Elizabeth M. Aparicio, PhD, MSW Heather Hokulani Porter Sociocultural Context of Teenage Pregnancy in Native Hawaiian Communities: A Mixed-Method Analysis of Population-Level Predictors and Youth Perspectives Elizabeth M. Aparicio, PhD, MSW Causha Spellman, MSW University of Maryland Department of Behavioral & Community Health Alyssa Foster, MSW Kamaile Keaunui, MSW University of Hawai‘i School of Social Work Andrew Wey, PhD Heather Hokulani Porter Minneapolis Medical Research Foundation Patricia McKenzie Waianae Coast Comprehensive Health Center #APHA2017 @LizAparicio22

Acknowledgements Study participants PRAMS Survey & qualitative interview youth participants State of Hawai‘i Department of Health, PRAMS team This study was partially supported by the National Institute on Minority Health and Health Disparities (U54MD007584), National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMHD or NIH. Travel funded by University of Maryland #APHA2017 @LizAparicio22

Presenter Disclosures No Relationships to Disclose. Department of Behavioral and Community Health Presenter Disclosures Elizabeth M. Aparicio The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No Relationships to Disclose.

Introduction: Teen Pregnancy in Hawaii As a state, rates slightly higher than U.S. average Major racial and ethnic disparities Native Hawaiian youth at high risk Compared to national rates, pregnancy rate is nearly 5 times higher (114 vs. 22.3/1,000 15-19 year olds) (Hawaii Health Data Warehouse, 2016; Hamilton et al., 2016) Compared to African American and Latino youth nationwide, 3 times higher (Hawaii Health Data Warehouse, 2016; Hamilton et al., 2016) Interdisciplinary team began to discuss and explore #APHA2017 @LizAparicio22

Research Questions What are the predictors of birth timing (teenage versus older birth) among Native Hawaiian women in Hawai‘i? What are youth perspectives of the sociocultural context of teen pregnancy in Native Hawaiian communities? #APHA2017 @LizAparicio22

Department of Behavioral and Community Health Method

Method: Sequential Mixed-Method Design Sequential mixed-method study (quant -> qual) Phase One: Quantitative Analysis Phase Two: Grounded Theory Qualitative Data Collection and Analysis Phase Three: Integration of Findings #APHA2017 @LizAparicio22

Method: Sequential Mixed-Method Design Phase One: Quantitative Analysis Secondary data analysis N=1,493 Native Hawaiian women Pregnancy Risk And Monitoring Survey (PRAMS) Prenatal and postpartum care, substance use, mental health, adjunct service use, demographics Stratified random sample of 200 women monthly 2009-2011 version #APHA2017 @LizAparicio22

Method: Quantitative Phase Sample Of the N=1493 Native Hawaiian women (unweighted percentages): n=516 (35%) live on O‘ahu n=981 (69%) have a family income over $10,000 N=171 (12%) are teenage mothers #APHA2017 @LizAparicio22

Method: Quantitative Phase Variables Household income Intimate partner violence (IPV) prior to & during pregnancy Use of WIC during pregnancy Pre-pregnancy emotional stress (composite variable: if anyone in their household was ill and hospitalized or if someone close died) Desire to become pregnant Actively trying to get pregnant Contraception use Previous birth Pre-pregnancy traumatic stress (composite variable: homeless, involved in a physical fight, partner or self went to jail, or someone very close had a problem with drinking or drugs) #APHA2017 @LizAparicio22

Method: Quantitative Phase Analysis Descriptive analysis to examine frequencies and correlates Logistic regression to examine predictors of birth timing after adjusting for income greater than $10,000 PRAMS is stratified by island and gestational age Survey weights account for the complex survey design #APHA2017 @LizAparicio22

Method: Qualitative Phase Key Informant Interviews Individual in-depth, semi-structured interviews Interview guide based on quantitative phase findings Family and community structure, relationship with parents and caregivers, recommendations for teen pregnancy prevention, circumstances of pregnancy and experiences of parenthood (if pregnant in past) Pseudonyms used throughout N=10 male and female Native Hawaiian teens (18-19 years) Majority female (n=7) Over half had/partner had experienced pregnancy (n=6) One third had/partner had a prior miscarriage or abortion (n=3) #APHA2017 @LizAparicio22

Method: Qualitative Phase Grounded Theory Open coded 3 randomly selected interviews Line-by-line codes of data relevant to participants’ perspectives on the sociocultural context of teenage pregnancy within their communities Developed team codebook of focus codes, used to code final 7 interviews Slightly broader, less idiosyncratic to individual participant Updated as needed to incorporate new, relevant codes Focus codes organized into themes and subthemes of participants’ perspectives Saturation of themes reached, indicating appropriate to conclude data collection and analysis #APHA2017 @LizAparicio22

Method: Integration of Findings Phase Findings were then integrated: Considered in relation to one another Used to create a final theoretical model #APHA2017 @LizAparicio22

