Maternal and Child Health Journal, Vol. 2, No. 1, 1998

Perceptions of Motivators and Barriers to PublicPrenatal Care Among First-Time and Follow-UpAdolescent Patients and Their Providers

Sarah E. Teagle, MA., Dr.PH.,1,3 and Claire D. Brindis, Dr.P.H.2

Objectives: To compare perceptions of the motivators and barriers to obtaining public prenatalcare from the perspectives of pregnant adolescents coming for first-time and follow-up ap-pointments, as well as among those of their prenatal care providers. Method: The patientsample consisted of 250 consecutive, adolescent, public prenatal patients coming to one ofthe 5 prenatal clinics in one county in Arkansas. Patient responses were analyzed by ap-pointment status (first-time vs. follow-up visitors). Sixteen providers at the same public pre-natal clinics were also interviewed using the same survey instrument. Results: We observedstriking differences between patients and providers with respect to their perceptions of boththe motivators and barriers to prenatal care. Adolescents reported "concern over the healthof their baby" as a primary motivation, while providers identified adolescents' "concern overtheir own health" as the most important reason. With regard to barriers, adolescents weremore likely to identify system-related barriers (e.g., lack of finances and transportation, andwaiting time for appointments), while providers were more likely to identify personal barriers(e.g., feeling depressed, fear of procedures, and needing time to deal with problems at home).Patients and providers agreed, however, that fear of procedures and not wanting to be preg-nant were important barriers to care. Conclusions: The differences in perceptions betweenadolescents and their prenatal care providers suggest that poor patient-provider communi-cation may represent one of the single most important nonfinancial barriers to care. Possibleexplanations for inadequate patient-provider communication as well as solutions to improvetheir clinic interactions are discussed.

KEY WORDS: Adolescent pregnancy; prenatal care; service access; patient-provider communication;participatory decision making.

INTRODUCTION

The prenatal care visit may represent a uniqueopportunity for prevention intervention, particularly

1Cecil G. Sheps Center for Health Services Research, Universityof North Carolina at Chapel Hill.

2Center for Reproductive Health Policy Research, Institute forHealth Policy Studies, and Department of Pediatrics, both at theUniversity of California at San Francisco.

3Correspondence should be directed to Sarah E. Teagle, Dr.P.H.,Cecil G. Sheps Center for Health Services Research, Universityof North Carolina at Chapel Hill, 725 Airport Road, CB No.7590, Chapel Hill, NC 27599-7590; e-mail: sarah_teagle@unc.edu

among hard-to-reach populations, such as pregnantadolescents. Studies have repeatedly documented thepositive association between prevention counselingand improved birth outcomes (1-4). For many ado-lescents, pregnancy poses a crisis and a time of reck-oning, and consequently a willingness to makepositive changes. For instance, studies have shownthat pregnant adolescents, even more so than preg-nant adults, abstain from or dramatically reduce sub-stance use and other behaviors during pregnancy (5,6). In addition, from a purely logistical standpoint,the prenatal care visit may represent one of the fewplaces to reach pregnant adolescents, because many

15

1092-7875/98/0300-0015$15.00/0 C 1998 Plenum Publishing Corporation

16 Teagle and Brindis

drop out of school before or when they find out theyare pregnant (7).

Despite the unique prevention opportunities as-sociated with the prenatal visit, many pregnant ado-lescents still receive no prenatal care, are slow toinitiate care, or fail to comply with their follow-upappointments once they have entered the service sys-tem (8). Among pregnant adolescents, inadequateprenatal care creates a situation of double jeopardywith regard to risk of poor birth outcomes becausetheir young age already puts them at risk (9, 10).Based on national birth certificate data, approxi-mately 10% of pregnant adolescents obtained no orlate prenatal care, as compared with 3% of pregnantwomen in their thirties (11). Once they initiate care,pregnant adolescents also tend to have higher no-show rates for appointments as compared with adults(12).

Knowledge of the barriers—and alternativelythe motivators—that influence pregnant adolescents'participation in prenatal care represents an impor-tant first step in developing prevention interventionsand improving service access. Numerous barriers toprenatal care have been identified in the literature,and can be broadly defined as either personal (e.g.,demographic and psychosocial characteristics) or sys-tem related (7, 13). Young age (14, 15), multiparity(14, 16), low educational status, poverty, being single,and minority status (17, 18) have been associatedwith inadequate or no prenatal care. Personal barri-ers to prenatal care among adolescents include thefollowing: depression (18, 19), denial of or ambiva-lence toward pregnancy or pregnancy "unwanted-ness" (14, 20, 21), fear of parents finding out (22),and fear of physicians and of medical procedures (23,24). The predominant system-related barriers to pre-natal care among adolescents include lack of trans-portation and finances, inconvenient clinic hours,clinic waiting time, and not knowing where to go forcare (15, 18, 22, 24, 25).

