Adolescent pregnancy is one family planning issue that is being addressed by initiatives under the Healthy People 2020. Adolescent or teen pregnancy is defined as pregnancy in females aged 19 years or younger (UMMC, 2011). Baseline figures show that in 2005, there were 40.2 pregnancies for every 1,000 girls between 15 and 17 years old and 116.2 pregnancies for every 1,000 girls between 18 and 19 years old (ODPHP, 2016). This issue needs to be addressed because of the physical, social, and economic consequences to young girls, their children, their families, and society. Teens have a higher risk of serious complications associated with pregnancy, and their infants are more likely to be born premature and with low birth weight (UMMC, 2011). Family members are also often involved in the care of the teen and her infant. Teen pregnancy is a major reason for academic underachievement which negatively affects future employability, income, and socioeconomic status (NCSL, 2016). The impact extends to the teens’ children creating a cycle of poverty. Finally, losses in tax revenue from teen mothers’ inability to earn higher incomes and the costs of related health and foster care can cost $9.4 billion annually (CDC, 2015).
Target Population and Setting
The target population of the FP-8.2 objective in Healthy People 2020 is to decrease the rate of teen pregnancies in females between 18 and 19 years. Adolescents of this age range are typically in senior high school and are expected to be sexually experienced. This population of young women has already reached legal age and able to provide informed consent without restrictions such as the need for parental notification or consent in relation to family planning interventions including the use of artificial contraceptives (Guttmacher Institute, 2016).
The setting is a community health center providing primary care to an inner city neighborhood with a sizeable population of African Americans. It serves as a safety net to low-income individuals and families. Services include family planning services and the assessment and treatment of sexually transmitted infections to adolescents and adults. A university nursing program and a community-based organization partnered to make the health center a possibility. It was initially funded by a 2-year federal grant and is now funded by a private non-profit organization.
Application to Advanced Practice
Advanced practice nurses (APNs) play an important role in helping the nation achieve a reduction in the rate of adolescent pregnancy. APNs possess the knowledge and skills to provide reproductive health education and counseling to adolescent girls, conduct screenings and assessments, and recommend appropriate types of contraceptives taking into consideration individual client preferences and needs (Taylor & James, 2011). By establishing rapport, building trust, collaborating with the client, and making using of evidence-based practice, APNs are able to provide services that are effective and acceptable. Aside from direct care, APNs employ their leadership, communication, collaboration, planning, and implementation skills in designing reproductive health programs that will benefit female adolescents and prevent early pregnancy (Boonstra, 2015). In addition, APNs are capable of advocacy such as influencing the policy process in order to bring about legislation, policies, and programs that support adolescents’ reproductive health (Kuzma & Peters, 2015).
Literature Review
Preventing adolescent pregnancy in a community health center setting requires employment of evidence-based interventions to help guarantee optimal outcomes. Margolis and Roper (2014) detailed the 3-year evaluation of the federally funded Teen Pregnancy Prevention Program (TPPP) which aimed for the replication of evidence-based, medically accurate, and appropriate for age interventions supported by robust evaluation studies. The TPPP had five key components – community mobilization, evidence-based programs, improved adolescent access to reproductive health care and contraceptive services, stakeholder education, and partnering with diverse communities (CDC, 2016).
First, the authors found that replication programs were ready for implementation when core components intended to achieve program objectives were clearly specified (Margolis & Roper, 2014). This means that for educational interventions, the content of reproductive health education, the teaching strategy or pedagogy, and the learning environment should be delineated. Second, the replication program must be guided by a theory or model to outline how it will work to attain the defined outcomes (Margolis & Roper, 2014). Third, the provision of reproductive health education should be structured by a curriculum and a facilitator guide (Margolis & Roper, 2014). Fourth, tools to monitor fidelity or adherence to the original replication program design should be selected to enable progress monitoring and quality improvement (Margolis & Roper, 2014).
There were 4 programs that fulfilled the filter criteria which were “sexuality education” for program type, “female” for target population, and “contraceptive use” and “pregnancy” or “birth” for outcomes. Only 2 of the 4 programs were selected for the literature review as they included sexually active teens aged 18-19 (Jemmott et al., 2005; Morrison-Beedy et al., 2013). The selected programs were based on social cognitive theory. The proportion of participating low-income African American teens ranged from 68% to 69% (Jemmott et al., 2005; Morrison-Beedy et al., 2013). The 2 programs were evaluated through high-quality randomized controlled trials (RCTs) in community center and/or clinic settings and scored 8 out of 8 in terms of implementation readiness (US DHHS, 2016).
