Intervention

Table of Contents

Executive Summary ...............................................................................................................3

Health Issue ...........................................................................................................................4

Epidemiology Profile ............................................................................................................5

Existing Resources ................................................................................................................7

Evidence-based “Best Practices” and Interventions .............................................................9

Behavioral Profile ................................................................................................................11

Priorities and Recommendations .........................................................................................12

References.............................................................................................................................14

Appendix A: U.S. Department of Health and Human Services Identified Programs ……..16

Executive Summary

The United States teenage pregnancy rate is a complex public health issue impacting many adolescents and their families. Teenage mothers are at risk of diabetes, heart disease, substance abuse, low birth weight, high blood pressure, and a higher rate of infant mortality. Key factors impacting the teenage pregnancy rates include lack of contraceptives, lack of knowledge, and lack of open communication. In Los Angeles County, there is a deep concern among the high growing rates of Hispanic teenage pregnancies. Due to the high rates among Hispanic females, there is an immense necessity for the implementation of interventions and access to contraceptives. In order to resolve the high rates of teenage pregnancy in Los Angeles County, local healthcare providers have supported the need for over the counter non-emergency contraceptives and other safe sex practices. Another contributing factor is the lack of resources needed to educate teenagers about the importance of safe sex. Interventions implemented in Los Angeles County lack the proper funding needed to educate teenagers on safe sex and reproductive health which will guide them when making informed decisions. Limitations hindering teenagers from practicing safe sex is access to transportation, money to purchase condoms, or the judgement of others when visiting local clinics. Limitation can be decreased by equipping teenagers with the proper resources.

Health Issue  

Teenage pregnancy is a complex public health issue in the United States impacting 750,000 adolescents (ages 15–19), their families, their partner, and society (Johnson, Nshom, & Nye, 2010). The Center for Disease Control and Prevention (CDC) believes teenage pregnancy rates are high enough to raise a public concern (CDC, 2003). Teenage pregnancy is associated with individuals who become pregnant under the age of 18 (American Pregnancy Association APA, 2017).  Females begin their first menstrual period during puberty which ranges between 9 and 16 years of age (University of California, Santa Barbara, 2018). During puberty the pituitary gland, located in the brain, produces hormones which fuel the ovaries to produce female hormones such as estrogen (Dowshen MD, 2016).

Teenagers are at high risk of experiencing medical difficulties during pregnancy because a teenager’s body is very vulnerable (Dalby, Hayon, & Carlson, 2014). Risk factors during teenage pregnancy include low birth weight, anemia, high blood pressure which can lead to preeclampsia, and a higher rate of infant mortality (American Pregnancy Association [APA], 2017).  The US National Library of Medicine believes the United States high teen pregnancy rates are highly contributed by the lack of contraceptive use or improper used as elaborated in the Behavioral Profile. It has been proven that reducing unplanned pregnancies among teenagers is achievable through the access of free contraceptives and the promotion of other effective methods as discussed in the Intervention section (Dalby, Hayon, & Carlson, 2014).

A little less than half of high school females and males have had sexual intercourse (CDC, 2003). Females experience their first intercourse on average at age 17 while boys experience theirs at 16 (Guttmacher, 2010). In Los Angeles County (LAC), most live births every year are to women 19 and under (County of Los Angeles Public Health, 2015). Key risk factors related to teenage pregnancy include lack of contraceptives, lack of knowledge, and lack of open communication with their parent’s and partner as explained in the Behavioral Profile. There are many communities with extremely high teenage pregnancy rates. LAC has “hot spots”, such as Boyle Heights, which is predominantly Hispanic, where the rates are two to three times high than other neighborhoods (Gonzalez, 2012). The main concern are the teenage birth rates among Hispanic and non-Hispanic Blacks which have doubled in comparison to Non-Hispanic Whites (Donovan, 2015). Some Los Angeles high schools have teamed up to create programs that can decrease their teen pregnancy rate by offering access to condoms and information as elaborated in the Intervention section. A main approach to decrease pregnancy rates is implementing sexual education in schools which covers sexually transmitted infections and birth control options (Gonzalez, 2012).