However, there are several weaknesses in thebarriers literature. One weakness is the lack of a dis-tinction made between barriers experienced by preg-nant women coming for their first visit and thosecoming for a follow-up appointment. Rather, existingresearch has focused on factors associated with eitherno prenatal care, late initiation of care, or follow-upappointment compliance. None of the studies com-pared barriers identified by first-time vs. follow-uppatients. This may be a significant omission, giventhat the literature on access to health care among

nonpregnant adolescents documents that the numberand type of barriers depend on previous visit history(26). Another common weakness in this type of re-search is poor recall among respondents, becausewomen are most commonly interviewed in the earlypostpartum period, as opposed to during their preg-nancy. Many postpartum women are unable or un-willing to recall their behaviors during pregnancy,particularly if their infant was born with any compli-cations.

A third weakness is that most studies designedto identify barriers to prenatal care are based on datacollected from prenatal patients or providers but,with few exceptions, not both. In a study by Wellsand colleagues (12), adolescent patients' and theirproviders' perceptions of risks and service needswere compared and the lack of congruence betweenthe two groups was found to be associated with poorappointment adherence. Similarly, in a study by Avedand colleagues (27), stark contrasts were observed inthe perceptions of the value of prenatal care amonga sample of low-income, minority prenatal patientsand a focus group of their physicians. In neitherstudy were patients and providers asked an identicalset of questions about barriers, and only the formerincluded an adolescent population.

One response to this dilemma is to obtain mul-tiple viewpoints. This strategy has been used formany years in community needs assessments gener-ally (28), but rarely in studies of service needs amongspecific clinic populations. There are a number of po-tential advantages to such an approach. A variety ofopinions about a problem may minimize the likeli-hood of misdiagnosing the problem and aid in de-fining the number and types of solutions. Obtainingmultiple perspectives on a problem may also helpidentify areas where various stakeholders differ intheir perceptions of the nature and scope of theproblem. The differences, in turn, point to potentialbarriers to implementing service recommendations.One specific contribution to prevention counseling inclinic settings may be to improve patient-providercommunications. Factors related to the patient-provider relationship, and the ability of this dyad tocommunicate more productively, have been found tobe very important in determining whether or notadequate or appropriate intervention services werereceived (29).

The present study was designed to obtain view-points from adolescents as well as from their prenatalcare providers by using identical patient and provider

Perceptions of Motivators and Barriers 17

surveys. The purpose of this study was twofold. First,we compared perceived motivators and barriers topublic prenatal care among pregnant adolescentscoming for their first prenatal care appointment andthose coming for a follow-up visit. Second, we com-pared the motivators and barriers identified by thesetwo groups of adolescents to those identified by theirprenatal care providers.

METHOD

Sample Selection

The patient sample consisted of 250 adolescent,public prenatal patients interviewed over 13 months(November 1993 through December 1994). In orderto be eligible, adolescents had to be at least 12 weekspregnant, between the ages of 15 and 19, and Eng-lish-speaking. Over the study period, consecutiveadolescent patients coming to one of the five publicprenatal clinics in one county in Arkansas were askedto participate. The study county included the City ofLittle Rock, and represents the major metropolitanarea in the state. The prenatal clinics included themain health department clinic (Pulaski Central), theone school-based clinic (Central High School), andthree smaller health department clinics located onthe outskirts of the study area (College Station, Jack-sonville, and North Little Rock clinics). In additionto the school-based clinic, the Pulaski Central clinicdedicated a specific time each week to serving preg-nant adolescent patients. Because some of the studysites had identical clinic hours, the timing of data col-lection varied across clinics. Interviews were collectedat each site for approximately two and a half months(an additional month and a half was spent at PulaskiCentral). During recruitment, no attempt was madeto distinguish between new patients (22% of the totalsample) and follow-up patients (78%). For the pur-pose of this study, however, first-time and follow-uppatients were separated, based on the literature sitedabove indicating that the motivators and barriers per-ceived by these two groups of pregnant patients maydiffer (14, 15). First-time patients were defined asthose coming to the clinic for their first prenatal visit.Follow-up patients were defined as those coming fora second or subsequent appointment. Participants re-ceived a $15 gift certificate to a local merchant if theycompleted the interview.

The response rate was 98%. Overall, the samplerepresented approximately 79% of all adolescent pub-lic prenatal patients in the county during the studyperiod. Because of "block" appointment scheduling inmost of the clinics, some eligible patients were missedbecause the interviewer was conducting an interviewat the time another patient was available to be inter-viewed, accounting for approximately 10% of all pub-lic prenatal patients. The remaining 11% were thosewho lived in the farthest locales of the study countyor, because of Medicaid "presumptive eligibility,"opted to obtain their prenatal care in a private clinic.