Department of Behavioral and Community Health Results

Phase One Results: Descriptive Analyses Among teenage mothers: 15% desired to get pregnant then 10% were trying to get pregnant Among those teenage mothers who did not desire to get pregnant then, 49% were using contraception 15% had a previous birth #APHA2017 @LizAparicio22

Phase One Results: Descriptive Analyses Native Hawaiian women who gave birth as teens (19 years or younger), as compared to older mothers (20 years or older) had significantly (p<.05) Lower household incomes (65% vs. 27% under $10,000/yr) Higher use of WIC during pregnancy (78% vs. 59%) Higher levels of intimate partner violence Prior to pregnancy (14% vs. 6%) During pregnancy (9% vs. 4%) Higher levels of pre-pregnancy marijuana use (15% vs. 7%) Lower rates of pre-pregnancy binge drinking (32% vs. 54%) #APHA2017 @LizAparicio22

Phase One Results: Descriptive Analyses Native Hawaiian women who gave birth as teens (19 years or younger), as compared to older mothers (20 years or older) had significantly (p<.05) Higher levels of stress Emotional stressors (41% vs. 31%) Traumatic stressors (32% vs. 20%) #APHA2017 @LizAparicio22

Phase One Results: Logistic Regression (adjusted for very low income <$10,000) Variable Odds Ratio 95% CI P-value Wanted Pregnancy 0.25 (0.13, 0.46) 0.000 Trying to get Pregnant 0.21 (0.10, 0.45) IPV Prior to Pregnancy 1.52 (0.71, 3.25) 0.285 IPV During Pregnancy 1.69 (0.72, 3.99) 0.229 Previous Birth 0.08 (0.04, 0.16) Emotional Stressors 1.78 (1.08, 2.93) 0.025 Traumatic Stressors 1.39 (0.82, 2.33) 0.218 Marijuana Use 1.59 (0.83, 3.06) 0.162 Binge Drinking 0.41 (0.25, 0.68) 0.001 These are the results of a logistic regression examining how these predictors affect the odds of women giving birth as a teen (meaning 19 and under) or as an older mother. After adjusting for family income, some of the bivariate differences we saw earlier were accounted for. I’ll highlight a few things from this table. After adjusting for family income, we can see that women who wanted to or were trying to get pregnant had lower odds of being a teen mother. IPV prior to pregnancy and during pregnancy did not significantly predict a difference in birth timing Experiencing emotional stressors was a significant predictor of birth timing. Women who experienced 1 or more emotional stressors had 78% greater odds of experiencing a teenage birth Women who engaged in pre-pregnancy binge drinking had lower odds of having given birth as a teen #APHA2017 @LizAparicio22

Individual, Family, and Community Risks Phase Two Results: Grounded Theory Analyses Individual, Family, and Community Risks “Everybody I know has kids. That’s why I’m doing the study because every teenager nowadays got kids.” “At the time [I got pregnant] I was seventeen...I was heavy into my disease. I had a very bad alcohol problem...dropped out of high school...I wanted to be a social worker. So I was either doing really bad things or trying to do really good things; there was no in between.” #APHA2017 @LizAparicio22

Individual, Family, and Community Resilience Phase Two Results: Grounded Theory Analyses Individual, Family, and Community Resilience “I wasn’t ready for the right girl or to settle down. I was always...banging girls, but I always used protection.” “Well, my community and my family...they’re really close and a lot of the community in the [Hawaiian housing community] homestead was family.” #APHA2017 @LizAparicio22

Risk Factors Protective Factors Model of Sociocultural Context of Teen Pregnancy among Native Hawaiian Youth Risk Factors Family Poverty Structural Barriers to Sexual Health Education & Services; Education; & Employment Family Violence Attitudes Towards & Intention of Pregnancy Risky Behaviors & Relationships Protective Factors Access to Contraception & Higher Education Strong Familial, Community, Religious, Spiritual, & Cultural Connections Individual Behaviors (extracurricular & educational focus; delayed sexual initiation)

Department of Behavioral and Community Health Discussion

Addressing Teen Pregnancy among Native Hawaiian Youth Risks similar to other disparity groups; some unique resiliency factors Impact of Poverty Access to Economic and Educational Opportunities Destructive Effects of Family Violence (both IPV and child maltreatment) and Substance Use Economic Solutions Affordable housing, enhancing public education, college pipeline programs, entrepreneurship Sexual Health Education & Healthcare Access Recent “opt in” converted to “opt out” policy for sex ed in middle schools Strengthening Cultural Solutions, Connections, & Intergenerational Context Kupuna (elders) Culture-based activities (e.g., paddling, working in the lo‘i) Risks similar to other disparity groups; some unique resiliency factors Impact of Poverty Access to Economic and Educational Opportunities Destructive Effects of Family Violence (both IPV and child maltreatment) Economic Solutions - affordable housing, enhancing public education, college pipeline programs, entrepreneurship Sexual Healthcare Access - Sexual health education linked to access Intergenerational Context: Kupuna (elders) Cultural Solutions #APHA2017 @LizAparicio22

Thank You! Elizabeth Aparicio aparicio@umd.edu #APHA2017 @LizAparicio22