5 page PUBLIC HEALTH LEADERSHIP Literature Review and Problem Statement OPIOID CRISIS

Section 2- Literature Review and Problem Statement

*Synthesis of Peer-Reviewed Scholarly Resources

In the United States, teen pregnancy rates declined nine percent from 2013 to 2013 but

adolescent teen pregnancy is still a pressing public health issue. A synthesis of the literature

reflects the differences in state policies and the effect of funding on reproduction and sexual

education and the availability of family planning and abortion services (Beltz, Sacks, Moore &

Terzian, 2015). An overview of recent research and theory concerning adolescent sexual and

reproductive health suggests that public health leaders implement evidence-based teen pregnancy

prevention initiatives that expand access to low-cost or free contraception and family planning

services and educational and media campaigns that promote safe sexual activity (Thomas, 2012).

Thomas (2012) indicates that new research has shown that efforts made by public health

leadership to expand rather than limit teen pregnancy prevention policies, on a state and federal

level, could produce economic savings to taxpayers. A review of the literature also suggest a

need for extensive social research to examine the deficiencies in state-level policies that may

restrict access to abortion services, public assistance benefits and contraceptive and reproductive

care for sexually active adolescents and use the data gathered to support policy-level changes

(Thomas, 2012).

Santelli, Lindbergh, Fine & Singh (2007) examined the effect of the overall effectiveness

of contraceptive use among sexually active adolescents as the primary determinant of declining

teen pregnancy rates. The authors note that the call for abstinence-only education programs

supported by leaders from the federal government has increased since 1998, even though there is

a deficient lack of evidence-based research support for abstinence –based programs for

reproductive and sexual health for adolescents (Santelli et al., 2007). Based on their study, using

an overall pregnancy risk index and the combined impact of changes in adolescent sexual

activity and effective contraception use, the author’s findings showed a large decline in

pregnancy risk among 15 to 17 year olds, from 9.7 to 4.4 from 1995 to 2002 (Santelli et al.,

2007). The authors also suggested that public health leadership in the United States that

promotes abstinence-based education as the primary strategy to delay initiation of sexual

activity, prevent teen pregnancy, and sexually transmitted illness (STIs) as a failure and

ineffective (Santelli et al., 2007).

Other literature reviews recommend public health leaders look to identify changes in

adolescent’s sexual behavior that may provide insight and an understanding of the social forces,

which influence behavior and motivation in the use or non-use of contraception (Kraft et al.,

2010). Overall, public policy recommendations for pregnancy prevention initiatives should be

comprehensive and promote the expansion of educational and informational resources on

contraception and sexual behavior, support expanded available and accessible effective

contraceptive supplies and resources and strengthen the value of empowering adolescents to

make decisions, that increase safe sex options to decrease unintended pregnancy and risk of STIs

(Kraft et al., 2010).

A review of scientific research has also shown that the use of long-acting reversible

contraception (LARC) such as intrauterine devices and subdermal implants are more effective,

reliable and user-friendly than user-dependent methods, condoms and oral contraception

(Manlove, Karpilow, Welti, & Thomas, 2016). Use of LARC has led to an 86% reduction rate in

adolescent pregnancy birth rates between 1995 and 2002 (Manlove et al., 2016). The authors

provided data to show the increased efficacy with LARC and increased condom use and

utilization of hormonal methods such as the pill, patch and ring for sexually active adolescents

(Manlove et. al, 2016).

Adolescents have faced obstacles when seeking to utilize reproductive health services in

the United States, including limited access to confidential reproductive health services,

contraceptive supply, and cost of contraception (Miller et al., 2014). Reproductive and sexual

health services has been an issue of debate between federal and national leaders, some in support

of abstinence-based education programs and others for expanded reproductive and contraceptive

services for teens that promote autonomy and protect confidential rights for adolescents

(Philliber, 2015). Using a situational leadership approach to pregnancy prevention, leadership on

a national and state level, should support policies that provide for the increased use of low-cost

and free LARC and publicly funded government based insurance and family planning services in

schools and community health organizations across states (Miller et al., 2014). The creation of

the Teen Pregnancy Prevention Program in 2004 by the Office of Adolescent Health (OAH) and

federal funds in 2010, has been an important contribution to increase awareness using a national

campaign to implement support for teen pregnancy prevention initiatives (Philliber, 2015).

Under President Obama’s administration, the Patient Protection and Affordable Care Act

of 2010, provides all Federal Drug Administration (FDA) - approved contraceptive methods

without cost (Peipert, Madden, Allsworth, & Secura, 2012). Challenges to the federal legislation,

have been seen in both federal and state courts by business and religious organizations opposed

to mandates to pay for contraceptive services and supply (Eisenberg, McNicholas, & Peipert,

2013). Despite the legal and political barriers, the Federal Drug Administration (FDA) gave

approval for over-the-counter sales of the emergency contraception pill (ECP) without a

prescription and purchase without age restrictions in 2009 and in 2013 (Upadhya, 2013). Even

with a decline in adolescent pregnancy rates, public health leaders should continue to implement

teen pregnancy prevention programs and policies that fund community-based programs and other

public health organizations (Kearney & Levine, 2015). Effective transformational leadership is

needed to promote access to confidential reproductive and contraceptive services, education and

resources that motivate and support strategies for long-term sexual behavior and activity change

in contraceptive use, and counseling for STI and HIV screening and treatment (Kearney &

Levine, 2015).