The provider sample included a conveniencesample of 16 health providers working at the samefive public prenatal clinics. The first author (Teagle)conducted all the provider interviews between Apriland July 1994. A minimum of two providers were in-terviewed at each clinic, with all additional interviewsoccurring among providers at the Pulaski Centralclinic, the most heavily staffed clinic in the study re-gion. The provider sample represented approxi-mately 69% of all providers employed at the clinics.The only eligibility criterion was a minimum of oneyear's work experience at the public prenatal clinic.The response rate was 100%. Seven individuals didnot meet the eligibility criterion.

Data Collection Protocol

Patient information was collected through 30-minute, in-person, anonymous interviews. The firstauthor (Teagle) conducted approximately 85% of theinterviews. During the first three months of data col-lection at the largest clinic (Pulaski Central), threenurse practitioner volunteers also conducted inter-views. These volunteers were completing a researchpracticum requirement in their graduate program.They were trained beforehand and met periodicallywith the principal investigator throughout the three-month period. The interviews were conducted at theprenatal clinics at the time of the visits. All interviewstook place in a private room or cubicle, away fromthe hub of clinic activity. In-person interviews withproviders required approximately 30 minutes to com-plete, and took place during nonclinic times at theclinic where the provider worked. The provider sur-vey was reviewed by an expert panel, and then pre-tested by the principal investigator on three providers(two pediatricians and one nurse practitioner) out-side of the study area before it was used in the pre-sent study.

18 Teagle and Brindis

Measurement of Main Study Variables

The patient interview included questions on basicdemographic background, current pregnancy andpregnancy history, and patients' perceptions of bothmotivators and barriers to obtaining prenatal care.Basic demographic information included ethnicgroup, age, marital status, school attendance status,and primary source of income. Pregnancy-relatedquestions included parity, weeks into pregnancy, and"wantedness" of current pregnancy. Among provid-ers, background information was collected on gender,ethnicity, education, and years of work experience.

The items on patients' and providers' percep-tions of motivators and barriers to prenatal care wereselected from an instrument that was developed byLia-Hoagberg and colleagues (13), and used with asimilar population of pregnant adolescents. Based onthe 250 observations used in the present study, wecalculated a Cronbach's alpha value of 0.71 for thebarrier items and 0.78 for the motivation items, in-dicating adequate internal consistency across items ineach subset. The section on perceived motivatorsconsisted of three parts. The first part included anopen-ended question to allow each respondent to de-scribe in her own words what motivated her to cometo the clinic in the first place. In the second part,each respondent was asked to rate four motivators(i.e., "You wanted to be sure the baby was healthy;""You had a health problem;" "You were not feelingwell;" and "Your family and friends said you should")on a 4-point Likert scale (1 = Very big reason; 4 =Not a reason at all). Due to small cell sizes in thefour response categories for the motivation items(and the barrier items) for this study, we collapsedthe values into two groups (1 = motivator; 0 = nota motivator). Lastly, adolescents were asked to iden-tify the most important motivator.

The section on perceived barriers also consistedof three parts. The first part included 13 items re-garding potential barriers to prenatal care (referred

to as "problems" in the actual interview). Barrierswere categorized as either personal or system re-lated. Table I lists the 13 barriers.

Each respondent was asked to rate how muchof a problem each item was for her on a 4-point Lik-ert scale (1 = Very big problem; 4 = Not a problemat all), again collapsed into two groups for this analy-sis. Second, respondents were asked to identify thebiggest problem for them. Third, an open-endedquestion was asked to determine, in the case of pa-tients, if they had experienced any other barriers and,in the case of providers, if they knew of any otherbarriers experienced by adolescents that were notmentioned in the above list. All data-collection meth-ods involving adolescents were approved by the in-stitutional review boards of the Arkansas StateDepartment of Health and the University of Arkan-sas for Medical Sciences.

Data Analysis

The sociodemographic profile of the sample offirst-time adolescent patients was compared with thefollow-up patients, using standard bivariate statistics,including chi-squares and t-tests. To compare moti-vations for seeking prenatal care among the first-time and follow-up adolescent patients and theirproviders, we compared the frequencies of each ofthe four motivation items using Mantel-Haenszel chi-squares. Next, to compare motivation across patientsand providers, we pooled all patients together andcompared their responses to those of their providersfor each of the four motivation items using Fisher'sexact tests.

