criteria are

convenient access to the participants (Denscombe, 2014). The advantages of using a

convenience sample are that they are less expensive and that it is easy. The disadvantages

of a convenience sample strategy are the quality of your information and credibility may

be limited (Creswell, 2013; Denscombe, 2014).

Snowball Sampling

Snowball sampling is a participant selection strategy where a qualifying

participant recommends one or more others with rich experiences on the topic to

participate in the study (Denscombe, 2014, Marshall & Rossman, 2015). Possible

advantages of this strategy include quicker identification of participants, faster access to

participants, and the ease with which referred participants share their experiences. The

ease of sharing experiences by referred participants is probably due to being introduced

by a friend of theirs (Denscombe, 2014). Disadvantages of using the snowball sampling

strategy are that it may limit socioeconomic, cultural, educational and intellectual

variation among study participants.

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Purposeful Sampling

Purposeful sampling refers to a strategy where participants are selected who have

experienced the phenomenon and are able to provide rich detailed information that will

help the researcher understand the phenomenon (Creswell, 2013; Denscombe, 2014).

Advantages of using a purposeful sample include getting participants with rich

experiences and the ability to include participants with a range of varied experiences. “A

purposeful sample can be used in order to ensure that a wide cross-section of items or

people is included in the sample” (Denscombe, 2014, p. 41). A possible disadvantage to

using purposeful sampling to select participants is that the researcher needs to be

knowledgeable about the phenomenon to be able to utilize the sampling method.

Selection of Sampling Strategies

Participants for this study were selected using a combination of purposeful and

snowball sampling strategies. Convenience sampling was not used for this study because

although it is relatively cheap and easy to do, it is not worth the risk of limiting the

quality or credibility of the study as some scholars suggest it might (e.g., Creswell, 2013;

Denscombe, 2014). Participants first identified through purposeful sampling, from one of

the two facilities, were asked to nominate additional participants for the study. In this

study, purposeful and snowball sampling involved selecting adolescent females who were

willing to share their experiences of PCC. It is believed participants selected from the two

facilities represent the typical PCC experience of adolescent females. The participants for

this study were adolescent females aged 18 to 21 years of age.

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Participant Selection

There is not an exact perfect number of participants or a mathematical formula to

use to determine the number of participants required to successfully complete a

qualitative phenomenological research study (Patton, 2014; Pope & Mays, 2006). A

cumulative approach to determining sample size was used. “The cumulative approach is

one in which the researcher continues to add to the size of the sample until a point is

reached where there is sufficient information and where no benefit is derived from adding

any more to the sample” (Denscombe, 2014, p. 40). Although sample size cannot be

predicted at the beginning of a phenomenological study, even using a cumulative

approach, it is anticipated that at least five participants will be needed to achieve

saturation for this study.

Many resources recommend between five to 25 participants to achieve a rich

description of the phenomenon (Creswell, 2013; Denzin & Lincoln, 2011). Multiple

sources emphasize that sample size should be determined by the research design,

purpose, research questions, and available resources (Creswell; Denscombe; Patton,

2014). Marshall and Rossman (2015) found that recent phenomenological health research

studies tended to include one to four informants. This sample consisted of five women

who meet the age criteria. I interviewed the first five participants of the

purposeful/snowball sample who agree to be interviewed. Data from those five

interviewed achieved saturation of data and did not require additional participants.

Inclusion criteria for this study is that participants were English-speaking females,

aged 18 to 21 years of age, and had not had a previous pregnancy or undergone a
 64
hysterectomy. Females who have had a hysterectomy in their teen years would have had

an extreme medical history and not be representative of the typical experience of teens,

therefore excluded from the study. Since the study is aimed at gaining the adolescent

experience of PCC, females over the age of 21 were excluded from the participant pool.

Pregnant participants were excluded from the study.

Data Collection Strategies

In phenomenological research, the interview is the most common method used to

collect data on the topic being explored (Moustakas, 1994; Polkinghorne, 2005). “The

phenomenological interview involves an informal, interactive process and utilizes open-

ended comments and questions” (Moustakas, 1994, p. 114). A set of open-ended

interview questions were prepared to guide the interview and help the participants focus

on ways to share their PCC experiences (Appendix A). It is important to remember that

the prepared interview questions were just a guide not a script (Moustakas, 1994; Patton,

2014). Interview questions needed to be flexible, may need to be changed during the

interviews, and many not even be needed during the interviews (Moustakas, 1994).

Capturing participants’ full descriptions and helping to understand and clarify the

meaning of the data collected “requires collecting a series of intense, full, and saturated

descriptions of the experience under investigation” (Polkinghorne, 2005, p. 139). To

achieve this, I conducted two, one-on-one interviews with all participants. I scheduled an

initial interview appointment with each participant when the consent was signed. At the

beginning of the second interview participants were asked to review the transcripts of the

first interview for accuracy. At the close of each interview a follow-up interview time,
 65
date, and location was arranged with each participant. Conducting at least two interviews

allowed the participant to reflect on PCC experiences and possibly share more during the

second interview. The second interview also allowed an opportunity for participants to

clarify their statements, transcribed from the first interview, and validate the researcher’s

interpretation of their statements. Any participants who do not participate in two

interviews were eliminated from the study.

Data Collection Steps

The following steps were used to collect data for this study:

1. Internal Review Board approval was obtained from Walden University.

2. I obtained permission from all recruitment sites. Participants were recruited

from the multiple sites using flyers and recommendations from recruited

participants.

3. Participant consents were obtained prior to conducting the interviews.

4. I interviewed five participants using in-depth phenomenological interviews

with each participant. I interviewed each participant at least twice. Moustakas’

(1994) phenomenological interview process was utilized as the guiding

framework to prepare and conduct the interviews. An interview guide was

prepared prior to the interviews to assist with the interview. Interview

questions were open-ended and designed to capture the participant’s

knowledge, attitudes, and beliefs about PCC. I conducted all interviews in

person and audio-taped with two recorders.

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Data Analysis Plan

“Data analysis is a systematic search for meaning” (Hatch, 2002, p. 148).

Moustakas’s (1994) modified version of the Stevick-Colaizzi-Keen’s method of analysis

was used because it has systematic steps to complete qualitative data analysis and

provides guidelines to develop the textural, structural, textural-structural, and composite

textural-structural descriptions.

Horizontalization

“Horizontalization is the process of laying out all the data and treating the data as

having equal weight; that is, all aspects of data have equal value at the initial data

analysis stage” (Merriam, 2002, p. 94). I began by reflecting on my own experience of

PCC through writing about it in rich detail. My own data were horizonalized by listing

each statement, sentence, or phrase about the phenomenon. This process helped me

identify and set aside some of my own biases and allow a fresh perspective while

analyzing participant data. Next the same process was completed on each participant’s

verbatim transcript. The horizonalized data was reviewed to remove any repetitive

expressions leaving only invariant constituents, “nonrepetitive, nonoverlapping

statements” also known as “the invariant horizons or meaning units of the experience”

(Moustakas, 1994, p. 122). The narrowed statements were then clustered to form themes.

These themes and units of experience were cross checked from the original transcripts to

verify that they were consistent with the data. I also had a peer review the themes to

verify that the data was appropriately clustered.

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Textural Description

A textural description was devised from these themes. Moustakas (1994)

described the construction of a complete textural description as

An interweaving of person, conscious experience, and phenomenon. In this

process of explicating the phenomenon, qualities are recognized and described;

every perception is granted equal value, nonrepetitive constituents of the

experience are linked thematically, and a full description is derived. (p. 96)

This process of constructing a textural description was completed to illuminate

the meaning of the PCC experience of participants. Each participant’s relevant

expressions, about PCC, were written out verbatim. Each participant’s interview

statements formed a whole textural description for that participant. I also had a peer

review the textural description to verify that the data was appropriately classified.

Structural Description

Structural description requires that the researcher take the data from the textural

description and categorize it into different meanings of the experience of the participants.

Use of imaginative variation was utilized to develop a structural description of each

participant’s experience. Moustakas (1994) defined imaginative variation as devising

every possible meaning of the experiences by using varying lenses. I sought all possible

meaning by using varied lens such as imagination, various roles, and different

perspectives. Through this process I developed a structural description of the participants’

experiences. I also had a peer review the data to verify that the data was appropriately

categorized into accurate meanings of the experience of the participants. An example of a

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textural statement was when a participant described what she had experienced during her

first gynecological exam. An example of moving the textural description to a structural

description was the participant found she was embarrassed by the medical questioning,

felt judged by the medical provider, and was scared by the noises made during the

Papanicolaou (Pap) smear collection procedure.

Textural-Structural Description

During this part of the analysis each participant’s textural and structural

descriptions were merged to reflect the meaning and essences of their experience

(Moustakas, 1994). The merging of the textural and structural descriptions developed a

synthesized description of each participant’s personal experiences. Core themes emerged

during this stage. I also had a peer review the data to verify that the data was

appropriately categorized into accurate core meanings. Peer support is an example of core

theme that emerged during the textural-structural description analysis.

Composite Textural-Structural Description

Developing a composite textural-structural description of all the participants is the

last step of the analysis. This involved an integration of all of the participants’ individual

textural-structural descriptions to yield one universal description of the experience that

represented the group’s experience as a whole (Moustakas, 1994). Lastly, I had a peer

review the data to verify that the data accurately reflected a universal description of the

experience that represented the group’s experience as a whole.

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Reliability

Reliability in qualitative research occurs when review of the research data

indicates that the results are consistent, dependable, and make sense to readers (Merriam,

2002). Member checking, peer examination, full description of data collection and data

analysis are ways to ensure reliability of a qualitative study. I used member checking as a

means of verifying the data and ensuring reliability (Busher & James, 2012; Creswell,

2013). I actively engaged in member checking by having the participants review their

own comments and my interpretation to validate that the interpretation reflected what was

intended during the second interview session. Only participants that completed both

interview sessions were included in the study. I asked a colleague, who is also a midwife,

to participate in peer examination by reviewing interview narratives and findings to

establish whether the findings were accurate or not. I also had the midwife review the

categorized data to verify that the data was appropriately categorized. This process

known as inter-rater reliability helped to establish “that the category system ‘fits’ the data

and that the data had been properly ‘fitted into’ it” (Patton, 2014, p.555). Trustworthiness

was upheld by keeping all audio taped interviews and transcriptions (Busher & James,

2012). Full descriptions of the steps used to collect and analyze data were provided to

ensure reliability. I included multiple citations of participants’ actual statements in my

findings to illustrate my data analysis and interpretation. Lastly, I reviewed my journal as

a means of assisting with accurate interpretation of the data and eliminating personal bias.
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Summary

I used a qualitative transcendental phenomenological research method to

understand adolescents’ knowledge, attitudes, and beliefs about preconception care. I

recruited five female adolescent participants from a housing development and an

apartment complex in a city in the southern U. S. I also recruited participants that lived

outside the targeted housing community that have been referred by participants who live

in the targeted housing community. Multiple in-depth interviews were conducted to

understand the adolescents’ perspective on PCC.

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Section 4: Results

Introduction

As outlined in Section 3, this study was designed to examine the lived experiences

of adolescent females in relation to their knowledge, attitudes, and beliefs about PCC.

The aim of this study was to identify themes and essences of adolescents’ experiences

with PCC. Moustakas’s (1994) modified Stevick-Colaizzi-Keen method was used to

organize and complete the analysis of data. This section is an explanation of the steps

used to review and analyze the data, the participant’s biographical information and

textural-structural descriptions, a combined composite description of themes, a discussion

of significant themes and essences, and the methods utilized to ensure trustworthiness of

the findings (See Appendix D for example of participants’ individual and structural

descriptions.)

Steps of Reviewing and Analyzing Data

Moustakas’s (1994) modified Stevick-Colaizzi-Keen method of data analysis was

used to complete the data analysis process. Each of the following subsections will

describe the processes used to analyze the data. To manage the data, I labeled the files as

Participant A through E and created a pseudonym for each participant with the starting

letter of the alphabet assigned to the participant. The pseudonyms Abby, Bella, Cici,

Deidra, and Elsa were used for participants. Moustakas’s (1994) modified Stevick,

Colaizzi, and Keen Method of organizing and analyzing phenomenological data was used

to process the data:

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1. Each participant’s statement was considered with respect to significance for

description of the PCC experience.

2. Each participants’ relevant statements were recorded.

3. Each nonrepetitive, nonoverlapping statement was listed for each participant.

These statements were the invariant horizons or meaning units of the

experience.

4. Invariant units were related and clustered into themes for each participant.

5. A textural description for each participant was developed. The description

synthesized invariant meaning units and themes and included supporting

verbatim examples.

6. A structural description was developed for each participant using imaginative

variation and reflection of the textural description. Verbatim statements were

used to help support the description statements.

7. Textural-structural description of the essences and meanings was constructed

for each participant.