The selected programs were called Sisters Saving Sisters (Jemmott et al., 2005) and Health Improvement Program for Teens (HIP Teens) (Morrison-Beedy et al., 2013). The key interventions were sexual risk reduction education delivered by trained facilitators to groups of 2-10 and 6-9 girls, respectively, with the use of curriculum materials. The Sisters program consisted of one 250-minute session (Jemmott et al., 2005) while the HIP program consisted of 4 120-minute sessions on a weekly basis (Morrison-Beedy et al., 2013). In addition, the HIP program added 2 booster sessions of 90-minute durations at 3 and 6 months after the intervention for reinforcement purposes (Morrison-Beedy et al., 2013). Jemmott et al. (2005) added the promotion of cultural and gender pride.
Jemmott et al. (2005) randomized participants into 2 intervention groups – one received an information-based intervention and the other a skills-based intervention. Morrison-Beedy et al. (2013) provided only a skills-based intervention. Both studies used general health promotion information as control intervention. Common information given to participants pertained to sexual risks such as unprotected sex and multiple sexual partners and teens responsibility for risk reduction. Information was also tailored based on specific teen concerns (Morrison-Beedy et al., 2013) and specific misconceptions about and barriers to risk reduction (Jemmott et al., 2005). Further, demonstrations by the facilitator or a video were provided in relation to condom use and interpersonal and other skills (Jemmott et al., 2005; Morrison-Beedy et al., 2013).
Activities were interactive, such as through games and group discussions, and the skills-based interventions promoted teens’ experiential learning of various skills (Jemmott et al., 2005; Morrison-Beedy et al., 2013). Participants learned problem-solving, interpersonal, communication, self-management, and negotiation skills by discussing how to overcome barriers to sexual risk reduction, practicing correct condom use on anatomical models, and role-playing the other skills (Jemmott et al., 2005; Morrison-Beedy et al., 2013). How to negotiate the use of a condom with a sexual partner was one topic of role-play. Even though a study by Peipert et al. (2012) showed that implants and IUDs were the most effective contraceptives, the focus on condoms is supported by statistics showing that 59.1% of teens aged 15-19 years used it for contraception in their most recent intercourse (Kaiser Family Foundation, 2014). Nineteen percent use birth control pills and only 1.6% use implants or IUDs (Kaiser Family Foundation, 2014). Moreover, the Sisters program was for both pregnancy and STI prevention warranting the promotion of condom use.
Both RCTs measured the rates of unprotected sex and the number of sexual partners presently or in the last 3 months (Jemmott et al., 2005; Morrison-Beedy et al., 2013). In addition, Morrison-Beedy et al. (2013) measured the rate and frequency of vaginal sex. Jemmott et al. (2005) also measured the rate of STI. There was a decline in the self-reported number of days wherein participating adolescents in the Sisters program had unprotected sex (Jemmott et al., 2005) and the rate of unprotected vaginal sex (Morrison-Beedy et al., 2013) at 12 months and six months post-intervention, respectively. In both studies, adolescents reported a significantly lower number of sexual partners. Morrison-Beedy et al. (2013) further found a reduction in the rate and frequency of vaginal sex. Jemmott et al. (2005) found a lower rate of STI.
Research-Based Guideline
The following guidelines are useful in the design and implementation of a community health center-based adolescent pregnancy prevention intervention targeting female low-income, sexually active teens aged 18-19 in a largely African-American neighborhood. The intervention fulfills the evidence-based program and reproductive health care access components of the TPPP.
Intended Outcomes
The intervention aims to reduce the adolescent pregnancy baseline rate by at least 5%. It also aims to increase the use of contraceptives, including condoms, among teens by 15% from the baseline thereby reducing the rate of unprotected. The intervention will further reduce the number of sexual partners and the frequency of sex within the last 3 months by 7% and 10%, respectively. Implementation is expected to contribute to the body of evidence supporting the HIP Teen and Sisters Saving Sisters models of prevention. It will also establish a baseline for the level of teen satisfaction with the intervention.