To assess patients' and providers' responses tothe barrier items, first we compared first-time andfollow-up patients' responses to each of the 13 items,by running Mantel-Haenszel chi-squares. Second, weran a t-test to see if there were any differences inthe mean number of barriers reported among first-

Table I. Personal and System Barriers

Personal

Felt depressed that dayFear of health professionalsFear of proceduresNot wanting to be pregnantNeeding time to deal with family barriersFear of parents finding out

System

Not knowing where to goToo hard to get an appointmentNot knowing how to payWaiting time for appointmentClinic too far awayNo way to get thereNo time (from school or work)

Perceptions of Motivators and Barriers 19

time and follow-up adolescent patients. Next, wecompared providers responses with those of all pa-tients using Mantel-Haenszel chi-squares. Finally, weran separate frequencies for the variable describingthe "most important problem" (13 possible responsevalues) for first-time patients, follow-up patients, andproviders separately; and recorded the highest fre-quency response for each group.

RESULTS

Patient and Provider Profiles

A sociodemographic profile of the sample popu-lation of 250 pregnant adolescents is presented inTable II. Adolescents were predominantly African-American, primiparous, and single. Most were com-ing for a follow-up appointment (78%). The samplewas evenly distributed across the five ages. On aver-age, adolescents were 21 weeks into their pregnancyat the time of the interview. About half of the ado-

Table II. Sociodemographic Profile of Pregnant Adolescents

Characteristics

Non-whiteSingleAge (15-17 years)School statusa

Source of financialsupport (parent)

PrimiparousGestation, weeks

(SD)Unwanted pregnancy

Totalsample

(N = 250)

60%81%58%54%

51%75%*21.3(7.58)74%

First-timepatients

(N = 54)

55%81%57%45%

51%81%*17.12(8.90)76%

Follow-uppatients

(N = 196)

61%80%59%49%

52%69%*25.5(7.88)72%

aFigure represents the percent of non-graduated adolescents whoare not currently in school.

*p = .05.

lescents who were in Grades 12 or lower indicatedthat they were not in school (nor in a home-schoolprogram) at the time they were interviewed. Mostadolescents indicated that they did not want to bepregnant.

Nearly all of the providers were female andwhite (92% for both). Over half were nurses. Therest of the sample included two physicians, three so-cial workers, and two nutritionists. The average num-ber of years providers had been working in the publicprenatal clinic at the time they were interviewed was5.7, but ranged from one to 20 years.

Patients' and Providers' Perceptions of Motivators

There were no significant differences in re-sponses to the four motivation items across the twopatient groups. Therefore, we listed responses amongall patients combined and compared them to theproviders (see Table III). Nearly all first-time patients(97%) and all follow-up patients (100%) indicatedthat concern over the health of their baby was theprimary motivation for obtaining prenatal care. Ap-proximately half of first-time and follow-up patientsindicated that a family member or close friend urgedthem to obtain prenatal care. "Not feeling well" wasreported by 42% of the first-time patients and 38%of the follow-up patients. Only one-third from bothgroups indicated that a personal health problem wasa reason for obtaining prenatal care.

As illustrated in Table III, there were significantdifferences in the patients' and providers' responses.Nearly all pregnant adolescents indicated that theycame to the clinic out of concern for the health oftheir baby, whereas only a third of the providers per-ceived this as a motivating factor among their ado-lescent patients. On the other hand, most providersthought adolescents sought prenatal care primarilyout of concern over their own health or because they

Table III. Patients' and Providers' Perceptions of Motivators to Seeking Prenatal Care

Motivator

Concern over health of baby

Health problem

Not feeling well

Urging by family and friends

Patients(N = 250)

99%

29%

41%

51%

Providers(N = 16)

33%

86%

96%

100%

Fisher'sexact test

16.3

21.3

19.8

13.5

P Value

.001

.001

.001

.001

20 Teagle and Brindis

were not feeling well. Adolescents themselves rarelyidentified these reasons. All providers indicated thaturging by family and friends was a primary motivatorfor adolescents in obtaining prenatal care, as com-pared with only half of the adolescent self-reports.

When asked to rate the most important motiva-tion, concern over the health of the baby was iden-tified by adolescents. In contrast, providers perceivedthat the most important motivation for their adoles-cent patients was concern over their own health.

Patients' and Providers' Perceptions of Barriers

The frequencies of first-time vs. follow-up pa-tients' responses to the barrier items as well as themean number of barriers mentioned are listed inTable IV Adolescents most frequently reported thefollowing barriers: not knowing how to pay for thevisit (44%), waiting time for appointment (33%), fearof procedures and not knowing where to go for care(30% each), transportation (22%), and fear ofproviders (17%). There were no significant differ-ences in the mean number of barriers identified be-tween first-time and follow-up patients; both groupsreported a mean of three.