8. A composite textural-structural description of essences and meanings from all

participants was completed. This composite formed the universal description

of the experiences that represented all participants.

Participant A

Biographical Information

Abby is an 18-year-old Black female who lives with her mother and is

unemployed. She identified herself as single at this time. Abby shares a two bedroom
 73
apartment with her mother, two sisters, and her two-year-old niece. Her mother is not

employed so the family depends on government support to live. Abby did not finish high

school but completed the ninth grade. Abby is not in school and does not work. The

apartment the family lives in is through government housing where a part of the rent is

paid by the government. She has full access to healthcare through her Medicaid coverage.

Textural-Structural Description of Participant A

Abby’s experiences with acquiring accurate, thorough PCC and RLP information

have been unsuccessful. Due to multiple factors Abby has not gained the knowledge

needed to prepare her for a healthy pregnancy. Beginning with Abby’s past medical

experiences she stated she had one visit with a medical clinic for a sore throat. Limited

contact with medical personnel in her adolescent years is one factor that has limited her

acquisition of knowledge of PCC and RLP She did not engage in conversation with the

medical personnel during the visit due to feeling unable to speak on her own behalf.

Limited contact has also led her to not establishing a rapport with medical personnel who

could have provided needed information. Abby’s lack of confidence in talking openly

with medical staff is also a barrier for her obtaining information on PCC and RLP. Her

mother was the person present who spoke to the medical personnel. She depends on her

mother to help her make doctor appointments and get her to the clinic.

Abby did not receive any information about PCC at her clinic visit. Her inability

to have open communication directly and openly with the medical staff was a barrier for

her not receiving more information about PCC during her clinic visit. Abby’s formal

school sex education classes did not offer the opportunity for her to gain the necessary
 74
knowledge about PCC and RLP. Abby’s experiences with PCC were provided by her

public school and focused on birth control and how to take care of babies. She said the

class was about “how to take care of babies” and “that we should use pills to keep from

getting pregnant.” Abby’s discussion of healthy and bad habits for preparing for a

pregnancy were focused on abstract answers such as “get a job” and “get your life

together for your child”. She was not able to correctly identify one known positive or

negative behavior associated with PCC.

Abby’s formal school sex education classes did not offer the opportunity for her

to gain the necessary knowledge about PCC and RLP. Abby’s experiences with RLP

revealed that she has not been taught how to make a plan nor has she considered making

one. She has thought about how many children she would like but has not considered

how to plan her family. Abby does not possess the information necessary to make a RLP.

Abby’s discussion of who she turns to for information was contradictory. She

readily identified “my friends mostly” as the people she turned to for information about

PCC and RLP. Although Abby identified several people she can talk to about PCC and

RLP, she reports she does not discuss these topics with them. It would be a logical

conclusion that Abby’s friends who attended the same schools as she did also lack

knowledge about PCC and RLP. Abby did not readily recognize the contradiction in her

statements about whom she gets information from about PCC and RLP and the admission

that she does not talk to her friends about PCC and RLP.

Abby is sexually active but does not realize that she is at risk for getting pregnant.

She is under the impression that because she has not gotten pregnant to date then it
 75
cannot happen. She stated “I don’t think it’ll happen. Cause it ain’t happen in all this time

yet.” Abby believes she is not at risk for pregnancy because she does not have

unprotected sex. Abby is at risk for pregnancy because she does not use birth control and

only uses “condoms sometimes.” She also does not understand that condoms are

considered a form of birth control. Abby also does not seem to understand what

unprotected sex means. She knew several girls who were pregnant in middle school and

“a whole bunch” in high school. Abby reported she does not feel prepared if she gets

pregnant. Abby does acknowledge that she is not prepared to get pregnant. Another

barrier for Abby is that she does not know what information she lacks regarding PCC and

RLP. Despite having full Medicaid coverage, Abby has limited ability to seek accurate

sources to gain this knowledge.

Participant B

Biographical Information

Bella is a 19 year-old Black female who lives with her unemployed mother and

sister in a two bedroom apartment. Her father is also unemployed and does not live with

the family. Bella completed the eighth grade but dropped out of high school. She is

currently unemployed. The apartment the family lives in is through government housing

where a part of the rent is paid by the government. She has full access to healthcare

through her Medicaid coverage.

Textural-Structural Description of Participant B

One-on-one interviews were done to understand this participant’s past

experiences with PCC and RLP. Opportunities for Bella to gain PCC and RLP
 76
information have been available through multiple clinic visits. Bella described multiple

medical visits with multiple clinics due to problems with her menses and her desire to

seek birth control. Her interactions with the first clinic’s medical personnel were

described as negative because she felt like they did not talk with her or answer her

questions. Bella stated:

I really didn’t like ‘em ‘cause they don’t never, um, really talk to me about

stuff…just told me to, um, take birth control pills to make my menstrual regular.

That is what the Planet (sic) Parenthood lady doctor said, I didn’t really like

going, um, I don’t get why they would give me birth control pills didn’t make

sense to give birth control pills for my menstrual if I wanted to get pregnant.

Bella further described an equally unhappy relationship with the second clinic’s medical

staff when she stated “yeah, it was about the same as before, they don’t really talk

nothing ‘bout what’s going on with you or what they doing. They just tell you do this.”

She has failed to develop a positive relationship with any medical personnel despite

multiple visits. Bella feels the medical personnel do not talk with her or answer her

questions but tell you what to do. Initially Bella’s mother set up and attended clinic

appointments with her. After the first few times Bella made her own appointments and

went on her own. Although Bella feels comfortable making and attending her medical

appointments she does not feel she has open communication with any of the personnel.

Bella does not recall anyone at the clinic discussing preparing for pregnancy

despite multiple opportunities to do PCC counseling. Bella’s school experience with PCC

was limited due to the fact that she was not allowed to complete her sex education class
 77
in school. She relayed how while starting school sex education classes “I got put out that

sex education class ‘cause some boy was cuttin’ up and got me in trouble and got us both

put out. So then they stopped the class nobody got the class.” Bella’s experience with

PCC during school was incomplete due to being thrown out of the sex education class in

school. Bella was unable to identify any of the positive habits to implement prior to

getting pregnant or negative behaviors to stop before attempting a pregnancy to help have

a healthy baby. She provided abstract answers like “get a job” and “ask my mama for

help” when discussing the healthy habits and bad habits to avoid to get ready to get

pregnant. Bella did add that her mother told her not to smoke or drink but did not know it

was something not to do if you are planning to get pregnant.

Bella denies learning about RLP. Her initial response to whether she has a RLP

she said: “I ain’t having kids anytime soon.” Bella does not believe she can control when

and how many children she has in her life. When asked whether or not a woman can

control when she has children her reply was: “No, I don’t think so, you have kids when

you do, it just happens when it happens.” Bella did not understand that a RLP is a means

of planning your children. Bella did not understand that a RLP can include planning to

not have children until she wants. She reports “it would be good to make a plan?” and

does see value in making a plan. Once RLP was discussed Bella did believe it would

valuable to make a RLP.

Bella has not found a reliable source for information on PCC and RLP. Bella’s

discussion of whom she turns to for information about PCC and RLP included friends

and her sister. During the discussion she reported she has not discussed PCC or RLP with
 78
any of her friends. The only related thing she has talked to her sister about is birth control

methods.

Bella does not use birth control but does not believe she will get pregnant in the

next year. She does not use birth control 100% of the time. Bella also does not identify

condoms as a type of birth control. She reports she uses condoms sometimes. Bella does

not understand condoms are a form of birth control when asked. There were several

common PCC and RLP terms that Bella did not understand when used in conversation. It

would be difficult to get accurate survey information about PCC and RLP from this

participant.

Participant C

Biographical Information

Cici is a 21 year-old Black female who lives with her mother, grandmother, and

three siblings in a three bedroom apartment. She identified herself as single and not

currently in a relationship. Cici completed the 11th grade before dropping out of high

school. She is not currently in school or employed at this time. The apartment the family

lives in is through government housing where a part of the rent is paid by the

government. She has full access to healthcare through her Medicaid coverage.

Textural-Structural Description of Participant C

One-on-one interviews were done to understand this participant’s past

experiences with PCC and RLP. All but one of Cici’s past experiences with different

medical personnel has been negative experiences. Cici described multiple medical visits

at multiple clinics for different reasons including school shots, a sexually transmitted
 79
diseases check, and once when she thought she was pregnant. Interactions with the staff

have been mixed. She had one brief positive interaction with a nurse at one clinic. She

reported once while checking in “It was okay, the nurse that checked me in was real nice,

but I was worried ‘cause I thought um I might have a STD.” Interactions have been

characterized as rushed and limited opportunity to talk to the doctor. She described the

interaction as “they always seemed like rushed, the doctor hardly talked to me at all, he

seemed like rushed.” CiCi has not regularly attended one clinic in her adolescent years

and has clearly not established a patient-client relationship with a medical provider.

Although Cici has full access to medical care her visits continue to be negative. Cici does

not feel comfortable making her own medical appointments. Her grandmother has always

scheduled her appointments.

Despite multiple opportunities to receive PCC through clinic visits Cici has not

received the information she needs. Cici’s experience with PCC has not been adequate.

She recalled when going to clinic concerned she might be pregnant that they did not

discuss PCC only “told me I wasn’t pregnant and um that I should use condoms.” Her

formal school class on sex education only focused on childcare and using birth control

and did not provide PCC. Cici’s PCC experience in school was described as “um Well,

we had sex ed in like the 10th grade. Mostly like how to change diapers, hold babies, and

stuff.” We “just talked about STD’s and use condoms and birth control. Just really kept

telling us don’t get pregnant before you go to school, get a job stuff like that.” She does

not remember any discussion about spacing children or what to do to get ready for

pregnancy. When asked about what healthy things could you do to prepare to get
 80
pregnant her responses were abstract and not correct. “Well, um maybe get an apartment,

get a job…no, oh yeah get your GED.” She further added “um, No I don’t know of any”

when asked what are bad things one should stop doing to prepare for pregnancy. Cici

does not know what positive or negative factors could affect a pregnancy.

Cici denied learning about RLP or even hearing the phrase anywhere. Cici’s

initially associated RLP only as wanting to get pregnant. Her initial response to hearing

the phrase RLP was “I ain’t trying to be pregnant.” When discussing whether or not it

would be valuable to formulate a RLP she indicated it would but then commented that it

was not in your control if you have children. Cici does not value RLP because she does

not believe a woman can control when she will get pregnant. Her statement when

referring to whether is valuable to make a RLP that it is not because pregnancy “it is

either meant to be or not.”

Cici does not understand the term sexually active. She reported she is not sexually

active but then stated “I only have sex maybe two times a week or so.” Cici does not

understand common terms associated with PCC and RLP. She does not intend to have

children for a few years. Cici does not have an effective plan to wait a few years to have

children. Cici does not believe she has unprotected sex but uses condoms “most of the

time” as her only means of birth control. Her lack of knowledge makes her more at risk

for pregnancy, STD’s, and poor fetal maternal outcomes.

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Participant D

Biographical Information

Deidra is a 21 year-old White female who lives with her mother, two siblings, and

her boyfriend in a three bedroom house. She identified herself as in a relationship with

her boyfriend who also lives with her family. Deidra has two younger sisters ages seven

and twelve. She has not had any contact with her biological father in over 6 years. Deidra

quit school before high school but is currently enrolled in a GED. She is not currently

employed but stated she is looking for a job to help out the family. Deidra’s mother and

boyfriend both work to support the family. The house they live in is through government

housing where a part of the rent is paid by the government. She has full access to

healthcare through her Medicaid coverage.

Textural-Structural Description of Participant D

One-on-one interviews were done to understand this participant’s past

experiences with PCC and RLP. Opportunities for Deidra to gain PCC and RLP

information have been available through multiple clinic visits but she has not gained PCC

and RLP information that she needs. Deidra could only remember one visit to the doctor

for a bladder infection. She reported she has gone for others but can’t remember what for.

Initially, her mother scheduled the clinic visits and her mother went with her to the clinic

visit. “Like the doctor’s offices and stuff I go usually with my mom but for the last

couple of visits I’ve been going by myself. But I usually go with my mama.” Deidra feels

you never see the same doctors and they don’t know who you are from one visit to the

next. She described the interactions with the medical staff as “I hardly saw the doctor
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any…yeah, um but you hardly ever see the same doctor or nurses, every time you go it’s

someone new, um, different. Then they don’t know you or seen you before.” She has

failed to develop a positive relationship with any medical personnel despite multiple

visits. When discussing how comfortable she is talking to medical personnel she felt she

could and does ask them questions. Although Deidra feels comfortable making, and

getting to her medical appointments she does not feel she has open communication

established with any of the medical personnel.