Epidemiology Profile

The United States currently holds a teenage pregnancy rate that is much higher than any other industrialized nation (Sedgh, Finer, Bankole, Eilers, & Singh, 2015). Factors that could play a role in the teen pregnancy could be unfavorable socioeconomic conditions, such as low education, low-income levels, as well teenagers being in the welfare system (Penman-Aguilar, Carter, Snead, Kourtis, 2013). A recent study done showed that teenagers that come from areas with high poverty rates are more at risk of an unplanned pregnancy. (Garkwood, Gerassi, Johnson-Reid, Plax & Drake, 2015). In 2015 the birth rate of Hispanic teenagers were still two times higher than the rate for non-Hispanic white teenagers (Martin, Hamilton, Osterman, et al. 2017).  California’s Hispanic teenage birth rate was nearly two time higher than the national average birth rate in the state. That same year 72% of all teenage births in California were to Hispanic adolescents (Minnis, Marchi, Ralph, & Biggs et.al.).

Social factors, such as relationship with families and parents, play an important role in shaping teenagers’ attitudes toward childbearing and decisions regarding contraception use, particularly for Hispanic teenagers (Biggs, Ralph, Minnis et., al, 2010). In an article published by the Department of Health and Human Services studies showed that 79% of female teenagers and 84% of male teenagers did use a method of contraception the first time they had sexual intercourse (Martinez & Abma, 2015). Only half of sexually active Hispanic teenagers reported using a condom during their last sexual intercourse, and only 1 in 7 teenagers used birth control pills or other contraceptives (Wang & Singhal 2016).  Hispanics have been observed to have high levels of misinformation, particularly about the short-term and long-term effects of hormonal methods and overall method safety (Biggs, Ralph, Minnis Aron, et., al. 2010). Although more teenagers are getting knowledge about safe sexual intercourse there has also been a rise of the use of emergency contraceptive at least once has increased from 8% in 2002 to 22% in 2011-2013. (Martinez & Abma, 2015).

Pregnant teenagers, who are in their first years of high school, have a much lower chance of finishing high school than those who did not give birth. Only about 50% of teen mothers receive a high school diploma by 22 years of age, whereas 90% of women who did not give birth (CDC, 2017).  Babies born of teen mothers are also at risk of developing their own health issues. Compared with babies of older mothers, those born to teenagers are more likely to have lower birth weights, increased infant mortality, and if the child is female an even greater risk, she herself will become a teenage parent. (Langille, 2007). Teenage mothers are also at greater risk of developing depression this maternal depression has been characterized as a chronic, adverse experience that contributes to a toxic stress response in young children. Leading to developmental delays and serious health concerns later in life, such as diabetes, heart disease and substance abuse (Huang, Costeines, Kaufman, & Ayala. 2014).  

Existing Resources

Teenage pregnancy is public health issue that calls for the implementation of interventions and access to contraceptives in Los Angeles, California. As mentioned in the Epidemiology Profile section, contraceptive use is a barrier that many teenagers face (Martinez & Abma, 2015). Approximately 79% of female teenagers and 84% of male teenagers did not use any method of contraception during their first sexual intercourse (Martinez & Abma, 2015). Many American agencies, including the CDC have not stopped their efforts to gather data, analyze, create/implement programs, and fund intervention programs to help reduce the number of teenage pregnancies. In Los Angeles, teenagers have a variety of resources that offer contraception options. Some of the most well-known contraception Centers in Los Angeles are Planned Parenthood and the CVS minute clinic.

Although there are a few contraceptive clinics that teenagers can go to, there were not enough organizations that educate teenagers about safe sex in Los Angeles. The Division of Reproductive Health is the area of the CDC that focuses of specifically supporting organizations that promote health and safety among the teenage population (CDC, 2017). The Division of Reproductive Health is currently supporting three organizations that provide sexual and reproductive health services to the youth between 2015-2020. One of the programs supported and funded by the CDC’s Division of Reproductive Health is the Georgia Association for Primary Health Care, Inc. in Chatham County, Georgia (CDC, 2017). The program has partnered with local and federally qualified health centers, clinics, schools, etc. that provide education and information to teenagers about safe sex and access to reproductive health services. They developed a referral system to increase the number of teenagers targeted and have developed community awareness programs.