As anticipated, we found some differences in per-ceptions between the two patient groups, though moreareas of similarities. Adolescents coming for the firsttime were significantly more likely to identify not

knowing how to pay for the visit as a barrier (63%),as compared with follow-up patients (39%). To exploreif age played an additional role in reporting a financialbarrier (not knowing how to pay for a visit), we con-ducted a stratified chi-square analysis by age of ado-lescent and found that adolescents in the 15- to17-year-old age group were significantly more likely toreport this as a problem as compared with older ado-lescents (chi-square = 9.51; p = .002). First-time pa-tients were also more likely to identify difficulty gettingan appointment as a barrier (17%), as compared withfollow-up patients (8%). Follow-up patients, on theother hand, were significantly more likely to identifynot wanting to be pregnant as a barrier (31%), as com-pared with first-time patients (18%).

With regard to the patient-provider comparison(see Table V), we found more differences than simi-larities. In 9 of the 13 barrier items, we observed sig-nificant differences across patient and providergroups in the proportion of people who reported theindividual barrier item. For instance, the vast major-ity of providers (71%) identified feeling depressedthat day as a barrier, while only 18% of the patientsmentioned this barrier. Closely related is our obser-vation that the mean number of barriers mentionedby the two groups differed significantly, with patientsidentifying half as many barriers (mean = 2.72; SD= 2.19) as providers (mean = 5.66; SD = 2.77).

Adolescents tended to identify system barriers asopposed to personal barriers. Four out of the top five

Table IV. Comparison of First-Time Patients' and Follow-Up Patients' Perceptions of Barriers to Prenatal Care

Barrier

PersonalFelt depressed that dayFear of health professionalsFear of proceduresNot wanting to be pregnantNeeding time to deal with family and other

problems before goingFear of parents finding out about pregnancy

SystemNot knowing where to goToo hard to get appointmentNot knowing how to pay for visitWaiting time for appointment too longClinic too far awayNo way to get thereNo time (from school or work)Mean no. of barriers (SD)

First-timepatients

(N = 54)

13%24%28%18%

19%20%

28%17%63%31%19%26%13%

3.18 (2.37)

Follow-uppatients

(N = 196)

19%16%31%31%

15%18%

26%8%

39%33%22%21%16%

2.96 (2.34)

X2 Statistic

1.021.991.583.31

0.320.12

0.063.40

16.410.00.380.490.361.02

P Value

.312

.158

.664

.069

.563

.730

.795

.065

.001

.761

.534

.483

.546

.892

Perceptions of Motivators and Barriers 21

Table V. Comparison of Patients' and Providers' Perceptions of Barriers to Prenatal Care

Barrier

PersonalFelt depressed that dayFear of health professionalsFear of proceduresNot wanting to be pregnantNeeding time to deal with family and other

problems before goingFear of parents finding out about pregnancy

SystemNot knowing where to goToo hard to get appointmentNot knowing how to pay for visitWaiting time for appointment too longClinic too far awayNo way to get thereNo time (from school or work)Mean no. of barriers (SD)

Patients(N = 250)

18%17%30%28%

16%18%

26%10%44%33%21%22%15%

2.72 (2.19)

Providers(N = 16)

71%43%86%57%

64%50%

36%7%

33%43%42%72%46%

5.66 (2.77)

Fisher'sexact test

23.615.51

20.10

20.448.25

0.580.120.710.563.41

16.999.50

16.90

P Value

.001

.030

.001

.022

.001

.004

.536

.590

.401

.561

.095

.001

.002

.001

most frequently mentioned barriers reported by ado-lescents were system related. In contrast, providerstended to perceive that personal barriers would bethe most frequently experienced by their adolescentpatients; all five of the top five barriers providersmentioned were personal barriers. In fact, the leastreported barriers among adolescents were personalbarriers. Our observation of what patients andproviders considered the most important barriersconfirmed our findings about the differences in typesof barriers mentioned. Among patients, financial bar-riers emerged as the most important problems,closely followed by transportation barriers, particu-larly among follow-up clients. Most providers (95%),on the other hand, perceived a personal barrier—notwanting to be pregnant—as the most important prob-lem.

The list of the most frequently mentioned bar-riers also differed between patients and providers. Incontrast to the five most frequently reported barriersamong adolescents listed above, providers mentionedthe following barriers: fear of procedures (86%),feeling depressed (71%), transportation problems(71%), needing time to deal with problems at home(64%), not wanting to be pregnant (57%), and fearof parents finding out (50%). However, patients andproviders did agree that two personal barriers (fearof procedures and not wanting to be pregnant) wereimportant barriers. Both were listed in the top five

most frequently mentioned barriers for patients andproviders.