Deidra has had limited experiences with learning about PCC. PCC was not

discussed during any of her clinic visits. While discussing whether or not she received

any PCC counseling from medical personnel her response was “No, huh, I don’t

remember any the, um, doctor’s office or nothing or anything talking about to me about

planning or planning parenthood or nothing like that.” She had limited informal school

sex education due to dropping out of school in the eighth grade. The majority of Deidra’s

experiences with PCC were provided by her public school in the seventh grade. Her

formal school sex education class focused on prevention of pregnancy and positive and

negative behaviors to observe when you are already pregnant. She stated the class did not

discuss PCC. Deidra stated, “They just talked about if you have sex use protection, use

the pill, stuff like that…just stuff like what to do while you are pregnant, the drinking,

smoking, the drugs.” Deidra did correctly identify two of the negative behaviors to stop

before getting pregnant but was not sure where she learned about that. When discussing

healthy habits to prepare to get pregnant Deidra initially said she did not know any but,

then added “if they do drugs they should quit the drugs completely. They should get their
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life organized before they plan to have a baby or anything. During discussion of her

knowledge of bad habits to stop during pregnancy she responded:

Like I said if the people, if the person is doing drugs they should stop before

getting pregnant. I live in a neighborhood where I see that a lot. Like the

demographics they don’t care if they get pregnant and they still they are smoking

marijuana and drink and stuff. That’s why I get concerned about when they are

doing the drugs before and while they are pregnant and even when they have the

baby.

Deidra does not have a RLP but would be interested in attending a class to learn

how to design one. Deidra denies learning about RLP. Her initial response to whether she

has a RLP was: “No, I don’t have a plan or anything like that.…nobody has never said

nothing about making a plan.” Discussing whether there is value in making a plan she

commented: “Probably so you got your life in order and were ready for kids. I think it

would be a good idea to have a plan if you knew something about how.” She does not

feel she knows what she needs to make an RLP on her own and has not received the

information needed to make one. Deidra does see the value in making a RLP but does not

feel she has the information needed to make one. Exploring what she would need to make

a RLP Deidra stated “You’d need to know lots of stuff…Pretty much about birth control,

more about how to not get pregnant.” When asked directly if she knows enough to make

a RLP her response was “No not me…I would like to go to a pregnancy plan class if I

could.”
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Deidra has not discussed PCC or RLP with anyone she identified as sources of

information. When discussing whom she turns to for information about PCC and RLP she

readily stated “Parents and doctors would be best.” Deidra’s lack of established positive

doctor-patient relationship with a medical provider would be a barrier to successfully

getting information on PCC and RLP. She then qualified that talking with “Some of the

doctors, my mama. But it wasn’t geared for planning a pregnancy it has been more about

preventing a pregnancy.” Deidra had contradictory statements about “my mom and I talk

all the time” to state they do not talk about PCC except “just about preventing a

pregnancy. She said she would take me for birth control if I needed it.”

Deidra reported she is sexually active. Deidra does not believe she has

unprotected sex despite her not always using birth control. She does not believe she has

unprotected sex but stated she does not use birth control. Deidra stated she uses condoms

most of the time but I’m thinking about going on the pill.” She apparently does not

understand that unprotected sex requires she use birth control 100% of the time. Deidra

did know girls in middle school who got pregnant. Since she did not attend high school

she was not able to address whether she knew girls in high school who became pregnant.

Participant E

Biographical Information

Elsa is a 21 year-old Black female who lives with her mother and sister in a three

bedroom apartment. She identified herself as single and not currently in a relationship.

Elsa has completed 1 year of college and is currently in school for cosmetology. Her
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mother is employed full time and supports the family. Elsa has a part-time job while

attending school. She has full access to healthcare through her Medicaid coverage.

Textural-Structural Description of Participant E

One-on-one scheduled interviews were performed to understand this participant’s

past experiences with PCC and RLP. Elsa could only recall one medical visit to “get birth

control and a Pap smear.” Elsa had only one medical visit during adolescence. Her

experience was a negative experience including feeling scared and not comforted by the

medical staff. She described the experience as “Kind of scary that was the first time I had

a Pap done. I was scared they might find something bad.… I heard how much it was

going to hurt and all.” Elsa reported the doctor did not explain what they were doing or

spend enough time with you during a visit. She further described how the doctor did not

explain how the Pap smear was going to be done he only said “just put your legs here,

they didn’t talk to me at all whiles they were doing the Pap.” Elsa reported “I feel

comfortable talking to both nurses and doctors.” When talking about her experience she

relayed she did not talk with doctor by stating “They don’t spend that much time in the

room with you, they um did the Pap and left.” She also stated she made her own medical

appointment. Elsa feels capable of making her own appointments. Elsa does not have an

established positive doctor-patient relationship with any medical personnel.

Elsa’s experiences with PCC have not been adequate to provide all the PCC and

RLP information she needs to have a healthy baby. PCC was not provided during her

medical visit. When asking if anyone at the clinic talked to her about PCC she responded

“Not at all, nobody has ever talked about what to do to get ready to get pregnant. Not that
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I remember.” Elsa was interested in attending a PCC/RLP class by stating “Yes, I would

want to know about how to ready to make a healthy baby. I would participate if they

offered it to me, just to find out.” Elsa correctly identified one healthy and one negative

behavior to implement before attempting a pregnancy. She responded to whether she

knows of any healthy behaviors to do when planning to get pregnant by stating “no not

really just take vitamins or something to make everything go smooth.” Elsa identified

only one healthy behavior to do before getting pregnant. She did identify one bad habit to

stop before attempting a pregnancy when she stated “I know to stop drinking for one.

Stop doing a lot of heavy duty (physical) working if you have a job like that.” Other

behaviors she identified were not associated with preparing for a pregnancy. Elsa’s

formal school sex education did not provide PCC instruction. Her sex education class

only provided information on preventing pregnancy. Elsa summed up her PCC education

in school as “in school we only talked about preventing it, just about not getting

pregnant.”

Elsa was not taught about RLP and does not have a RLP formed. When asked

about has she thought about a RLP she stated “no haven’t really thought about it, kinda of

think I would like a couple of kids.” She does not know of any source that could help her

with learning about a RLP or helping develop one. She responded “Nope I don’t know,

not anywhere that I know.” She believed the best time to get PCC/RLP counseling is “If

you are looking to have a baby”.

Although Elsa identified multiple sources of information for PCC and RLP she

reports she has not discussed PCC or RLP with anyone. Elsa identified multiple sources
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of who to turn to get information about PCC/RLP including her aunt, mother, the

Internet, and Planned Parenthood. With discussion Elsa revealed “No I haven’t ever

talked to my mom about sex or birth control… she tried to talk about how to prevent

pregnancy” Although her aunt is an identified source of information she reports “we talk

about birth control, boys, and stuff” but no other aspects of PCC or RLP.

Elsa would like to have children, but not in the near future. Elsa does not believe

she will be pregnant in the next year but does not use birth control 100% of the time. Elsa

does not have an effective means of preventing pregnancy in place to prevent a

pregnancy. She does not think she has unprotected sex but her only method of birth

control is using condoms. Although Elsa does not use birth control 100% of the time she

does not believe she will be pregnant within the next year. When asked about how often

she uses condoms she responded “Sometimes we use condoms….No, we don’t use

condoms every time but mostly yes.” Elsa would like to have a couple of kids “but not

right now.” She knew “a lot of girls got pregnant in high school that were there with me.”

Elsa does not feel prepared to get pregnant. She stated “I don’t really know too much

about what to do before or when I’m pregnant guess I’ll find out then.”

During the interview, it became obvious that Elsa had misinformation or a lack of

communication regarding several issues. Elsa has been misinformed about how long to

be off of birth control pills before attempting a pregnancy, saying “Um, well from my

aunt I know she told me uh maybe like a year or 2 years to be off that.” Her aunt did not

advise her correctly. In addition she reported she stopped taking birth control because “I

just didn’t like how the way the pills made me feel, they made my stomach feel bad.”
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Elsa did not understand she should return to the doctor if she had side effects from birth

control pills. Elsa did not discuss the side effects of her birth control to see if an

adjustment could be made to her birth control pills to eliminate the side effects. She did

not understand that the pills could have been changed to eliminate the side effects and be

able to continue using this form of birth control.

This study’s five participants’ PCC experiences were presented in this section.

Each individual’s PCC experience was described from a textural-structural perspective.

The following themes emerged from the composite: negative interactions with medical

personnel, no experiences with PCC or RLP, inaccurate knowledge about the relationship

between unprotected sex and pregnancy, lack of knowledge about preparing for

pregnancy, and miscommunication. Multiple participants shared similar themes that will

be presented in Section Five to provide “a unified statement of the essences of the

experience of the phenomenon as a whole” (Moustakas, 1994, p. 100).

Composite Textural-Structural Description of Themes and Essences

The following themes emerged from the composite: relationships with medical

personnel, interactions, and communication; experiences with PCC; experiences with

RLP; perceived sources of information; perceptions of ability to get pregnant; perception

of being prepared to get pregnant; and miscommunication. Table 2 provides examples of

the verbatim statements from the interviews to support each theme.

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Table 2

Supporting Statements
Themes/meaning units Examples of participants statements
Negative Interactions with “they don’t really talk nothing ‘bout what’s going on with you or what they
Medical Personnel doing. They just tell you do this.”

“I really didn’t like ‘em ‘cause they don’t never um really talk to me about
stuff…just told me to um take birth control pills to make my menstrual regular.”

“they always seemed like rushed, the doctor hardly talked to me at all he seemed
like rushed.”

“I hardly saw the doctor any…yeah, um but you hardly ever see the same doctor
or nurses, every time you go it’s someone new um different. Then they don’t
know you or seen you before.”

“Kind of scary they don’t spend that much time in the room with you, they um
did the Pap and left.”
No Experiences with PCC “No huh I don’t remember any the um doctor’s office or nothing or anything
talking about to me about planning or planning parenthood or nothing like that.”

“how to take care of babies” and “that we should use pills to keep from getting
pregnant.”

“Mostly like how to change diapers, hold babies, and stuff.”

“just talked about STD’s and use condoms and birth control. Just really kept
telling us don’t get pregnant before you go to school, get a job stuff like that.”
No Experiences with RLP “No, I don’t have a plan or anything like that.…Nobody has never said nothing
about making a plan.”

“it would be good to make a plan?”

“I would like to go to a pregnancy plan class if I could.”

Inaccurate Knowledge About “I ain’t trying to be pregnant.”
the Relationship Between
Unprotected Sex and “no haven’t really thought about it, kinda of think I would like a couple of kids.”
Pregnancy
Lack of Knowledge About “you have kids when you do, it just happens when it happens.”
Preparing for Pregnancy
uses condoms “most of the time” as her only means of birth control.

“I don’t really know too much about what to do before or when I ‘m pregnant
guess I’ll find out then.”
Miscommunication “I know some stuff but you know I’m not the smartest person in the world, you
know. But I don’t do drugs, I don’t drink, you just drink plenty of water and you
know, you know but, I don’t know everything.”

“it is either meant to be or not.”

“I just didn’t like how the way the pills made me feel, they made my stomach feel
bad.”

“I am not sexually active, I only have sex maybe two times a week or so.”
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Composite Description of Themes

The experience of PCC for these participants has not successfully provided the

necessary information needed for them to prepare for the healthiest pregnancy possible.

Their lack of knowledge has placed them at risk for poor maternal and fetal outcomes

during pregnancy. Multiple common themes and essences have emerged during the

compiling of the combined participants’ textural-structural descriptions of their

experiences.

Negative Interactions with Medical Personnel

All participants except one had experienced numerous clinic visits during

adolescence. Despite multiple clinic visits none of the participants received PCC during

their medical visits. None of the participants have established a positive working

physician-patient or nurse-patient relationship. All participants described significant

negative interactions with medical personnel including feeling unimportant, scared,

dissatisfied, uninformed, ignored, powerless, and not treated as an adult. Due to

participants lack of a positive working physician-patient or nurse-patient relationship puts

them at high risk for poor maternal and fetal outcomes with a pregnancy. It is also a

barrier for obtaining accurate PCC/RLP information in the near future. Seeking care for

women’s health issues was the majority of the reasons participants previously visited the

clinic including seeking birth control, abnormal menses, Pap smears, and STD checks.

Most participants rely on adult caretakers such as their mother or grandmother to

make their clinic appointments and transport them to the visit. All of the participants have

access to medical care through Medicaid that fully pays for the medical visit. Only a few
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participants have independently and successfully made their own medical appointments

and transported themselves to the medical visit.

No Experiences with PCC

Participants did not receive PCC during medical visits despite multiple

opportunities. Generally participants reported that they were not given information on

any topics. Participants who experienced a formal school sex education class were not

taught about PCC or RLP. Participants’ experiences in sex education classes were

focused on pregnancy prevention, birth control, child care, and limited information on

positive and negative behaviors to observe during pregnancy. Many of the participants

had negative school sex education classes including feeling uncomfortable when males

were included in the class and the information was joked about instead of being discussed

seriously.

