1. 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

2. 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

3. 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.

4. 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, 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

5. 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?

6. Department of Behavioral and Community Health
Method

7. 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

8. 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
version

9. 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

10. 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)

11. 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

12. 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)

13. 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

14. Method: Integration of Findings Phase
Findings were then integrated:
Considered in relation to one another
Used to create a final theoretical model

15. Department of Behavioral and Community Health
Results

16. 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

17. 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%)

18. 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%)

19. 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

20. 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.”

21. 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.”

22. 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)

23. Department of Behavioral and Community Health
Discussion

24. 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

25. Thank You! Elizabeth Aparicio aparicio@umd.edu