DISCUSSION

The main strength of our study was that weasked patients and their providers an identical set ofquestions, a method that has rarely been used instudies on this topic. We were also able to separateresponses from adolescents coming for their first pre-natal care visit from those coming for a follow-up ap-pointment. By doing so, we were able to compareperceptions between these three groups. For both pa-tients and their providers, two barriers—fear of pro-cedures and not wanting to be pregnant—were listedin the top five most frequently mentioned accessproblems. Both barriers have been identified pre-viously (14, 21, 24) as important problems for ado-lescents. Other barriers commonly perceived by bothpatients and providers were transportation, finances,waiting time for appointment, and not knowingwhere to go—all of which have been identified pre-viously (15, 18, 22, 24). Furthermore, all of the abovebarriers—with the inclusion of fear of providers-were expressed by all patients, regardless of whetherthey were coming for the first time or not. In fact,fear of providers (sometimes described in thebroader literature as patients' dissatisfaction withtheir interactions with physicians) represents the

22 Teagle and Brindis

most important nonfinancial barrier identifiedamong nonpregnant adolescent patients (39), andpregnant adolescents and adults in prenatal care set-tings, as well as among a host of other diverse patientpopulations (23, 24, 30).

Our findings also parallel the existing researchbase in that the obstacles to entry into prenatal caremay differ markedly from those associated with con-tinued service use. For instance, not knowing how topay for visit is a problem, especially for first-time pa-tients. Once they have entered the service system,however, transportation problems and depression be-come more commonly experienced obstacles to care.

A more surprising finding was that patients andproviders not only differed in their perceptions, butthat they differed a great deal. And they differed interms of their views of the motivators and barriersto prenatal care. Adolescents' overriding motivatorwas their concern for the health of their babies, ashas been documented in previous studies (6). In con-trast, providers perceived that the most importantmotivator was adolescents' concern for their ownhealth.

Patients' and providers' perceptions of the bar-riers to care seemed to represent opposite poles ofa continuum with personal and system-related barri-ers at either end. Providers tended to identify per-sonal barriers, while adolescents most frequentlymentioned system barriers. Of the top five most fre-quently reported barriers among providers, four werepersonal; whereas among adolescents, three of thetop five barriers were system related. In addition,providers perceived that the most important barrierfor adolescents was fear of procedures, which wasthird on the list of barriers reported by patientsthemselves. On the other hand, adolescents, espe-cially first-time patients, reported that not knowinghow to pay for the visit was the most important,whereas providers viewed this barrier as one of theleast important.

These findings must be situated in the contextin which we observed them. First, we interviewedadolescents and prenatal care providers in LittleRock, Arkansas, a southern, semiurban region of theU.S. A small portion of eligibles were not inter-viewed; those who enrolled in Medicaid, but thenelected right away to obtain their prenatal care inthe private sector, usually because they lived on theoutskirts of the county and a private clinic was moreaccessible to them. Second, we did not interview ado-lescents who received no prenatal care. Approxi-

mately 12.5% of pregnant adolescents in PulaskiCounty received no prenatal care during the studyperiod. Nonetheless, we believe the current re-sponses are generalizable to other adolescents livingin similar settings, given our nearly 100% responserate and that our sample represented the vast ma-jority of pregnant adolescents seeking public prenatalcare in our sampling frame. Another potential limi-tation to the generalizability of our findings is thesmall sample of providers. However, we interviewedwell over the majority of providers (69%) who wereworking in the public prenatal clinics in the county.That one person conducted essentially all of the in-terviews also introduces the possibility of a systematicbias in the responses. On the other hand, our strat-egy allowed for greater consistency in data collectionand avoided the more serious problem of poor in-terrater reliability. Finally, a common weakness inthis type of research is poor recall among respon-dents. We minimized this problem by interviewingadolescents during their pregnancy, as opposed to themore frequently used method of postpartum inter-viewing. By shortening the time to recall, we in-creased response accuracy and avoided the problemof respondents' potential unwillingness right after de-livery (especially if their infant was having difficul-ties) to recall their feelings and behaviors duringpregnancy.

Despite these limitations, this study suggests animportant nonfinancial barrier to prenatal care, poorpatient-provider communication. While this barrierhas been alluded to in previous studies (e.g., thosereporting that fear of or dissatisfaction with providersis a key barrier to care), few studies have demon-strated the extent of the problem. Because most ofthe previous studies utilize a single-perspective de-sign, their research has not captured the often strik-ing differences in perceptions between the twogroups, which provide compelling evidence for poorpatient-provider communication.

When examining the broader literature on pa-tient-provider communication, one finds a small butgrowing research base that addresses the question ofwhy there might be significant differences in percep-tions between adolescents and their providers. Verylittle of this research has been conducted specificallyin the prenatal care setting (31), or among adoles-cent patients (32). Nearly all of the research concernspatient-physician communication, rather than that ofpatient-provider in general (33).