Participants do not possess the necessary knowledge regarding positive or

negative behaviors to observe prior to attempting a pregnancy to maximize maternal and

fetal outcomes. Only one participant was able to correctly identify one healthy habit that

would prepare them for a pregnancy. The other participants were not able to correctly

identify even one healthy positive habit that would prepare them for a pregnancy. Their

statements included abstract statements such as getting your life organized, finish high

school, and get a job. Most participants were not able to identify any negative behaviors

to stop prior to attempting a pregnancy. Drug and alcohol use were the only two negative

behaviors identified by two participants. All of the participants’ PCC experiences have
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not provided them with the necessary information to be optimally prepared to become

pregnant.

No Experiences with RLP

Participants acknowledged they were not familiar with the term RLP and were not

taught how to develop a RLP in school or at medical visits. Many participants associated

with the need to make a RLP only if you are planning to have children immediately.

Participants reported value in making a RLP but did not feel they had the tools or

information necessary to make one. The reason one participant did not value making a

RLP because she did not believe women can control when she gets pregnant. Participants

readily identified multiple sources for information on PCC and RLP. Sources included

friends, sisters, parents, caregivers, relatives, Internet, and medical clinics. Participants

have not discussed PCC or RLP with any of their identified sources of information.

Inaccurate Knowledge about the Relationship Between Unprotected Sex and

Pregnancy

Participants did not believe they are at risk for getting pregnant despite being

sexually active and not using birth control 100% of the time. Participants associated

condoms as having protected sex but did not understand that condoms are a form of birth

control. Participants generally described feelings about their perceptions of ability to get

pregnant as not believing they can get pregnant since it has not happened yet to believing

they have an effective means of birth control to prevent a pregnancy. Participants did

know girls who were pregnant in middle and high school.

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Lack of Knowledge About Preparing for Pregnancy

Participants did not feel prepared to attempt a pregnancy. Many participants felt

they do not even know what information they are lacking. Generally participants have not

been able to gain PCC and RLP information necessary to prepare for a pregnancy. They

felt they lacked the knowledge and access to gain the knowledge to prepare for a

pregnancy. Most participants first learned about PCC and RLP through the interviews

they participated in for this study.

Miscommunication

Participants did not know many of the common PCC and RLP terms used during

the interview. Many also did not know the correct definition of many common terms such

as sexually active, birth control, and unprotected sex. Many of the participants learned

definitions of terms and clarification of terms during their interviews for this study. Some

participants were given wrong information or misinformation regarding medical issues

during medical visits or from relatives.

Methods to Address Trustworthiness

The primary methods used to increase trustworthiness of this study were member

checking, peer examination of data and findings, researcher reflection through journaling

during data collection, and full description of data collection and data analysis. I used

member checking by having each participant review their verbatim transcribed statements

for accuracy and validate their statements were what they intended. Member checking is

one means a researcher can use to increase reliability and trustworthiness of the study.
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I also used peer examination of data and findings to increase trustworthiness. One

of my colleagues, a midwife who provides OB/GYN services for adolescent females,

participated in peer examination of this study. My colleague reviewed all participants’

interview narratives and findings to verify that the findings were accurate. She also

reviewed the categorized data and verified that the themes were correctly identified.

Inter-rater reliability is the process used to establish that the data themes and essences are

accurate by a peer.

Researcher reflection through journaling during data collection was done to

increase trustworthiness. Reflection and journaling were a means of decreasing personal

bias and assisted with interpreting data accurately. I journaled my feeling prior and after

every interview. I also reflected on my journal entries prior to conducting interviews with

the participants.

Moustakas’s (1994) modified version of the Stevick-Colaizzi-Keen method of

analysis is a well known and established method of analysis. This method provided clear

detailed steps that guided my analysis. Full description of data collection and data

analysis was provided to increase trustworthiness. Textural, structural, and textural-

structural descriptions were presented for each participant. Multiple verbatim citations

were presented to support and illustrate data analysis and interpretation. The entire

composite textural-structural description was presented.

Summary

This section was an overview of the data analysis and findings. The steps used to

analyze this study’s data were outlined. Next I presented the completed textural,
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structural, and textural-structural descriptions of each participant. I then discussed the

synthesis of all the participants’ textural-structural descriptions to yield one universal

description of the PCC experience for these women. Lastly, I described the methods

employed to ensure trustworthiness of the study.

Section 5 will include the interpretation of findings, conclusions, implications for

social change, recommendations for action, and recommendations for further study.

Section five will also include my reflection of the entire research experience including

how my thinking on the phenomenon has changed as a result of this study.

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Section 5: Discussion, Conclusions, and Recommendations

Overview

This section includes the interpretation of findings, implications for social change,

recommendations for action, recommendations for further study, researcher reflections,

personal biases, and personal changes made due to the findings of the study. I interpreted

the findings from the perspective of this study’s two research questions.

The purpose of this phenomenological research study was to understand PCC and

RLP from the perspective of adolescent females. I also sought to identify barriers that

these adolescents have when seeking PCC and RLP. My initial interest stemmed from

concerns that women are not prepared for pregnancy prior to conception. In addition,

despite the CDC mandate to provide PCC, including RLP, many women are not receiving

it prior to pregnancy (CDC, 2006; Hillemeier et al., 2008; Maryland PRAMS: Pregnancy

Risk Assessment Monitoring System, 2013; Wilensky & Proser, 2008). Previous

researchers have focused on PCC in individuals with preexisting medical conditions such

as diabetes and alcoholism (Mathiesen et al., 2007; Steel et al., 1991; Temple et al.,

2006). Researchers on PCC in healthy females has mostly focused on college and adult

women (Corbett, 2011; Coonrod et al., 2009; Delgado, 2008). I chose to focus on

adolescents because more information is needed to understand their perspectives

(Bearinger et al., 2007; Daley et al., 2004; Tylee et al., 2007) and because of the high rate

of adolescent unintended pregnancy (Hamilton et al., 2012). This study has begun to fill

in the gap in the literature about PCC and RLP in healthy adolescents females.
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Research Questions

1. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding preconception care?

2. What are the differences and similarities between adolescent females’

knowledge, attitudes, and beliefs regarding participating in a reproductive life

plan?

To address these research questions, I interviewed five adolescents using multiple

in-depth, one-on-one interviews with each participant. I used Moustakas’s (1994)

phenomenological interview process to conduct the interviews and the Stevick-Colaizzi-

Keen method to organize and analyze the data collected during the interviews. I

integrated all of the participants’ individual textural-structural descriptions to yield one

universal description of the experience that represents the group’s experience of PCC and

RLP as a whole. Seven major themes and 12 subthemes emerged during data analysis.

Interpretation of Findings

In this section, I will provide a brief summary of findings as they relate to each of

the research questions. Findings related to the literature and the conceptual frameworks

used to guide the study will also be presented.

Research Question 1

The aim of answering the first research question was to explore the differences

and similarities between adolescent females’ knowledge, attitudes, and beliefs regarding

preconception care. The four major themes that emerged were that the participants had:

(a) no experiences with PCC, (b) negative interactions with medical personnel, (c) a
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general lack of knowledge about preparing for pregnancy, and (d) desire for PCC. These

four themes are interrelated to one another to help address the first research question.

Participants’ experiences with PCC. There are multiple ways and sources through which

adolescents can gain PCC information. Sources include medical professionals, school sex

education courses, and informal personal relationships. Participants’ experience with

PCC included three subthemes: (a) no discussion of PCC during clinic visits, (b) no PCC

during sex education classes, and (c) their own failure to utilize perceived sources of

information.

Lack of discussions of PCC during clinic visits. Despite having had multiple

clinic visits during adolescence the majority did not recall discussions of PCC during

their visits. In contrast, they recalled discussions about other topics such as preventing

pregnancy using birth control pills. The finding that participants did not receive PCC

information from medical professionals during medical visits was consistent with the

findings of multiple studies (Coonrod et al., 2009; Corbett, 2011). Corbett found that

more than 80% of their participants reported that they had not talked to a medical

professional about PCC. Coonrod et.al found that over 85% of their participants did not

receive PCC from their medical providers. Another key finding was that 87% of their

participants desired PCC, and they wanted their doctors to provide it.

Lack of discussions of PCC during sex education classes. I found that the

majority of my participants were not taught PCC in their sex education classes. The

participants’ experiences in their sex education classes were focused on pregnancy

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prevention, birth control, and child care, and there was limited information on positive

behaviors to observe and negative behaviors to avoid during pregnancy.

The finding of not receiving adequate PCC during sex education classes was also

consistent with multiple studies (Coonrod et al., 2009; Delgado, 2000). However, in

contrast to my study, multiple researchers found their participants were knowledgeable in

regard to avoiding illegal substances during pregnancy (Coonrod et al., 2009 & Delgado,

2008). Delgado attributed participants’ knowledge to either information obtained through

junior or senior sex education classes or the increased media campaign addressing the

issue. Although Delgado found that over 87% of participants took a sex education course

in high school, they still scored low in knowledge of PCC. Overall both of these studies

and my own study suggest that content regarding PCC that was delivered through sex

education classes in middle or high school was inadequate.

Failure to utilize perceived sources of information. I found that the majority of

participants readily identified multiple sources who could have shared information about

PCC, but they did not actually utilize them. These sources included sisters, friends,

mothers, parents, grandmother, aunts, and the Internet. Coonrod et al. (2009) found a

similar trend in their study of PCC with Mexican Americans. Their survey also found that

about 10% of their participants identified families and friends as their preferred source to

receive PCC. I found participants identified family and friends as a source of PCC, but

my study differed from Coonrod et al.’s study in that I also inquired if participants

actually utilized their sources for PCC. The majority of my participants reported they did

not actually ask or receive PCC from family or friends.

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The finding of several researchers reviewed aligned with my finding that

participants did not receive adequate PCC, but they did not distinguish whether PCC was

not provided during medical visits or during school sex education classes (Delgado,

2008; Heavey, 2010; Kaiser & Hays, 2005). For example, Delgado discussed PCC

received in sex education classes, but did not investigate if PCC information was or was

not gleaned from medical professionals. It would be important to further investigate all

potential sources of PCC to help identify where the strengths and deficits exist in

providing adequate PCC.

Interactions with medical personnel. This theme also included two subthemes:

negative interactions with medical personnel were unfavorable, and multiple missed

opportunities for building a positive medical professional-patient relationship occurred,

and access to care was not a barrier.

Negative interactions with medical professionals. The majority of participants

reported that they had only negative interactions with medical professionals during clinic

visits, unlike the findings of other PCC studies (Coonrod et al., 2009; Corbett, 2011;

Delgado, 2008; Heavey, 2010; Kaiser & Hays, 2005; Quillin et al., 2000; Wang et al.,

2006). The other PCC researchers used many different methods. Several used a

quantitative research methodology to examine PCC (Coonrod et al., 2009; Corbett, 2011;

Delgado, 2008; Kaiser & Hays, 2005; Quillin et al., 2000; Wang et al., 2006) used

exploratory research method. One additional study utilized a retrospective research

method to investigate PCC (Heavey, 2010). In contrast, using a qualitative

phenomenological approach I found a preponderance of negative interactions.

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Multiple missed opportunities for building a positive medical professional-

patient relationship. All of my participants reported they had access to care and this was

not a barrier to receiving PCC. The majority of participants in my study also reported

they had multiple clinic visits during the past few years. Multiple researchers also found

that the majority of their participants reported that they had access to care (Heavey, 2010;

Kaiser & Hays, 2005). Multiple researchers also reported their participants had numerous

recent clinic visits with opportunities to receive PCC, but did not (Corbett, 2011; Heavey,

2010). Another important finding in Heavey’s study was participants who had previous

visits and desired pregnancy were found to have multiple risk factors that would have

been addressed if PCC was covered. PCC was not covered in those previous visits.

General lack of knowledge about preparing for pregnancy. There were two

subthemes of this finding. The first was participants’ inability to identify healthy

behaviors during and limited knowledge regarding unhealthy behaviors that could be

detrimental to a pregnancy.

Inability to identify healthy behaviors. I found all but one participant in my study

was unable to name even one healthy behavior that would prepare them for pregnancy.

Participants’ responses were abstract and did not address aspects of healthy habits of

PCC. The abstract statements elicited including get your life organized, get a job, and

finish high school.

Multiple researchers were consistent in finding participants generally did not

possess the knowledge of which healthy behaviors would help a woman prepare for

pregnancy (Coonrod et al., 2009; Delgado, 2008; Kaiser & Hays, 2005; Heavey, 2010).
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Coonrod et al. found that the younger the participant the less knowledge she possessed of

healthy behaviors. This may explain why participants in my study, whose average age

was 20, were even less knowledgeable than participants in other studies.

