Literature Review in Research: An Annotated Bibliography

Teen Pregnancy Prevention: A New Paradigm

Kristen A. Plastino, MD

Despite common myths, teen pregnancy and teen birth ratesare decreasing in the United States.1 The two most ob- vious reasons for this decline are that more teens are abstaining from intercourse and sexually active teens are increasingly using contraception. Despite this decrease, teen childbearing in the United States remains a public health issue. The cost for local, state, and federal taxpayers was at least $10.9 billion in 2008, with most of the costs being associated with negative consequences for the children of teen mothers.2 An increase in healthcare costs, increased rates of incarceration, and lost tax revenue caused by unemployment adversely affect the children of teen mothers, in addition to the high likelihood of the child’s placement in foster care.3

When the lay public and media discuss solutions to this problem, often, highly politicized terms such as abstinence only, abstinence plus, or comprehensive sex education are used. These terms do not reflect whether a program is effective and these labels often do not truly describe the content of the program. As medical professionals, we often discuss evidence- based medicine and best practices; therefore, we should con- sider a similar paradigm with regard to sex education. There are more than 30 curricula found on the Web site of the Office of Adolescent Health (www.hhs.gov/ash/oah) that are considered evidence-based programs (EBPs). These programs have strongly influenced the behaviors and/or sexual health out- comes of youth exposed to a specific program. In addition, these programs have been shown to influence one or more of the following behaviors: delayed sexual debut, increased use of condoms and/or contraception, reduced frequency of sexual intercourse, and reduction of the number of sexual partners.4

That said, being labeled as an EBP does not define whether the program discusses contraception. It is behavioral change that is recognized as the most important point.

Instituting an EBP in a school can be difficult because of the subject matter (sex) and the time constraints of the school day. It is important to begin the process with a thorough needs

assessment to gather data with regard to social norms and at- titudes about teen pregnancy within that community. The as- sessments can be as simple as scheduling informal meetings with key stakeholders, organizing focus groups, or assessing a process or program that has already been initiated. When conducting a needs assessment, it is important to engage the various stakeholders such as teens, parents, school adminis- trators, teachers, and other organizational staff. Once the as- sessment has been completed, it is imperative that the data be shared with the involved groups so that a program can be chosen that best fit the community’s needs.

EBPs are only one component of a community saturation or community-wide initiative to combat teen pregnancy. Com- munity mobilization, stakeholder education, linking teens to preventive services, sustainability, and cultural competency are also required togain success from a program. Engagement teams should be constructed to include youth, community members, and involved stakeholders. The terms youth leadership team, community action team, and core partner leadership team have been used to delineate their focus. These teams are used to mobilize the community and provide a grassroots component to ensure sustainability of the project. The stakeholders in a com- munity effort could include superintendents, other teen preg- nancy prevention groups, clinical providers, health departments, Women,Infants,andChildrenprograms,probationoffices,foster care systems, medical societies, and medical alliances.

Implementation of EBPs and mobilization of the com- munity work best when there are both formal and informal linkages of teens to clinical services. Teens, in general, do not seek preventive services. Often, they are seen by a healthcare provider only if they need an immunization, need a sports physical, or have an acute illness/injury such as strep throat or a broken bone. It is important to advocate that all visit types with all providers include time alone to ask sensitive questions and to complete a sexual health history. More important, we must ensure that physicians and physician extenders are not com- pletely responsible for all of this additional questioning. It is acceptable to ‘‘task-shift’’ the questions to a medical assistant or nurse, who can then alert a physician to key or trigger re- sponses to the questions.5 Organizations such as the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have specific best practices for teen- friendly care. They include same-day appointments, stream- lined clinic visits, and no Pap smear or pelvic exam for females younger than 21 years unless there are pelvic complaints. The Centers for Disease Control and Prevention’s guidelines indi- cate chlamydia testing for all sexually active females younger than 25 years.6

Empowering parentsVmaking sure parents know that they should be talking early and often to their teens, monitoring their teen’s behavior and friends, and discouraging early datingVis an important component of any adolescent’s care. Teens need to be counseled so they can begin to think ahead, value themselves, and know their emotional and physical limits. In

Editorial

Southern Medical Journal & Volume 106, Number 9, September 2013 493

From the Department of Obstetrics & Gynecology, University of Texas Health Science Center at San Antonio.

Reprint requests to Dr Kristen A. Plastino, Department of Obstetrics & Gy- necology, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail: [email protected]

The author has no financial relationships to disclose and no conflicts of interest to report.

Accepted June 14, 2013.

Copyright * 2013 by The Southern Medical Association

0038-4348/0Y2000/106-493 DOI: 10.1097/SMJ.0b013e3182a5f005

Copyright © 2013 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.

many of the EBPs, role-playing is an integral part of the pro- gram, allowing teens to practice being in risky situations and handling them successfully. One can compare this to learning a surgical skill so that it becomes second nature, no matter where or when it happens. Parents should incorporate this role-playing into their daily conversations with their children.

Teen pregnancy prevention is no longer a one-time pre- sentation advising teens to ‘‘just say no.’’ It needs to be a community effort to find common ground in providing the best evidence-based practices in schools, faith-based organi- zations, youth-serving organizations, and clinics. It is ensuring that parents are supported with knowledge and skills, and that teens are provided safe places to engage in healthy activities that allow them to take safe risks, which is part of normal adolescent development. It is a package that includes total teen health, which requires an entire community to embrace its philosophy and implementation.

References 1. Centers for Disease Control and Prevention. National Vital Statistics System:

birth data. http://www.cdc.gov/nchs/births.htm. Accessed July 14, 2013.

2. The National Campaign to Prevent Teen and Unplanned Pregnancy. Counting it up: the public costs of teen childbearing: key data. http:// www.thenationalcampaign.org/costs/pdf/counting-it-up/key-data.pdf. Published June 2011. Accessed August 6, 2013.

3. The National Campaign to Prevent Teen and Unplanned Pregnancy. Teen pregnancy, birth, and sexual activity data. http://www.thenationalcampaign. org/national-data/teen-pregnancy-birth-rates.aspx. Accessed May 20, 2013.

4. Department of Health and Human Services, Office of Adolescent Health. TPP Resource Center: evidence-based programs. http://www.hhs.gov/ash/ oah/oah-initiatives/teen_pregnancy/db/index.html#cite-4. Published October 2012. Accessed August 6, 2013.

5. Walker I, McManus MA, Fox HB. Medical home innovations: where do adolescents fit? Report no. 7. http://www.thenationalalliance.org/pdfs/ Report7.%20Medical%20Home%20Innovations.pdf. Published December 2011. Accessed August 7, 2013.

6. Centers for Disease Control and Prevention. Sexually transmitted diseases (STDs): chlamydia. http://www.cdc.gov/std/chlamydia. Accessed July 14, 2013.

The SMJ is pleased to offer a special interview with Dr Plastino. CME credit pertaining to the webinar is available.

Visit http://sma.inreachce.com.

Plastino & Editorial

494 * 2013 Southern Medical Association

Copyright © 2013 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.