Perceptions of Motivators and Barriers 23

Across these diverse studies there seems to beagreement that the reasons for poor communicationmay fall into two broad categories that either indi-vidually or in combination may apply to adolescent-provider interactions. The first is that culturaldifferences between patients and providers may rep-resent an underlying cause for their diverse percep-tions. A number of studies have documented thatcultural and language differences represent impor-tant real and perceived obstacles to health care (34).In the present study, all but one of the providers areWhite, whereas the majority of patients (60%) areAfrican-American. Additional research among largerpopulations of providers of diverse ethnic back-grounds is needed to confirm our findings.

A second, perhaps more compelling, explanationfor our finding that adolescents perceptions differfrom those of providers may be related to the factthat they do not participate equally in the clinic en-counter. Research on treatment of chronic disease,for example, suggests that physicians who involvetheir patients in planning and treatment decision-making have better patient health outcomes thanthose who do not. For instance, in a study by Kaplanand colleagues on factors related to decreased par-ticipatory decision making (35), young age and mi-nority status were found to be significant predictors.Adolescents' lack of participation may be due to theirage and developmental status. It could also be re-lated to the fact that adolescents are not given achance to participate equally because providers arelikely to be trained in unidirectional, nonparticipa-tory clinical decision-making styles.

The literature suggests two possible explanationsfor the tendency for nonparticipatory decision mak-ing among adolescent patients and their providers.A number of studies have documented providers'lack of training and resulting unwillingness to discusspsychosocial problems with their patients (36). Manyproviders may also lack specialized training in ado-lescent health care (32). Simple and effective strate-gies to overcome these communication problemsinclude conducting the clinic visit in as private a set-ting as possible, assuring confidentiality of the visitat the outset, and explaining the disease transmissionrisks in the clinic setting (32). Specific strategies toassist providers in becoming "less dominant" in theirinteractions with patients in general have also beenidentified, and include the use of "illness diaries"(37) and "psychosocial registration sheets" (38). Alonger term solution may be to incorporate special-

ized education during providers' formal medi-cal/health care training to sensitize them to theunique concerns and health care service needs of theadolescents they serve.

The main finding of this study is that pregnantadolescents' perceptions of what motivates them toobtain prenatal care and what obstacles they face toget to their appointments are quite different from theperceptions of their prenatal care providers. Thesedifferences suggest that poor patient-provider com-munication may represent one of the single most im-portant nonfinancial barriers to care. Given theuniqueness of the prenatal care visit as an interven-tion avenue for this high-risk population of adoles-cents, developing service delivery strategies as wellas educational programs for providers to bridge thecommunication gaps will remain a high priority forthe field.

ACKNOWLEDGMENTS

The authors thank Arkansas Children's Hospitaland Bethany Christian Services in Little Rock fortheir financial support of this study; Joycelyn Eldersfor her assistance in gaining access to the study popu-lations; and Milton Kotelchuck for his guidance andencouragement in the design and editing of themanuscript.

Dr. Brindis' contributions were supported by agrant from the Maternal and Child Health Bureau,MCJ06A80, Health Resources and Services Admini-stration, Public Health Service, U.S. Department ofHealth and Human Services.

REFERENCES

1. Ershoff DH, Quinn VP, Mullen PD, Lairson DR. Pregnancyand medical cost outcomes of a self-help prenatal smokingcessation program in an HMO. Public Health Rep 1990;105:340-47.

2. Morgan C, Rosenbach M, Otsby E, Butrica B. Targeting spe-cial populations with drug abuse problems: Pregnant women.National Institute on Drug Abuse, Drug Abuse Research Series1991;l:123-43.

3. Kogan MD, Alexander GR, Kotelchuck M, Nagey DA. Re-lation of the content of prenatal care to the risk of low birthweight: Maternal reports of health behavior advice and initialprenatal care procedures. JAMA 1994;271:1340-44.

4. Sable MR, Herman AA. The relationship between prenatalhealth behavior advice and low birth weight. Public HealthRep 1997;112:332-39.

5. Cornelius MD, Day NL, Cornelius JR, Taylor PM, Richard-son GA. Drinking patterns and correlates of drinking amongpregnant teenagers. Alcohol Clin Exp Res 1993; 17:290-94.

24 Teagle and Brindis

6. McBride CM, Pine PL. Postpartum smoking relapse. AddicBehav 1990; 15:165-68.

7. Brown SS. Drawing women into prenatal care. Fam PlannPerspect 1989;21:73-80.

8. National Center for Health Statistics. Advance report on fi-nal natality statistics, 1988. Mon Vital Stat Rep 1990;29:2-4.

9. Fraser AM, Brockert JE, Ward RH. Association of youngmaternal age with adverse reproductive outcomes. N Engl JMed 1995;332:1113-7.