A key finding of Delgado (2008) was that the majority of participants believed

they knew more about the healthy behaviors a woman should implement prior to a

pregnancy than they actually did know. Kaiser and Hays (2005) focused on prenatal care

classes with pregnant adolescent participants as the healthy behavior to prepare for

pregnancy. They found that the majority (53%) of their pregnant adolescent participants

did not attend either a prenatal or parenting class during their pregnancy.

Heavey (2010) focused on taking folic acid/prenatal vitamins and monitoring of

disease states as the healthy behaviors that would promote a healthy pregnancy. Heavey

found that the majority (95%) of her participants reported that they were not taking folic

acid or prenatal vitamins despite a desire to be pregnant. Almost 50% of the adolescents

who desired pregnancy were diagnosed with chlamydia, gonorrhea, bacterial vaginosis,

diabetes, and urinary tract infections during clinic visits. All of these diagnoses are

associated with detrimental maternal and fetal effects (Lowdermilk et al., 2016). It is

important to note all of the healthy behaviors should normally be addressed during

regular clinic visits that include routine PCC for all women of childbearing age.

Detrimental unhealthy behaviors. I found that the majority of participants could

not correctly identify any unhealthy behaviors that could be detrimental to a pregnancy.

Two participants were able to correctly identify drugs and alcohol, two unhealthy

behaviors to stop to prepare for a pregnancy. Multiple researchers reported similar

 103
findings that participants were generally lacking in knowledge of unhealthy behaviors

that could be detrimental to a pregnancy (Coonrod et al., 2009; Delgado, 2008; Kaiser &

Hays, 2005; Heavey, 2010). Coonrod et al.’s (2009) and Delgado’s findings were

consistent with my study’s finding that some of the participants were able to identify

alcohol and drug use as negative health behaviors to cease prior to and during pregnancy.

Delgado attributed sex education classes and media campaigns to the participants’

awareness that alcohol and drug use could have detrimental effects on an unborn child.

Desire for PCC. The majority of participants reported they did desire information

regarding PCC and/or RLP information. This study found participants wanted

information and would participate if a program were offered on PCC. They also were

interested in receiving information regarding developing a RLP. Multiple studies also

found that participants desired information about PCC (Delgado, 2008; Kaiser & Hays,

2005). Other PCC researchers did not support this findings (Coonrod et al., 2009;

Corbett, 2011; Delgado, 2008; Heavey, 2010; Kaiser & Hays, 2005; Quillin et al., 2000;

Wang et al., 2006.)

Research Question 2

The second research question was asked to explore the differences and similarities

between adolescent females’ knowledge, attitudes, and beliefs regarding participating in

developing a reproductive life plan. Three major themes emerged, that the participants

had: (a) no experiences with RLP, (b) inaccurate knowledge about the relationship

between unprotected sex and pregnancy, and (c) miscommunication regarding birth

control.
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No experiences with RLP. The first major theme of no experiences with RLP

included three subthemes. Limited RLP during clinic visits, limited discussions of RLP

during sex education, and perceived value in developing a RLP were the three subthemes

identified during data analysis.

Limited RLP during clinic visits. I found that participants reported that they did

not discuss the components of a RLP during medical visits. A few stated the only aspect

discussed at medical visits was birth control. The majority of participants believed RLP

was only for women who wanted to have children now. Delgado’s (2008) finding was

consistent with my study’s finding in regard to one component of RLP, spacing of

children. She found that the majority (85%) of participants had a low awareness of

appropriate recommended spacing of children and did not identify getting the information

during clinic visits. None of the other PCC researchers investigated RLP during clinic

visits as a concept (Coonrod et al., 2009; Corbett, 2011; Delgado, 2008; Kaiser & Hays,

2005; Quillin et al., 2000; Wang et al., 2006).

Limited discussions of RLP during sex education. The majority of participants in

my study identified being told to use birth control during sex education classes but could

not remember receiving education regarding different types of birth control methods, how

to use birth control, and the like. The findings in my study were consistent with Coonrod

et al. (2009) and Delgado (2008) in that despite participating in sex education in a formal

classroom setting participants still lacked adequate RLP knowledge.

Perceived value in developing a RLP. This finding was consistent with

Delgado’s (2008) research indicating that women are interested and open to receiving
 105
information about RLP. Although Coonrod et al.’s (2009) study was consistent in finding

a majority (77%) of participants reported they were very interested in receiving

information about pregnancy, the study did not discriminate between an interest in PCC

or RLP or both.

Inaccurate knowledge about the relationship between unprotected sex and

pregnancy. I found that participants were not practicing birth control but they did not

understand that they were at risk for pregnancy. Only one other study reported that a

small number (5%) of their participants didn’t believe that they were able to get pregnant

(Coonrod et al., 2009). Because many of the studies in this field included pregnant

participants, this question was not relevant (Coonrod et al., 2009; Heavey, 2010; Kaiser

& Hays, 2005).

Miscommunication regarding RLP. Two subthemes that emerged were lack of

knowledge of common terms associated with PCC and RLP and misinformation

regarding RLP.

Lack of knowledge of common terms. I found the majority of participants had

multiple common terms associated with PCC and RLP that they did not understand

during interviews. An example was the majority of participants reported they did not

have unprotected sex but did not use some form of birth control 100% of the time.

Another example is that condoms are considered birth control in addition to safe sex.

Other PCC studies did not report this findings (Coonrod et al., 2009; Corbett, 2011;

Delgado, 2008; Heavey, 2010; Kaiser & Hays, 2005; Quillin et al., 2000; Wang et al.,
 106
2006). In contrast, using a qualitative phenomenological approach I found a

preponderance of lack of knowledge of common PCC/RLP terms.

Misinformation regarding RLP. Several participants revealed a

misunderstanding about key aspects of RLP. Participants were misinformed regarding

daily timing of birth control pills, availability of different pills to address side effects

experienced, and how long they needed to be off their birth control pills before

attempting a pregnancy.

Other researchers did not identify this subtheme (Coonrod et al., 2009; Corbett,

2011; Delgado, 2008; Fuhrmann, 1986; Heavey, 2010; Kaiser & Hays, 2005; Mathiesen

et al., 2007; Steele et al., 1990; Temple et al., 2006). Perhaps since these studies used

quantitative, retrospective, prospective, and randomized intervention methods for data

collection they were not afforded the opportunity to identify these finding in their

participant pools.

Interpretation of Conceptual Framework

In this section, I will provide a brief summary of findings as they relate to the

conceptual framework. Three theories contributed to the framework: the health belief

model, social cognitive theory, and adolescent affective and cognitive theory. The

framework was utilized to analyze the data and formulate the recommendations for future

studies.

Health Belief Model (HBM)

The HBM is based on the understanding that a person will participate in behaviors

that will prevent a detrimental health outcome if they believe it will successfully work
 107
(Champion & Skinner, 2008). The four key factors of the HBM are: perceived

susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action,

and self-efficacy. I discuss each of these factors in relation to my findings.

Perceived susceptibility is concerned with whether an individual believes they

will get pregnant. Participants’ responses indicate there is a general belief that they are at

not at risk for getting pregnant despite being sexually active and not using birth control.

This finding is consistent with adolescents’ general belief that they are infallible.

Participants in this study did not perceive their own susceptibility.

Perceived severity is concerned with whether an individual believes pregnancy is

a serious condition that that could have serious effects or consequences. Participants’

responses indicated a lack of knowledge of detrimental effects and possible consequences

that are associated with pregnancy. Findings in this study supported participants did not

perceive that pregnancy could have serious consequences.

Perceived benefits is concerned with whether an individual believes that actions

could be taken to decrease or prevent risks or lessen serious effects. In this study, this key

factor is closely related to perceived severity and perceived susceptibility in that

participants did not believe they were susceptible to pregnancy and generally lacked

knowledge of possible serious effects or consequences. Findings indicated participants

did perceive benefit in participating in PCC and RLP but other factors prevented them

from seeking it.

Within this study, perceived barriers are whether an individual believes there are

any physical or psychological reasons that would prevent one from engaging in PCC or
 108
RLP. Findings from this study showed that participants had multiple perceived barriers

that will prevented them from seeking PCC or RLP. These perceived barriers are:

negative interactions with medical professionals, lack of knowledge of common terms,

and lack of discussions of PCC and RLP during clinic visits and sex education classes.

Cues to action in this study are participants’ ability to verbalize how to participate

in PCC. The study found that participants would not cue to action due to the identified

barriers including negative interactions with medical professionals and lack of

discussions of PCC and RLP during clinic visits and sex education classes.

Self-efficacy in this study is participants’ belief that they can successfully

participate in PCC and RLP. To utilize self-efficacy one must possess a level of maturity

and self-confidence. Findings from this study show that participants were capable of self-

efficacy. Without self-efficacy the ability to successfully participate in PCC and RLP is

doubtful.

In summary, the HBM provided insight as to what barriers and perceptions would

prevent participants from seeking PCC and RLP. Each of HBM’s factors are interrelated

and also support participants’ inability to participate PCC and RLP successfully.

Social Cognitive Theory

SCT is based on the understanding that human behavior is influenced by many

factors including environmental, personal, and behavioral experiences (Bandura, 1986).

This theory helped explain how negative past interactions with medical personnel has

created a barrier for participants seeking additional information regarding PCC and RLP.

Negative past experiences influences how participants will interact in the future with
 109
other medical professionals. Negative past experiences also created a barrier to

participants implementing new healthy behaviors.

Adolescent Affective and Cognitive Theory

AACT is how adolescent’s emotional, behavioral, and cognitive systems mature

at different rates and are influenced by many factors including social, biological, and

cultural factors (Casey & Jones, 2010; Piaget, 1970; Steinberg, 2005). This theory was

utilized to understand how the participants’ perceptions of the same event differed from

each other. The theory also indicated that adolescents are likely to have immature levels

of cognitive and emotional ability and lack self-efficacy as shown in these participants,

meaning that interventions with adolescent girls about PCC and RLP need to take their

developmental stage into consideration.

In summary the three theories selected did relate to the results. As expected

adolescents did not possess self-efficacy behaviors. The adolescents’ belief systems were

influenced by peers and negative experiences with school and medical personnel.

Participants relied on information from uninformed peer sources. Information from

parental sources was not adequately utilized by participants. As anticipated the

participants were a vulnerable group with few tools to navigate a complex medical arena

to derive needed information on PCC and RLP to make good choices. Therefore, these

adolescents are exclusively dependent on schools and medical facilities to steer them

positively to PCC and RLP, and to develop their ability to become informed patients.
 110
Implications for Social Change

This study contributes to the body of knowledge on PCC in healthy female

adolescents. It provides insights into adolescent females’ knowledge, beliefs, and

attitudes regarding PCC and RLP. Multiple barriers to their knowledge were identified

through this study and reported in the findings. Readers of this study, who work with

adolescents, will become more aware of the educational needs of adolescents in regards

to information about and planning for pregnancy including school administrators,

teachers, and school nurses. Findings of this study may encourage school administrators

and teachers to examine the sex education programs to evaluate how they could be

enhanced to meet the needs of adolescents. Recognition of adolescent’s desire for PCC

and RLP may encourage others to provide PCC and RLP counseling in other

nontraditional arenas such as community centers, church programs, and teen camps. In

addition, this study may serve to encourage health care providers to make changes in the

delivery of services to adolescents by building positive health care provider-patient

relationships with adolescent patients in their practices. Building positive health care

provider-patient relationships may increase dialogue about and education on PCC and

RLP with adolescent patients to ultimately improve the care of women.

Recommendations for Action

In this study, I explored the lived experiences of PCC and RLP in adolescent

females. I discovered that the participants’ experiences with PCC have been limited and

have not prepared them for a future pregnancy. I also found that participants’ did not

have opportunities to participate in RLP. In this study multiple participants expressed a

 111
need for more knowledge and/or wanting more PCC/RLP education. More striking is the

desire expressed by the participants for PCC and RLP. These findings spurred multiple

questions about how knowledge of PCC and RLP could be provided to increase

adolescents’ knowledge of PCC and RLP. This research also raised the question of what

practices could be implemented to encourage a meaningful relationship between medical

professionals and adolescent females.

As a nurse practitioner, I can personally meet this need in my workplace by

integrating PCC/RLP in every health care visit for women of child bearing age. I can also

seek a change in the electronic medical record system that would provide an easily

accessible checklist for all physicians and midlevel providers to include PCC and RLP in

every health care visit for women of child bearing age.

Initially, I plan to present a poster presentation of my findings to nurse

practitioners at the Louisiana State Nurse Practitioner Association (LANP) annual 2015

state convention. I also plan to present a PCC/RLP workshop at the Louisiana State

Nurse Practitioner Association (LANP) annual 2016 state convention. As a workshop

presenter, I will be able to help others consider how to provide PCC and RLP knowledge

in the clinic settings to parents and adolescents. Emphasizing the need for medical

providers to instruct parents on PCC and RLP will ultimately prepare them to be a more

knowledgeable source for their adolescent children. The workshop will also serve to

inform nurse practitioners regarding the mandate to provide PCC and RLP and give an

overview of content that should be included. I will also emphasize the need to establish

positive working medical provider-client relationships with teens.