Evaluation Plan
Evaluation will focus on the outcomes and process. The baseline incidence of primary pregnancy and number of sexual partners, frequency of sexual intercourse, rate of unprotected sex, and contraceptive use for the last 3 months as well as incidence of STI will be measured using data from teen self-reports and medical records. Self-reports will be obtained via questionnaires. These outcomes will again be measured during follow-ups which will be conducted by phone for practicality purposes. The baseline and post-intervention measures will be compared to determine significant statistical differences. An increase in contraceptive use and safe sex and a decline in all the other outcomes signify effectiveness.
In regard to process, data on the number of clients who attended the first session, rate of intervention completion and attrition, rate of facilitator training completion, facilitator fidelity to manual, and adolescent satisfaction will be obtained. In addition, qualitative feedback needs to be obtained from participating teens to complement the quantitative data and generate a richer picture of intervention impact. The open-ended questions will inquire about the positive and negative aspects of their experience and what they think are needed for further improvement.
References
Boonstra, H.D. (2015). Meeting the sexual and reproductive health needs of adolescents in school-based health centers. Guttmacher Policy Review, 18(1), 21-26. Retrieved from https://www.guttmacher.org/sites/default/files/article_files/gpr1802115.pdf
Centers for Disease Control and Prevention (CDC) (2015). Sexual risk behaviors: HIV, STD, and teen pregnancy prevention. Retrieved from http://www.cdc.gov/healthyyouth/sexualbehaviors/
Centers for Disease Control and Prevention (CDC) (2016). Community teen pregnancy prevention initiatives. Retrieved from http://www.cdc.gov/teenpregnancy/prevent- teen-pregnancy/
Guttmacher Institute (2016). An overview of minor’s consent law. Retrieved from https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_OMCL.pdf
Jemmott, J. B., Jemmott, L. S., Braverman, P. K., & Fong, G. T. (2005). HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: A randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 159, (5) 440–449. doi:10.1001/archpedi.159.5.440.
Kaiser Family Foundation (2014). Sexual health of adolescents and young adults in the United States. Retrieved from http://kff.org/womens-health-policy/fact-sheet/sexual- health-of-adolescents-and-young-adults-in-the-united-states/
Kuzma, E.K., & Peters, R.M. (2015). Adolescent vulnerability, sexual health, and the NP’s role in health advocacy. Journal of the American Association of Nurse Practitioners, Epub ahead of print. doi: 10.1002/2327-6924.12331
Margolis, A.L., & Roper, A.Y. (2014). Practical experience from the Office of Adolescent Health’s large scale implementation of an evidence-based teen pregnancy prevention program. Journal of Adolescent Health, 54, S10-S14. http://dx.doi.org/10.1016/j.jadohealth.2013.11.026
Morrison-Beedy, D., Jones, S.H., Xia, Y., Tu, X., Crean, H.F., & Carey, M.P. (2014). Reducing sexual risk behavior in adolescent girls: Results from a randomized controlled trial. Journal of Adolescent Health, 52, 314-321.
http://dx.doi.org/10.1016/j.jadohealth.2012.07.005
National Conference of State Legislatures (NCSL) (2016). Postcard: Teen pregnancy affects graduation rates. Retrieved from http://www.ncsl.org/research/health/teen-pregnancy- affects-graduation-rates-postcard.aspx
Office of Adolescent Health (OAH) (2016). Evidence-based TPP programs: Key resources. Retrieved from http://www.hhs.gov/ash/oah/oah- initiatives/tpp_program/db/index.html#
Office of Disease Prevention and Health Promotion (ODPHP) (2016). Family planning. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/family- planning/objectives
Piepert, J.F., Madden, T., Allsworth, J.E., & Secura, G.M. (2012). Preventing unintended pregnancies by providing no-cost contraception. Obstetrics & Gynecology, 120(6), 1291-1297. doi: http://10.1097/AOG.0b013e318273eb56.
Taylor, D., & James, E. A. (2011). An evidence-based guideline for unintended pregnancy prevention. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(6), 782– 793. http://doi.org/10.1111/j.1552-6909.2011.01296.x
United States Department of Health and Human Services (US DHHS) (2016). Teen pregnancy prevention evidence review. Retrieved from http://tppevidencereview.aspe.hhs.gov/EvidencePrograms.aspx