10. Cooper LG, Leland NL, Alexander G. Effect of maternalage on birth outcomes among young adolescents. Social Biol1995;42:22-35.

11. National Center for Health Statistics. Advance report of finalnatality statistics 1992. Mon Vital Stat Rep 1994;43:l-26.

12. Wells RD, McDiarmid J, Bayatpour M. Perinatal health be-lief scales: A cost-effective technique for predicting prenatalappointment keeping rates among pregnant teenagers. JAdo-lesc Health 1990;11:119-24.

13. Lia-Hoagberg B, Rode P, Skovholt CJ, Oberg CN, Berg C,Mullett S, Choi T. Barriers and motivators to prenatal careamong low-income women. Soc Sci Med 1990;30:487-95.

14. Young CL, McMahon JE, Bowman VM, Thompson DS. Psy-chosocial concerns of women who delay prenatal care. Fami-lies in Society 1990;September:408-14.

15. Goldenberg RL, Patterson ET, Freese MR Maternal demo-graphic, situational and psychosocial factors and their rela-tionship to enrollment in prenatal care: A review of theliterature. Women Health 1992;19:133-51.

16. Blankenson ML, Goldenberg RL, Keith B. Noncomplianceof high-risk pregnant women in keeping appointments at anobstetric complications clinic. South Med J 1994;87:634-8.

17. McDonald TP, Cobura AE Predictors of prenatal care utili-zation. Soc Sci Med 1988;27:167-72.

18. York R, Grant C, Gibeau A, Beecham J, Kessler J. A reviewof problems of universal access to prenatal care. Nurs ClinNorth Am 1996;31:279-92.

19. Scupholme A, Robertson EG, Kamons AS. Barriers to pre-natal care in a multiethnic urban sample. J Nurse Midwifery1991;36:lll-6.

20. Joyce TJ, Grossman M. Pregnancy wantedness and the earlyinitiation of prenatal care. Demography 1990;27:1-17.

21. Cartwright PS, McLaughlin FJ, Martinez AM, Caul DE,Hogan IG, Reed GW, Swafford MS. Teenagers' perceptionsof barriers to prenatal care. South Med J 1993;86:737-41.

22. Poland ML, Ager JW Olson JM. Barriers to receiving ade-quate prenatal care. Am J Obstet Gynecol 1987; 157:297-303.

23. Kalmuss D, Fennelly K. Barriers to prenatal care among low-income women in New York City. Fam Plann Perspect1990;22:215-8.

24. Kinsman SB, Slap GB. Barriers to adolescent prenatal care.J Adolesc Med 1992;13:146-54.

25. Baker TJ. Factors related to the initiation of prenatal carein the adolescent nullipara. Nurse Pract 1996;21:29-32.

26. Irwin CE, Millstein SG, Ellen JM. Appointment-keeping be-havior in adolescents: Factors associated with follow-up ap-pointment-keeping. Pediatrics 1993;92:20-3.

27. Aved BM, Irwin MM, Cummings LS, Findeisen N. Barriersto prenatal care for low-income women. West J Med1993;158:493-8.

28. McKillip J. Need analysis. Newbury Park, CA: Sage Publica-tions, 1987.

29. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE.Patient and visit characteristics related to physicians' partici-patory decision-making style. Med Care 1995;33:1176-87.

30. Institute of Medicine—Brown S, editor. Prenatal care: Reach-ing mothers, reaching infants. Washington DC: National Acad-emy Press, 1988.

31. Browner CH, Press N. The production of authoritativeknowledge in American prenatal care. Med Anthropol Q1996;10:141-56.

32. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE. In-fluence of physician confidentiality assurances on adoles-cents' willingness to disclose information and seek futurehealth care. JAMA 1997;278:1029-34.

33. Ginsburg KR, Menapace AS, Slap GB. Factors affecting thedecision to seek health care: The voice of adolescents. Pedi-atrics 1997;100:922-30.

34. Hornberger JC, Itakura H, Wilson SR. Bridging languageand cultural barriers between physicians and patients. PublicHealth Rep 1997;112:410-7.

35. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE.Patient and visit characteristics related to physicians' partici-patory decision-making style: Results from the Medical Out-comes Study. Med Care 1995;33:1176-87.

36. Ford S, Fallowfield L, Lewis S. Doctor-patient interactionsin oncology. Soc Sci Med 1996;42:1511-19.

37. Stensland P, Malterud K. New gateways to dialogue in gen-eral practice: Development of an illness diary to expand com-munication. Scand J Prim Health Care 1997;15:175-9.

38. DeValck C, Van de Woestijne KP. Communication problemson an oncology ward. Patient Educ Couns 1996;29:131-6.