During a recent mock interview with the Ramona Opportunity High School health education coordinator, Ann Salazar, she stated that in a recent survey conducted in seven East Los Angeles high schools, approximately 73% of students between the ages of 14-17 did not have enough information about reproductive health or access to reproductive health services (Salazar, 2018).  The statistics called for action and the implementation of the Safe & Smart program that like the Georgia Association for Primary Health Care, Inc provides education and resources to teens in East Los Angeles. Teachers, counselors, healthcare providers, and staff of the East Los Angeles Planned Parenthood will be trained to communicate with teens, educate about the importance of safe sex, provide local contraceptive resources, and provide information about the new Safe & Smart referral system. Once the teens have had the opportunity to speak to one of the Safe & Smart educators, they will be given a referral slip that may be given to friends who may be in need of contraceptives. If the referral slip is brought back to any of the programs educators, the teen will be given a $5 Starbucks gift card. (See Appendix A for Interview Guide)

The Safe & Smart program will host two meetings per month to train all participating educators and to analyze the progress of the program. All educators will also have the opportunity to share the positive and negative areas of the program. In order to further evaluate the its effectiveness, a follow-up survey will be conducted at Ramona Opportunity High School on February 15, 2019. According to the program coordinator Susan Burke, there will be an extensive analysis of the teenagers who have gained knowledge of reproductive health services and access at school and in local clinics. There will also be an analysis of teenagers who were referred to clinics by friends who used the local community services. Susan Burke states that they have already seen an increased number of teenagers using the local clinic services.

Evidence Based “Best Practices” and Interventions

As mentioned in the Existing Resources section, approximately 229,715 babies were born to teenage mothers between the ages of 15-19 in 2015 (CDC). The statistics suggest that teen pregnancy is a public health issue in the United States and calls for the successful development of effective interventions. There are four programs that were implemented to educate teenagers about the importance of safe sex and the reduction of teen pregnancy. Positive Prevention PLUS is a school-based program that educates middle school and high school students about the importance of safe sex (Lachausse. R, 2015). Love Notes, takes a different approach and focuses on teaching adolescents how to build healthy romantic relationships (Barbee, Cunningham, Van Zyl, Antle, Langley, 2016); The program focuses on teaching teenagers how to love rather than abstain – teenagers learn the importance of safety, communication skills, decision making, and how family formation can impact children (Barbee, Cunningham, Van Zyl, Antle, Langley, 2016). Healthy Futures, is a current three-year program that encourages and empowers middle school students to avoid risky health, social, and psychological behaviors (Calise, Chow, Dore, O’Brien, Heitz, Millock, 2016). Lastly, All4you, is a program designed to reduce the number of teenagers who have unprotected intercourse. The Program teaches students the risks of unprotected intercourse such as risks of HIV, STIs, and unplanned pregnancies (Coyle, Kirby, Robin, Banspach, Baumler, Glassman, 2006).

Positive Prevention PLUS, Healthy Futures, and Love Notes all share similar models to build their curriculum. Healthy Futures program seeks to meet their curriculum and goal by providing knowledge, skills, and self-efficacy (Lachausse. R, 2015). Positive Prevention Plus uses the social cognitive as they understand that behavior change occurs through several constructs such as observation learning, behavioral capability, and self-efficacy (LaChausse, 2015). Love Notes also seeks to teach teenagers the importance of morals and self-efficacy (Barbee, Cunningham, Van Zyl, Antle, Langley, 2016). In a study conducted by the U.S Department of Public Health in April 2015, 15 different middle schools in three different cities in northeastern Massachusetts found that by the end of 8th grade, teenagers who had been part of the Healthy Futures program were significantly less likely to ever have vaginal sex (Calise T.V., W. Chow, and K.F. Doré, 2015). In the same study conducted by the U.S. Department of Public Health, Positive Prevention PLUS was evaluated, and it was concluded that after the completion of the program, students were less likely to initiate sexual activity or have intercourse without contraceptives (LaChausse, R. 2016). (See appendix B for the U.S. Department of Health and Human Services successful identified programs)

There are a few different limitations to consider while evaluating the effectiveness of these interventions. The most important limitation is the inability to reduce risky behaviors (LaChausse, 2016). Although teenagers may have gained knowledge about safe sex during the programs, teachers and program educators cannot reduce the number of teenagers choosing to participate in risky behaviors. Teenagers may have access to contraceptives, but they may choose to have unprotected sex because they do not have access to transportation, may not have money to purchase condoms, or want to avoid the judgement of adults when approaching local clinics. It is difficult as a teenager to take action when there are limitations that prevent them from making the right decision.