 112
Presenting my findings and working with nurse practitioners at a state and

national level to provide PCC and RLP to all women of child-bearing age has the

potential to expand beyond the attendees of the convention. Presenting my findings at the

national level of nurse practitioner faculty conferences may encourage a change in the

curriculum to include and emphasize PCC in programs that prepare nurse practitioners

who will ultimately serve adolescents. Since practicing nurse practitioners take an active

role in educating nurse practitioner students the positive changes in PCC and RLP

practice could extend to multiple others and ultimately improve the care of women.

Recommendations for Further Study

Participants involved in this study were from a low socioeconomic group,

predominately African-American, and represented only one area of a large metropolitan

city in the Southeast United States. Although participants were from only one location,

some of the findings of this study were similar to several previous studies (Coonrod et al.,

2009; Corbett, 2011; Delgado, 2008; Kaiser & Hays, 2005). Heavey’s (2010) participants

most closely aligned with my study’s demographics, including that they were adolescent

aged, were mainly African American, and were from a lower socioeconomic urban

setting. Both studies found the majority of participants had multiple risk factors that

could have been addressed in one of their multiple previous clinic visits. Despite the

similar finding I would recommend replicating the study with participants from varied

socio-economic groups, diverse cultures, and varied areas of the US. Further research on
 113
PCC needs to be targeted at the under 18 years of age and include adolescent males and

females.

I used a qualitative approach for this study. Based on my participants’ lack of

knowledge of common terms associated with PCC and RLP terms I would not

recommend using a pure quantitative approach. The ability to capture accurate

information from adolescents using only surveys could be compromised. Completing

more studies using a qualitative approach with adolescents would allow researchers to

identify and clarify when participants need help to accurately provide the information the

researcher is trying to collect.

Further research examining the relationships among between medical providers,

patients, and patient teaching about preconception counseling would strengthen the

research in the area of preconception health. Future researchers examining current PCC

practices among medical providers and development of culturally appropriate PCC

programs could increase implementation and effectiveness of PCC interventions.

Reflections on the Research Experience

Researcher Reflections

This study has given me the opportunity to appreciate the circumstances that

effect adolescents’ ability to gain information about such important issues in their lives

such as preparing for pregnancy and developing a RLP. Before beginning, I was

concerned about whether I could complete the numerous rigorous tasks of a

phenomenological study. I used journaling as a method of self-encouragement and a way

to track my progress through this journey of completing my research study.

 114
Personal Biases

At the beginning of this study I was concerned that my own professional

experiences with the phenomenon would bias my collection and interpretation of data.

My role as a nurse practitioner was both helpful and a hindrance during the interview and

data collection. As a nurse practitioner who works with teens, I was able to easily gain a

rapport with each participant and thereby gather the data needed for the study. A

disadvantage was limiting my role to a researcher and not as a health care provider. I

used journaling to express my frustration of not being able to educate when knowledge

deficits existed. Reviewing my journaling prior to interviewing also helped me reinforce

and honor my sole role as a researcher and to refrain from entering into the role of health

care provider. In addition I used personal reflection and journaling to help identify any

potential biases, personal feelings, and professional experiences to help center myself and

keep an open, unbiased approach to each interview session.

Changes Due to Findings of the Study

Reflection on the results of this study has spurred me to make a commitment to

effect change on a larger scale. I have changed the way I practice in my clinic in that I am

spending more time with adolescents providing PCC and RLP during routine visits. I also

have made a commitment to make other medical providers more aware of adolescents

need for PCC and RLP during routine clinic visits. Even during this study, while

discussing my doctoral work, I have engaged multiple medical providers in discussion

about what PCC and RLP is and the need for women of child bearing age to learn about it

during clinic visits.

 115
Conclusion

In this study, I explored the lived experiences of female adolescents with PCC and

RLP. I used a phenomenological approach with two one-on-one interviews with five

adolescents to gather information about their experiences with PCC and RLP. I found that

my participants had (a) no experiences with PCC, (b) negative interactions with medical

personnel, (c) a general lack of knowledge about preparing for pregnancy, and (d) wanted

more information about PCC and RLP. The findings of this study are important because

they align with and bring additional information about preconception care with

adolescent females to the field. A new and important finding was that although

adolescents lack PCC knowledge, they desire it.

 116
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Appendix A: Background Information Form

Please answer the following questions. If multiple options are given pick the one that

describes you best.

1. Where do you currently live?

Beechwood & Claiborne Homes

Beechwood Apartments

Other

2. Sex

Female

Male

3. Select which racial/ethnic identity best describes you.

Asian or Pacific Islander

Bi-racial

(Specify__________________________________________________)

Multi-racial

(Specify________________________________________________)

Multi-racial

(Specify________________________________________________)

Black/African American

White/European American

Latino/Hispanic
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Multi-racial

(Specify________________________________________________)

Native American

4. Age ________ years old

5. Indicate your relationship status:

Single

With a partner (boyfriend or girlfriend)

Married

6. Select your current living situation:

I live alone

I live with roommates

I live with my parents/guardian

I live with my partner (husband/boyfriend or girlfriend)

I live with my partner’s parents

Other

_______________________________________________________

7. Employment Status:

Unemployed

Employed

8. Your mothers’ employment status:

Unemployed
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Employed

9. Your father’s employment status:

Unemployed

Employed

10. To the best of your knowledge your family’s yearly income?

Below $30,000 per year

$30,000 to $50,000

$50,000 to $75,000

$75,000 to $100,000

Over $100,000

11. Highest level of school that you have completed:

Did not finish high school (Specify last grade completed___________)

High School Diploma

GED

Some College (Specify last grade completed___________________)

College Degree

12. Do you currently have health insurance?

Yes

No

Medicaid

13. How many days each week do you drink alcohol?

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None

1 to 2 per week

3 to 4 per week

5 or more per week

14. Do you smoke cigarettes?

Yes

No

15. Have you been diagnosed with a chronic illness in the past (asthma, diabetes, high

blood sugar, etc.)?

Yes

No

16. Are you currently sexually active?

Yes

No

17. Are you currently taking birth control (“the Pill”)?

Yes

No

18. How often do you use condoms when having sex?

N/A (I am not sexually active)

I do not use condoms

Not much of the time

Some of the time

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Appendix B: Interview Guide

Question 1: Can you describe your medical visits from age 12 until now that you can

remember. (AACT Affective Component/AACT Cognitive Component)

For each visit:

What was the reason for the visit?

Who did you see at the visit? (Doctor, nurse, etc.)

Were the visits only when you were sick?

Did you ever have a visit for just a checkup or when you were not sick?

Please tell me (describe) what they talked to you about at the visit. (AACT

Cognitive Component)

Did they teach you anything during the visit? (AACT Cognitive

Component/SCT Observational Learning)

How old were you at your last medical visit? (AACT Affective

Component)

Did the Doctor talk directly to you or to the person who brought you?

(AACT Affective Component)

Describe what it is like to talk to the doctor or nurse during the visit.

(AACT Affective Component)

Do you feel it is easy to talk to the doctor or nurse? (AACT Affective

Component/Perceived Barriers)

Did you understand what the doctor/nurse talked about? (AACT Cognitive

Component/HBM Perceived Barriers)

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Were you able to ask the doctor or nurse questions during the visit?

(AACT Cognitive Component/HBM Perceived Barriers)

How comfortable are you talking with the doctor/nurse? (AACT Cognitive

Component/HBM Perceived Barriers)

Do you feel more comfortable asking questions to the doctor or the nurse?

(AACT Cognitive Component/HBM Perceived Barriers)

Do you feel comfortable asking questions in front of your mom/parent at

the doctor’s appointment? (AACT Cognitive Component/HBM Perceived

Barriers)

What about when you are talking about sex, birth control, alcohol, or drug

use in front of your mom/parent? (AACT Cognitive Component/HBM

Perceived Barriers)

How did you pay for the visit? (HBM Perceived Barriers)

If Medicaid/Private insurance was used: Are you able to go to a

doctor’s visit without your mom/parent knowing or having them

present? Can you use your Medicaid/Insurance card without your

mom/parent/friend/sibling/family member? (AACT Cognitive

Component/HBM Perceived Barriers)

If paid cash: Would you be able to pay cash for a visit, by yourself,

if you needed to go without your mother? (AACT Cognitive

Component/HBM Perceived Barriers)

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Question 2: Can you describe how you got your doctor appointments in the past?

(AACT Cognitive Component/HBM Perceived Barriers)

Describe how you would make an appointment if you needed one today. (AACT

Cognitive Component/HBM Perceived Barriers)

For a visit if you were sick?

For a visit if you were not sick?

For a visit if you were pregnant or thought you might be pregnant? (AACT

Cognitive Component/HBM Perceived Barriers)

If mom/parent usually makes their appointment, then ask would

you be able to ask mom/parent/friend/sibling/family member to

make an appointment if you were pregnant or thought they were

pregnant? (AACT Cognitive Component/HBM Perceived Barriers)

What would your mom/parent/friend/sibling/family member say or

do if they told them it was for that? (SCT Reciprocal Determinism)

Have you ever made your own doctor’s appointment? Could you make a

doctor’s appointment if you needed one? (AACT Cognitive

Component/HBM Perceived Barriers)

Who could you could ask to help you get an appointment besides your

mom/parent? (AACT Affective Component/HBM Perceived Barriers)

Question 3: PCC Knowledge

Are you familiar with what PCC is? (AACT Cognitive Component)
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Can you describe what PCC is and what is PCC for? (AACT Cognitive

Component)

Have you or anyone you know participated in PCC? (SCT Reciprocal

Determinism)

Describe where you could go to get PCC. (HBM Cues to Action)

Describe how to set up an appointment for PCC. (HBM Cues to Action)

Have you talked to anyone about what to do to plan a pregnancy or prevent a

pregnancy? (SCT Reciprocal Determinism)

When is the best time for a woman to seek PCC? (HBM Self-efficacy)

Will you participate in PCC prior to a pregnancy? (HBM Self-efficacy)

Do you think you would participate in PCC? (HBM Perceived Benefits)

Are you planning to make an appointment for PCC? (HBM Self-efficacy) When?

Question 4: Before trying to get pregnant what are things someone can do to have a

healthy pregnancy and healthy baby? (AACT Cognitive Component)

What things do you plan to do to prepare for a pregnancy? (HBM Perceived

Benefits)

Is there anything you plan to do before getting pregnant? (HBM Perceived

Benefits)

What kinds of things can someone do to have a healthy pregnancy? (AACT

Cognitive Component/HBM Perceived Benefits)

When should they start doing _____ to have a healthy pregnancy/baby?

What does ______ do for the baby? (Ask for each behavior)
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Where did you learn to _ (Fill in each behavior identified by

participant)____ before getting pregnant?

Where did you first hear about it?

Could having a doctor’s visit, before getting pregnant, help

someone have a healthier pregnancy or healthy baby?

If interviewee does not identify early and continued prenatal care,

eating balanced and nutritious meals, and taking prenatal vitamins

ask about each of them and the effect on an unborn child.

Question 5: Are there things someone should not do or quit doing before getting

pregnant to have a healthy baby? (AACT Cognitive Component/HBM Perceived

Severity)

Do you know any medical conditions or lifestyle behaviors that could harm

(negatively affect) a pregnancy or a baby? (HBM Perceived Severity)

What things do you think might hurt a baby during pregnancy? (AACT Cognitive

Component/HBM Perceived Severity)

What does ______ do to an unborn baby? (AACT Cognitive

Component/HBM Perceived Severity)

Where did you learn not to do ________ before getting pregnant? (AACT

Cognitive Component/HBM Perceived Severity)

Who or where did you first hear about it?

If the interviewee does not identify cigarette smoking, drinking alcohol,

delayed prenatal care, and poor nutrition then ask them about each of them
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and the effect on the unborn baby. (AACT Cognitive Component/HBM

Perceived Severity)

Question 6: Are you planning to get pregnant in the next year? Do you think you will be

pregnant in the next year, 2 years? (HBM Perceived Susceptibility)

Do you think you “might” or could get pregnant in the next year or two years?