*Description of Theoretical Gaps in the Research

Several studies have shown that teen pregnancy prevention programs are more effective

when public health leaders and strategic partners, which include health care providers, teachers

and parents and policy advocate collectively, to promote policies that implement reproductive

services and contraceptive resources to make a positive impact on the reduction of adolescent

pregnancy (Aaro et al., 2014). Leaders that use a theoretical approach to understand social and

behavioral cognition, specifically in the development of interventions that motivate and empower

teens, can increase positive sexual and reproductive health outcomes among adolescents and are

more effective as predictors of sexual behavior and sexual decision-making (Aaro et al., 2014).

Brindis, Sattley, and Mammo (2005) expressed a need for a strategic approach to teen pregnancy

prevention, which included abstinence counseling, contraception education, access to adolescent

family-planning clinics, and programs that incorporate youth mentorships and volunteer

opportunities. The authors supported the use for further exploration of theoretical applications

and frameworks to provide a comprehensive evaluation and development of effective teen

reproductive health initiatives. According to Brindis et al (2005), there has been limited

exploration of program strategies to determine the impact of factors that influence adolescent

behavior, self-esteem and motivation to use contraception or delay sexual activity. The authors

also note the lack of research studies which examine the application of theoretical frameworks to

support the complexities of teen pregnancy and reproductive health (Brindis et al., 2005).

Gottschalk and Ortayli (2014) reported that recent literature reviews did not adequately

capture effective contraceptive service initiatives and prevention interventions, especially in low

and middle-income countries. The authors provided recommendations for intervention programs

and identified gaps in the evidence-base to guide future studies (Gottschalk & Ortayli, 2014).

The authors reported that both user-sided and provider-sider interventions that targeted both

adolescent behavior and change and the service delivery system that includes training for

providers to provide effective contraception counseling and making contraceptive free for

adolescents, could improve adolescent’s use of contraception, knowledge and attitudes, and

access to contraceptives (Gottschalk & Ortayli, 2014).

Aiken, Gold & Parker (2005) also conducted research to compare attitudes, perception

and awareness about EC use in adolescent females and found that provider training and

education to increase awareness about EC, could lead to a positive changes in attitudes and use

in young women in 2002. Similar studies about the use of EC among adolescents has shown that

easier access to EC, lower cost and increased knowledge can lead to higher utilization of EC to

reduce unintended teen pregnancy (Alford et al., 2010). Barriers to adolescent use of EC are cost,

lack of provider confidentiality, and lack of insurance to defray the cost for male and females

seeking EC (Johnson, Nye, & Cohall, 2010). Overall, gaps in evidence-based research show the

need to identify approaches that are adaptive and effective for reaching sexually active

adolescents and that successfully address how to provide reliable contraceptive methods,

counseling and education (Gottschalk & Ortayli, 2014).

Problem Statement

*Explanation of the specific problem that addresses identified gaps within

the literature

In the United States, the cost of adolescent pregnancy in 2010, accounted for an estimated

9.4 billion dollars in public health expenditures related to foster care, low education and

socioeconomic status and health care costs (Centers for Disease Control and Prevention [CDC],

2016). In 2014, adolescent females, aged 15-19 years, gave birth to 249.078 babies for a birth

rate of 24.2 per 1,000 women (CDC, 2016). Although birth rates for 15-19 year olds dropped to

9%, the birthrate for adolescent females is still higher than other developed counties with noted

racial/ethnic and geographical disparities (CDC, 2016). The CDC (2016) cites that non-Hispanic

blacks and Hispanic teen birth rates in 2014, were still more than two times higher than the

birthrates for non-Hispanic white teens. Each year, birthrates show geographical differences

within and across states with the unintended and highest rates seen amongst women with low

socioeconomic status, lower levels of education, and adolescents in the foster care system (CDC,

2016).

Studies that show states that show support for public health policies that promote access

to reproductive and contraceptive services, education and birth control methods for adolescents

are associated with lower teen birth rates (Manlove et al., 2016). Evidence has shown that the

provision and use of LARC methods has been cost-effective, user-friendly, and consistent with a

less than 1% typical-use failure rate that can assist in the reduction of unintended teen pregnancy

(Modi et al., 2013). A literature review has also demonstrated the emphasis for effective public

health leadership to advocate for legislation and intervention programs to provide increased

public health funding for education, reproductive health counseling, and publicly funded

government insurance-based and family-planning programs (Peipert et al., 2012).

*Explanation of how the problem statement incorporates implications for positive social

change

There are notable differences in how state policies can influence trends in teen birth rates

based on reported data, availability of reproductive and abortion services, and the amount of

public health funds available for education and impact the delivery of adolescent reproductive

and family-planning services and the gap that exists in the approach to making effective wide-

spread social change (American Congress of Obstetricians and Gynecologists [ACOG], 2015).

Evidence –based research methodology has shown the need for effective leadership strategies to

use both behavioral and social cognitive theories along with concrete intervention modalities that

include education, counseling and the provision of trained health care providers and access to

effective birth control methods to reduce teen pregnancy (Gottschalk & Ortayli, 2014).

Leadership that seeks to develop and expand policies and programs to support adolescent

reproductive and sexual health could impact positive social change by transforming the social

norms of acceptance for risky teen sexual behavior and practices (Ott, 2014). The implications

for social change could result in an increased adoption of free or low-cost programs that build

motivation, empowerment and decision-making skills to help assist teens make better

reproductive health choices and increase utilization of effective birth control methods to (Ott,

2014). Current public health policy should be expanded to reduce eligibility for Medicaid family-

planning eligibility for healthcare providers to provide no-cost or free contraception such as

LARC. Overall, public health leaders should be agents for social change by acknowledging the

need for adolescent’s autonomy for reproductive health care, provide confidential and balanced

sexual health care education, and continuing to expand advocacy and policy initiatives that

increase funding for access to education and contraceptive services to reduce unintended teen

pregnancy (Ott, 2014).