Behavioral Profile

There is a public health concern in LAC attributed to the high and growing trend of teen pregnancies. Apparently, the problem is attributed to high sexual risk behaviors among teenagers within the county (CDC, 2018). For instance, many youths in South LA chose to engage in premarital sex. In the process, they fail to put into consideration safety measures like the use of a condom or alternative contraceptive use that would otherwise help reduce the risk of unplanned pregnancies. Many others are also using drugs and abusing alcohol which impairs one’s judgment to make the right decisions like the use of safety measures during sex. Apparently, the sexual risk behaviors pre-exposes many of the youths in South LA to teenage pregnancy leading to the high incidence and subsequent growth rates.

In a reaction to the growing trend of teenage pregnancies, the local health providers blamed it all on the US Food and Drug Administration’s (FDA’s) action to restrict the availability of less expensive morning-after generic pills. The action was cited as hindering access considering that nearly 1 in 3 households in South Los Angeles earns below the federal poverty level (Martinez, 2013). Therefore, the lack of knowledge in reproductive health is a key contributor to the high-risk sexual behavior (and by extension teen pregnancy problem) among teenagers in South LA. In order to resolve the high rates of teen pregnancy in Los Angeles, is through a focus group. A hypothetical focus group was conducted with a total of 70 Hispanic teen participants from McAlister High School in South LA. Participant was pregnant and shared their experience what limitation lead them to pregnancy and it emerged that a significant population of teenagers in the school does not have information about reproductive health including access to similar services.

In resolving the high rates of teen pregnancy in Los Angeles, local healthcare providers have recommended the provision of more non-emergency contraceptive over the counter (OTC). The recommendation is alongside their call to FDA to expand access to the limited emergency pills (Martinez, 2013). Additionally, they should give people over-the-counter options for birth control without necessarily having to see a doctor for the same reason. The State Department of Health should also consider sponsored campaigns on reproductive health and targeting teenagers within the county of LA.

Priorities and Recommendations

As stated in the Health issues section the high rates of teen pregnancy in South LA schools call for actions to curb the situation. Approximately, 50 percent of Hispanic teenager become pregnant each year as stated in the Epidemiology profile section. The factors contributing to the high teen pregnancy rates in South LA include limited information on reproductive health, poor access to the right reproductive health services (Chandra-Mouli, Lane, & Wong, 2015). The difficulties accessing the right reproductive health services include the US Food and Drugs Administration’s (FDA’s) restricted access to the less expensive generic morning-after pills and oral contraceptives. The teen pregnancy problem can be said to be equally contributed by poverty.

 Addressing the teen pregnancy rates among lower income Hispanic teenagers would require a multipronged approach. One of the strategies is for the State Department of Education to introduce a reproductive health course in high schools and colleges and make it mandatory in the county of LA (Marques & Ressa, 2013). The course, in this case, should target all teenagers in the childbearing age to ensure they are adequately equipped with the relevant reproductive health education. Secondly, California'’ State Department of Health should coordinate with FDA to allow the less expensive generic morning-after pills and oral contraceptives to be made available OTC to all women of childbearing age. The department can equally introduce a public-private-partnership program targeting teenagers in South LA schools with the objective of reducing the rate of teen pregnancies in LA County (Loke & Lam, 2014). The State Department of Health should organize to fund and support the organizations in collaboration with the private players to ensure they reach as many teenagers as possible, provide reproductive health education and help distribute the oral contraceptives besides condoms for males. The health awareness campaign should target to empower the South LA teen with relevant reproductive health information that would enable them to make informed choices on sex and pregnancy.

References

Alan Guttmacher Institute. Sex and America's Teenagers. New York, NY: Alan Guttmacher Institute; 2010

Barbee, A. P., Cunningham, M. R., van Zyl, M. A., Antle, B. F., & Langley, C. N. (2016). Impact of two adolescent pregnancy prevention interventions on risky sexual behavior: A three-arm cluster randomized control trial. American Journal of Public Health, 106(S1), S85-S90.

Biggs, M. A., Ralph, L., Minnis, A.M., Arons, A., Marchi, K.S., Lehrer, J.A., Braveman, P.A., & Brindis, C. D. (2010). Factors Associated with Delayed Childbearing: From the Voices of Expectant Latina Adults and Teens in California. Hispanic Journal of Behavioral Sciences, 32(1), 77-103.

Calise, T. V., Chow, W., Doré, K. F., O’Brien, M. J., Heitz, E. R., & Millock, R. R. (2016). Healthy futures program and adolescent sexual behaviors in 3 Massachusetts cities: A randomized controlled trial. American Journal of Public Health, 106(S1), S103-S109.