(HBM Perceived Susceptibility)

Have you ever had sex? (HBM Perceived Susceptibility)

Have you ever had unprotected sex? (HBM Perceived Susceptibility)

Have you used contraception every time you have had sex? (HBM Perceived

Susceptibility)

What type of contraception have you used? (HBM Perceived Susceptibility)

Have you ever thought you might be pregnant? (HBM Perceived Susceptibility)

Have you ever taken a home pregnancy test? (HBM Perceived Susceptibility)

Do you think you will be pregnant in the next four years? (HBM Perceived

Susceptibility)

If you are planning to get pregnant what type of things should one do to prepare or

get ready before the pregnancy? (AACT Cognitive Component)

Or Before you get pregnant have you or do you plan to do anything to

prepare?
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Question 7: In middle-school or high school do you remember learning anything about

what to do or not to do when someone is thinking about getting pregnant. (AACT

Cognitive Component/SCT Observational Learning/SCT Reciprocal Determinism)

Do you remember learning anything about what to do or not to do when someone

wants not to get pregnant? (AACT Cognitive Component/SCT Observational

Learning/SCT Reciprocal Determinism)

If “yes”: Source of information?

Name of class, grade level?

Peer, parent, any source identified probe the circumstances

(Who, what, when)

What about what to do or not to do if you are pregnant? (AACT Cognitive

Component/SCT Observational Learning/SCT Reciprocal Determinism)

If “yes”: Source of information?

Name of class, grade level?

Peer, parent, any source identified probe the circumstances

(Who, what, when)

Question 8: Has anyone ever told you that you should get special medical care and

advice before you become pregnant or plan for a pregnancy (preconception care)?

(AACT Cognitive Component)

Where have you gotten information from about getting ready for pregnancy or preventing

a pregnancy? (SCT Observational Learning)

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Doctors/clinic/school/Mother, grandmother, family, friends, books, clinic,

internet, TV? (SCT Observational Learning)

What were you told? (for each one identified by interviewee will be

probed.)

Do you feel you know everything you need to have a healthy baby?

(AACT Affective Component/AACT Cognitive Component)

What do people use birth control for? Prevent pregnancy/plan

pregnancies? (AACT Cognitive Component)

Who would be the best person to receive information PCC from? (SCT

Facilitation)

What is the best age to start receiving PCC? (SCT Facilitation)

Question 9: Do you have any additional thoughts or things you would like to add?
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Appendix C: Informed Consent (Aged 18 & Over)

You are invited to take part in a research study about your experiences with

preconception care. This study seeks to describe your knowledge, attitudes, and beliefs

about preparing before you get pregnant (preconception care). You have been invited to

participate in this study because you are an adolescent female. Your participation in this

study will help provide important information about what adolescents want and need in a

preconception program.

Exclusion Criteria:

Women who are under 18 or are 22 years old or older are not able to participate.

Also women who have been pregnant or are now pregnant may not participate in the

study. Women who have had a hysterectomy will not be able to participate.

Inclusion Criteria:

You may participate in this study if you are a female between the ages of 18 to 21

years old.

This study is being conducted by a researcher named Lynette Collins, who is a

doctoral student at Walden University. The researcher is a family nurse practitioner at

Daughters of Charity Health Clinic in New Orleans, Louisiana. She has been a nurse

practitioner for 16 years.

Background Information:

The purpose of this study is to understand preconception care from the

perspective of adolescent females. Participants’ descriptions of preconception care will

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help the researcher propose new ways to provide preconception care that will meet the

needs of adolescents. It will also help to identify barriers to seeking preconception care.

Procedures:

If you agree to be in this study, you will be asked to:

Sign the consent form

1st meeting: (Should last about 45 minutes)

Complete a demographic questionnaire

Complete interviews about your experiences with preconception care.

2nd Meeting: (Should last about 30 to 45 minutes)

Review a written copy of your interview statements made during the 1st

meeting.

Duration of the Study:

The study will begin in TBA.

The researcher may collect data until TBA.

Voluntary Nature of the Study:

Your participation in this study is voluntary. This means you have the right not to

participate. No one will treat you differently if you decide not to be in the study. If you

decide to be in the study you always have the right to not participate later. If you feel

stressed during the study you may stop at any time. You do not have to answer questions

that you feel are too personal or do not feel comfortable answering.

Risks and Benefits of Being in the Study:

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There are no direct benefits to you for being in the study. There are no foreseeable

physical or emotional risks or discomforts involved in this study.

Compensation:

All participants will receive a $20 gift card from Walmart for participating in the

interviews.

Confidentiality:

Your real name or any information that would identify you will not be used to

protect you and the information you provide for this study. All information you provide

will only be used for this research project. The written report will not include your real

name or any information that would reveal your identity.

Contacts and Questions:

The researcher’s name is Lynette Collins. The researcher’s faculty chair is Dr.

Carol Philips. You may ask any question you have now or later by contacting the

researcher on the phone (504-201-2502) or by email ([email protected]). You

may also contact the researcher’s faculty by phone (802-272-2058) or by email

([email protected]). Also if you would like to talk to someone about your rights

as a participant, you can call Dr. Leilani Endicott at 612-312-1210. Walden University

approval number for this study is Enter number and will expire on Enter expiration

number.

If you wish to participate, please sign this form as a record of your agreement.

Signing this consent form indicates that you agree to the terms written. If you do not want

to participate then this form will be shredded. You may want to keep a copy of this
 145
consent with contact numbers for your records. Please sign your name and phone number

as a record of your participation.

Thank you.

Name: ___________________________________ Date: _________________

Phone number: ___________________________________

Address: ___________________________________
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Appendix D: Participants’ Textural and Structural Descriptions of Participants

Textural Description of Participant A

One-on-one interviews were done to understand this participant’s past

experiences with PCC and RLP. Beginning with Abby’s past medical experiences she

stated she had one visit with a medical clinic for a sore throat. She did not engage in

conversation with the medical personnel during the visit due to feeling unable to speak on

her own behalf. Her mother was the person present who spoke to the medical personnel.

Abby’s experiences with PCC were provided by her public school and focused on

birth control. The issue of not communicating directly and openly with the medical

personnel was a barrier for her not receiving more information about PCC. During

discussion of healthy and bad habits for preparing for a pregnancy Abby’s answers

focused on abstract answers like “get a job” and “get your life together for your child”.

She was not able to identify one known positive or negative behavior associated with

PCC. Abby’s sex education classes did not focus on PCC or how to have a healthy

pregnancy. She said the class was about “how to take care of babies” and “that we should

use pills to keep from getting pregnant.”

Abby’s experiences with reproductive life planning (RLP) revealed that she has

not been taught how to make a plan or considered making a plan. She has thought about

how many children she would like but has not considered how to plan her family. Abby

does not know the information necessary to make a RLP.

Abby’s discussion of whom she turns to for PCC and RLP information were

contradictory. She readily identified “my friends mostly” as the people she turned to for
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information about PCC and RLP. When asked if she had talked to her friends about PCC

and RLP she answered no.

Abby does not believe she can ever have children. Abby does not believe she is at

risk for pregnancy because she reports she does not have unprotected sex. Abby is at risk

for pregnancy because she does not use any other type of birth control and only uses

condoms sometimes. She does not identify condoms as a birth control method. Abby also

does not seem to understand what unprotected sex means. She knew several girls who

were pregnant in middle school and “a whole bunch” in high school. Abby reports that

she does not feel prepared if she gets pregnant.

Structural Description of Participant A

Abby’s experiences of acquiring accurate thorough PCC and RLP information

have been limited. Due to multiple factors Abby has not gained the knowledge needed to

prepare her for a healthy pregnancy. Limited contact with medical personnel in her

adolescent years is one factor that has limited her acquisition of knowledge of PCC and

RLP. Limited contact has also led to not establishing a rapport with medical personnel

who could have provided needed information. Abby lacks confidence in talking openly

with medical personnel and that also is a barrier for her obtaining information on PCC

and RLP. She depends on her mother to help her make doctor appointments and get her

to the clinic.

Abby’s formal school sex education classes did not offer the opportunity for her

to gain the necessary knowledge about PCC and RLP. Her sex education class focused on
 148
birth control and how to take care of babies. Abby was not able to identify one correct

positive or negative behavior that would affect her having a healthy pregnancy and baby.

Although Abby identified several people she can talk to about PCC and RLP she

reports she does not discuss these topics with them. It would be a logical conclusion that

Abby’s friends who attended the same schools she did also lack knowledge about PCC

and RLP. Abby did not readily identify the contradictions in her statements about who

she gets information from about PCC and RLP and the statements that contradict that she

talks to them about PCC and RLP.

Abby is sexually active but does not realize that she is at risk for getting pregnant.

She is under the impression that because she hasn’t gotten pregnant yet, then it cannot

happen. Abby does acknowledge that she is not prepared to get pregnant. Another barrier

for Abby is that she does not know what knowledge she is lacking regarding PCC and

RLP. Despite having full Medicaid Abby has limited ability to seek accurate sources to

gain this knowledge.

Textural Description of Participant B

The first scheduled interview was to understand the participant’s past experiences

with PCC and RLP. Bella described multiple medical visits with multiple clinics due to

problems with her menses and seeking birth control. Her interactions with the first

clinic’s medical personnel were described as negative because she felt like they did not

talk with her or answer her questions. Bella stated “I really didn’t like ‘em ‘cause they

don’t never, um, really talk to me about stuff…just told me to um take birth control pills

to make my menstrual regular. That is what the Planet (sic) Parenthood lady doctor said, I
 149
didn’t really like going, um, I don’t get why they would give me birth control pills didn’t

make sense to give birth control pills for my menstrual if I wanted to get pregnant.” Bella

further described an equally unhappy relationship with the second clinic’s medical staff

when she stated “yeah, it was about the same as before, they don’t really talk nothing

‘bout what’s going on with you or what they doing. They just tell you do this.”… Initially

Bella’s mother set up and attended clinic appointments with her. After the first few times

Bella made her own appointments and went on her own. Bella reported she has full

Medicaid that pays for her visits.

Bella’s experience with PCC was limited due to the fact that she was not allowed

to complete her sex education class in school. She relayed how while starting school sex

education classes “I got put out!”… “That sex education class.”… : “Cause some boy

was cuttin’ up and got me in trouble and got us both put out. So then they stopped the

class.” nobody got the class.” Bella does not recall anyone at the clinic discussing

preparing for pregnancy despite multiple opportunities to do PCC counseling. She

provided abstract answers like “get a job” and “ask my mama for help” when discussing

the healthy habits and bad habits to avoid to get ready to get pregnant. Bella did add that

her mother told her not to smoke or drink but she did not know it was something not to

do especially if you are planning to get pregnant.

Bella denies learning about RLP. Her initial response to whether she has a RLP

she said: “I ain’t having kids anytime soon.” When asked whether or not a woman can

control when she has children her reply was: “No, I don’t think so, you have kids when

you do, it just happens when it happens.” Bella did not understand that a RLP can include
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planning to not have children until she wants. She reports “it would be good to make a

plan.” and does see value in making a plan.

Bella’s discussion of who she turns to for information about PCC and RLP

included friends and her sister. During the discussion she reports she has not discussed

PCC or RLP with any of her friends. The only thing she has talked to her sister about is

birth control methods.

Bella does not believe she will get pregnant in the next year. She does not use

birth control all the time. Bella also does not identify condoms as a type of birth control.

She reports she uses condoms sometimes.

Structural Description of Participant B

Opportunities for Bella to gain PCC and RLP information have been available

through multiple clinic visits. She has failed to develop a positive relationship with any

medical personnel despite multiple visits. Bella feels the medical personnel do not talk

with her or answer her questions but just tells her what to do. Although Bella feels

comfortable making and attending her medical appointments she does not feel she has

open communication with any of the personnel.

Bella’s experience with PCC was incomplete due to being thrown out of the sex

education class in school. She was unable to identify any of the positive habits to

implement prior to getting pregnant or negative behaviors to stop before attempting a

pregnancy to help have a healthy baby.

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Bella does not believe she can control when and how many children she has in her

life. Bella did not understand that a RLP is a means of planning your children. Once RLP

was discussed Bella did believe it would valuable to make a RLP.

Bella has not found a reliable source for information on PCC and RLP. She does

not use birth control but does not believe she will get pregnant in the next year. Bella

does not understand condoms are a form of birth control. Therefore, it would be difficult

to get accurate survey information about PCC and RLP from this participant.

Textural Description of Participant C

The goal of this interview was to understand the participant’s past experiences

with PCC and RLP. Cici described multiple medical visits at multiple clinics for different

reasons including school shots, a sexually transmitted diseases check, and once when she

thought she was pregnant. Interactions with the staff have been mixed. She reports one

interaction while checking in as “It was okay, the nurse that checked me in was real nice,

but I was worried ‘cause I thought, um, I might have a STD.” Interactions with the

doctors was characterized as “they always seemed like rushed, the doctor hardly talked to

me at all he seemed like rushed.” Cici has full Medicaid that pays for her medical visits.

Setting up medical appointments has always been done for her by her grandmother.

Cici’s experience with PCC has not been adequate. She recalls that when she went

to the clinic concerned that she might be pregnant, the staff did not discuss PCC only

“told me I wasn’t pregnant and, um, that I should use condoms.” Cici’s PCC experience

in school was described as “um, Well, we had sex ed in like the 10th grade. Mostly like

how to change diapers, hold babies, and stuff.” We “just talked about STD’s and use
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condoms and birth control. Just really kept telling us don’t get pregnant before you go to

school, get a job stuff like that.” She does not remember any discussion about spacing

children or what to do to get ready for pregnancy. When asked about what healthy things

could you do to prepare to get pregnant her responses were abstract and not correct.

“Well, um maybe get an apartment, get a job…no, oh yeah get your GED (General

Education Diploma).” She further added “um, No I don’t know of any” when asked what

are bad things one should stop doing to prepare for pregnancy.

Cici denies learning about RLP or even hearing the phrase anywhere. Her initial

response to hearing the phrase RLP was “I ain’t trying to be pregnant.” When discussing

whether or not it would be valuable to formulate a RLP she indicated it would be, but

then commented that it was not in your control if you have children. Her statement when

referring to whether it is valuable to make a RLP that it is not because pregnancy “it is

either meant to be or not.”

Cici does not understand the term sexually active. She reported she is not sexually

active but then stated “I only have sex maybe 2 times a week or so.” She does not intend

to have children for a few years. Cici does not have an effective plan to wait a few years

to have children. Cici does not believe she has unprotected sex but uses condoms “most

of the time” as her only means of birth control.

Structural Description of Participant C

All but one of Cici’s past experiences with different medical personnel have been

negative. She had one brief positive interaction with a nurse at one clinic. Interactions

have been characterized as rushed and the doctor hardly spoke with her. CiCi has not
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regularly attended one clinic in her adolescent years and has clearly not established a

patient-client relationship with a medical provider. Although Cici has full access to

medical care her visits continue to be negative. Cici does not feel comfortable making her

own medical appointments.

Despite multiple opportunities to receive PCC through clinic visits Cici has not

received the information she needs. Her formal school class on sex education focused on

childcare and using birth control and did not provide PCC. Cici does not know what

positive or negative factors could affect a pregnancy.

Cici’s initially associated RLP only as wanting to get pregnant. Cici does not

value RLP because she does not believe a woman can control when she will get pregnant.

Cici does not understand common terms associated with PCC and RLP.

Therefore, it would be difficult to get accurate survey information about PCC and RLP

from this participant. She also does not believe she has unprotected sex but only uses

condoms most of the time. Her lack of knowledge makes her more at risk for pregnancy,

STD’s, and poor fetal maternal outcomes.

Textural Description of Participant D

The first scheduled interview was to understand the participant’s past experiences

with PCC and RLP. Deidra could only remember one visit to the doctor for a bladder

infection. She reported she has gone for others but cannot remember what for. Initially

the clinic visits were set up by her mother and her mother went with her to the clinic.

“Like the doctor’s offices and stuff I go usually with my mom but for the last couple of

visits I’ve been going by myself. But I usually go with my mama.” Interactions with the
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medical staff have not been positive as indicated when she described “I hardly saw the

doctor any…yeah, um but you hardly ever see the same doctor or nurses, every time you

go it’s someone new um different. Then they don’t know you or seen you before.” Deidra

has full Medicaid that pays for the visit. When discussing how comfortable she is talking

to medical personnel she felt she could and does ask them questions.

The majority of Deidra’s experiences with PCC were provided by her public

school in the seventh grade. While discussing whether or not she received any PCC

counseling from the clinic her response was “No ,huh, I don’t remember any the, um,

doctor’s office or nothing or anything talking about to me about planning or planning

parenthood or nothing like that.” When discussing healthy habits to prepare to get

pregnant Deidra initially said no, then added “if they do drugs they should stop the drugs

completely, quit the drugs completely. They should get their life organized before they

plan to have a baby or anything.” During discussion of her knowledge of bad habits to

stop during pregnancy she responded “Like I said if the people, if the person is doing

drugs they should stop before getting pregnant. I live in a neighborhood where I see that a

lot. Like the demographics they don’t care if they get pregnant and they still they are

smoking marijuana and drink and stuff. That’s why I get concerned about when they are

doing the drugs before and while they are pregnant and even when they have the baby.”

While discussing she shared “They just talked about if you have sex use protection, use

the pill, stuff like that.… drinking, smoking, the drugs.” Deidra’s formal sex education

class was in the seventh grade. She stated the class did not discuss PCC they just talked

about “They just talked about if you have sex use protection, use the pill, stuff like
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that…just stuff like what to do while you are pregnant, The drinking, smoking, the

drugs.”

Deidra denies learning about RLP. Her initial response to whether she has a RLP

she said: “No, I don’t have a plan or anything like that.…Nobody has never said nothing

about making a plan.” Discussing whether there is value in making a plan she

commented: “Probably so you got your life in order and were ready for kids. I think it

would be a good idea to have a plan if you knew something about how.” Exploring what

she would need to make a RLP Deidra stated “You’d need to know lots of stuff…Pretty

much about birth control, more about how to not get pregnant.” When asked directly if

she knows enough to make a RLP her response was “No not me…I would like to go to a

pregnancy plan class if I could.”

When discussing of who she turns to for information about PCC and RLP she

readily stated “Parents and doctors would be best.” She then qualified that talking with

“Some of the doctors, my mama. But it wasn’t geared for planning a pregnancy it has

been more about preventing a pregnancy.” Deidra had contradictory statements about

“my mom and I talk all the time” to state they do not talk about PCC except “just about

preventing a pregnancy. She said she would take me for birth control if I needed it.”

Deidra reports she is sexually active. She does not believe she has unprotected sex

but stated she does not use birth control. Deidra stated she uses condoms most of the time

“but I’m thinking about going on the pill.” She apparently does not understand that

unprotected sex requires she use birth control 100% of the time if she does not want to

become pregnant. Deidra did know girls in middle school that got pregnant. Since she did
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not attend high school she was not able to address whether she knew girls in high school

who became pregnant.

Deidra reports she does not feel prepared if she gets pregnant. She stated “I know some

stuff but you know I’m not the smartest person in the world, you know. But I don’t do

drugs, I don’t drink, you just drink plenty of water and you know, you know but, I don’t

know everything.”

Structural Description of Participant D

Opportunities for Deidra to gain PCC and RLP information have been available

through multiple clinic visits but she has not gained PCC and RLP information she needs.

She has failed to develop a positive relationship with any medical personnel despite

multiple visits. Deidra feels you never see the same doctors and they don’t know who you

are from one visit to the next. Although Deidra feels comfortable making, and getting to

her medical appointments she does not feel she has open communication established with

any of the medical personnel.

Deidra’s had limited experiences with learning about PCC. PCC was not

discussed during any of her clinic visits. She had limited informal school sex education

due to dropping out of school in the eighth grade. Her formal school sex education class

focused on prevention of pregnancy and positive and negative behaviors to observe when

you are already pregnant. Deidra did correctly identify two of the negative behaviors to

stop before getting pregnant but was not sure where she learned about it.

Deidra does not have a RLP but would be interested in attending a class to learn

how. She does not feel she knows what she needs to make a RLP on her own and has not
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received the information needed to make one. Deidra does see the value in making a RLP

but does not feel she has the information needed to make one.

Deidra has not discussed PCC or RLP with anyone she identifies as sources of

information. She identified that medical personnel would be the best source of PCC and

RLP information but this would probably not be a good source unless she was able to

develop a doctor-patient relationship with one. Deidra’s lack of established positive

doctor-patient relationship with a medical provider would be a barrier to successfully

getting information on PCC and RLP.

Deidra does not believe she has unprotected sex despite her not using birth control

100% of the time. Deidra does not feel she has the knowledge needed to be prepared for a

healthy pregnancy. Deidra does not understand some of the basic terms of PCC and RLP.

Therefore, it would be difficult to get accurate survey information about PCC and RLP

from this participant.

Textural Description of Participant E

The first scheduled interview was to understand the participant’s past experiences

with PCC and RLP. Elsa could only recall one medical visit to get birth control and a Pap

smear. She described the experience as “Kind of scary that was the first time I had a Pap

done. I was scared they might find something bad.… I heard how much it was going to

hurt and all.” She further described how the doctor did not explain how the Pap smear

was going to be done he only said “just put your legs here, they didn’t talk to me at all

whiles they were doing the Pap.” Elsa reported “I feel comfortable talking to both nurses

and doctors.” When talking about her experience she relayed she did not talk with doctor
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by stating “They don’t spend that much time in the room with you, they, um, did the Pap

and left.” She also stated she made her own medical appointment.

Elsa’s experience with PCC has not adequate. She denied ever having anyone

discuss PCC with her from the clinics. When asking if anyone at the clinic talked to her

about PCC she responded “Not at all, nobody has ever talked about what to do to get

ready to get pregnant. Not that I remember.” Elsa was interested in attending a PCC/RLP

class by stating “Yes, I would want to know about how to ready to make a healthy baby. I

would participate if they offered it to me, just to find out.” She responded to whether she

knows of any healthy behaviors to do when planning to get pregnant by stating “no not

really just take vitamins or something to make everything go smooth.” Elsa identified

only one healthy behavior to do before getting pregnant. She did identify one bad habit to

stop before attempting a pregnancy when she stated “I know to stop drinking for one.

Stop doing a lot of heavy duty (physical) working if you have a job like that.” Elsa

summed up her PCC education in school as “in school we only talked about preventing it,

just about not getting pregnant.”

Elsa denies learning about RLP or having one. When asked about has she thought

about a RLP she stated “no haven’t really thought about it, kinda of think I would like a

couple of kids.” Elsa said she did not know of anywhere she could go to get PCC or RLP

counseling she responded “Nope I don’t know, not anywhere that I know.” She believed

the best time to get PCC/RLP counseling is “If you are looking to have a baby”.

Elsa identified multiple sources of who to turn to get information about PCC/RLP

including her aunt, mother, internet, and Planned Parenthood. With discussion Elsa
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revealed “No I haven’t ever talked to my mom about sex or birth control… she tried to

talk about how to prevent pregnancy” Although her aunt is an identified source of

information she reported “we talk about birth control, boys, and stuff” but no other

aspects of PCC or RLP.

Elsa does not believe she will be pregnant in the next year but does not use birth

control 100% of the time. She does not think she has unprotected sex but her only method

of birth control is using condoms. When asked about how often she uses condoms she

responded “Sometimes we use condoms….No, we don’t use condoms every time but

mostly yes.” Elsa would like to have a couple of kids “but not right now.” She knew “a

lot of girls got pregnant in high school that were there with me.” Elsa does not feel

prepared to get pregnant. She stated “I don’t really know too much about what to do

before or when I ‘m pregnant guess I’ll find out then.”

During the interview it became obvious that Elsa had misinformation or lack of

communication regarding several issues. First how long she needed to be off birth control

pills before attempting a pregnancy Elsa stated “Um, well from my aunt I know she told

me, uh, maybe like a year or 2 years to be off that.” Her aunt did not advise her correctly.

In addition she reported she stopped taking birth control because “I just didn’t like how

the way the pills made me feel, they made my stomach feel bad.” Elsa did not discuss the

side effects of her birth control to see if an adjustment could be made to her birth control

pills to eliminate the side effects.

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Structural Description of Participant E

Elsa had only one medical visit during adolescence. Her experience was negative

including feeling scared and not comforted by the medical staff. Elsa reports the doctor

did not explain what they are doing or spend enough time with you during the visit. Elsa

has access to care through Medicaid and feels capable of making her own appointments.

Elsa does not have an established positive doctor-patient relationship with any medical

personnel.

Elsa’s experiences with PCC have not been adequate to provide all the PCC and

RLP information she needs to have a healthy baby. PCC was not provided during her

medical visit. Elsa’s formal school sex education did not provide PCC instruction. Her

sex education class only provided information on preventing pregnancy. Elsa correctly

identified one healthy and one negative behavior to implement before attempting a

pregnancy. Other behaviors were not associated with preparing for a pregnancy.

Elsa was not taught about RLP and does not have a RLP formed. She does not

know of any source that could help her with learning about a RLP or helping develop

one.

Although Elsa identified multiple sources of information for PCC and RLP she

reports she has not discussed PCC or RLP with anyone. Elsa would like to have children

but not in the near future. Elsa does not have an effective means of preventing pregnancy

in place.

Although Elsa does not use birth control 100% of the time she does not believe

she will be pregnant in the next year. She does not feel prepared to get pregnant.
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Elsa does not understand what unprotected sex means. Elsa does not understand

terms associated with PCC and RLP. Therefore, it would be difficult to get accurate

survey information about PCC and RLP from this participant.

Elsa has been misinformed about how long to be off of birth control pills before

attempting a pregnancy. Elsa did not understand she should return to the doctor when she

had side effects from birth control pills. She did not understand that the pills could have

been changed to eliminate the side effects and be able to continue using this form of birth

control.