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This article draws on data from the ongoing federal Evaluation of Adolescent Pregnancy Prevention Approaches to discuss the early implementation experiences of two new and innovative programs intended to delay rapid repeat pregnancy among teen mothers: (1) AIM 4 Teen Moms, in Los Angeles County, California; and (2) Teen Options to Prevent Pregnancy (T.O.P.P.), in Columbus, Ohio. Program staff report common challenges in working with teen mothers, particularly concerning recruitment and retention, staff capacity and training, barriers to participation, and participants' overarching service needs. Lessons learned in addressing these challenges provide useful guidance to program developers, providers, policy makers, and stakeholders working with similar populations.
Researchers, policy-makers, and practitioners are engaged in an ongoing effort to better serve adolescent mothers who are hard to reach, at high risk for negative health outcomes, and living under adverse conditions. This paper aims to inform these efforts by discussing the lessons learned from the implementation experiences of two innovative teen pregnancy prevention programs designed to delay rapid repeat pregnancies. The findings reflect the multiple barriers and factors that must be considered when designing programs to serve teen mothers.
Three in 10 young women have a birth before the age of 20 years, and one in five of those women will go on to have a subsequent birth while still in their teens [
Martin JA, Hamilton BE, Ventura SJ, Osterman MJK. Births: final data for 2011. Hyattsville (MD): National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed on July 8, 2013.
]. Teens are much less likely to use reliable, user-independent methods of birth control, such as long-acting reversible contraceptives, which thereby increases the risk of repeat pregnancy in this already vulnerable population [
Adolescents and long-acting reversible contraception: Implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists.
]. Teen mothers who have repeat births are less likely to receive prenatal care, complete school, work or maintain economic self-sufficiency, or have children who are ready for school [
To receive assistance from traditional community-based programs, teen mothers have to navigate complicated circumstances and challenges. Financial pressures and parenting demands often prevent teen mothers from attending classes or activities outside school or work [
]. Teen mothers could also be discouraged from seeking services by their partners or families, especially if the services are perceived to conflict with parenting or other responsibilities [
This article discusses how two new and innovative programs aim to circumvent some of these obstacles by providing targeted interventions to at-risk teen mothers in their homes or by telephone. Both programs seek to increase long-term contraceptive use and delay repeat pregnancies among teens; one program is in Los Angeles, California, and the other is in Columbus, Ohio. Repeat pregnancy rates among teens (19% in Los Angeles and 21% in Columbus) are higher than the state averages [
AIM 4 Teen Moms (AIM) is a nine-session program for new teen mothers in the Los Angeles County, California. Seven of the sessions are delivered one-on-one in the homes of participants or other community-based locations. The program was developed by researchers at Children's Hospital Los Angeles (CHLA) and is being offered in collaboration with El Nido Family Centers (El Nido) in Metro Los Angeles, South Los Angeles/Compton, and the San Fernando Valley.
Teen Options to Prevent Pregnancy (T.O.P.P.) is offered to teen mothers in the Columbus, Ohio, area by OhioHealth, a faith-based, not-for-profit health care system. The program provides services for 18 months, using telephone-based care coordination, motivational interviewing (MI), and access to family-planning services.
Both programs are part of the ongoing federal Evaluation of Adolescent Pregnancy Prevention Approaches (PPA), a large-scale, multisite random assignment evaluation of promising approaches to teen pregnancy prevention [
]. The evaluation is being conducted under contract to the Office of Adolescent Health within the United States Department of Health and Human Services.
The PPA evaluation is conducted by Mathematica Policy Research and its partners, Child Trends and Twin Peaks Partners LLC.
1The PPA evaluation is conducted by Mathematica Policy Research and its partners, Child Trends and Twin Peaks Partners LLC.
In each participating site, the PPA study involves an impact and program implementation study. This article draws on data from the implementation study to discuss lessons learned from the early implementation experiences of the AIM 4 Teen Moms and T.O.P.P. programs. Both programs are supported by the Personal Responsibility Education Innovative Strategies program at the Administration on Children and Families.
Methods
The AIM 4 Teen Moms and T.O.P.P. programs are being implemented as part of rigorous random assignment impact evaluations. Teen mothers recruited for the evaluations (Figure 1) are randomly assigned to either a treatment group (which receives the intervention) or a control group (which does not receive the intervention but may continue to receive other services).
Figure 1AIM 4 Teen Moms and T.O.P.P. program snapshots.
T.O.P.P. and AIM 4 Teen Moms take different approaches to addressing rapid repeat pregnancies among at-risk teen mothers (Figure 1). Both programs conducted pilots early in their development and incorporated input from teen mothers and key stakeholders as part of their models.
OhioHealth designed T.O.P.P. to help young mothers access and use existing pregnancy prevention and reproductive health services. The intervention draws on the Behavioral Model of Health Services Use, which suggests that contraceptive behavior will be changed by altering a woman's perception of her need for birth control and providing her easy access to it [
] to educate and inform teen mothers about different birth control options (including abstinence), help them select their own method of birth control, promote birth spacing, and delay repeat pregnancies (Figure 2). In addition to MI delivered through monthly telephone contacts with an assigned nurse educator, T.O.P.P. provides access to contraception (via transportation to clinics or hospitals, home visits with birth control models, or a mobile clinic) and referrals by a social worker, as needed. Participants pay for contraceptives through Medicaid.
OhioHealth staff recruits from the patient caseloads of seven affiliate clinics and five hospitals in the Columbus area. T.O.P.P. focuses on Medicaid-eligible teens aged 10–19 years, who are at least 28 weeks' gestation or newly postpartum. T.O.P.P. predominantly serves white and African-American adolescents in Columbus, Ohio (Table 1).
Table 1Key characteristics of T.O.P.P. program participants
Sample size for each question varies from 153 to 197, based on logical skips and item nonresponse. For some questions, not all response options are displayed. Data are based on enrollment in the first 20 months of a 36-month enrollment period.
Percentage of participants (unless noted otherwise)
Demographic and background characteristics
Age, years (mean)
18.0
Race
White Non-Hispanic
45.4
Black Non-Hispanic
46.9
Hispanic
5.2
American Indian or Alaskan Native
1.6
Asian
1.0
Language spoken at home
Spanish
1.5
English
98.5
Highest grade completed
7 or 8
3.6
9–11
49.0
High school/Graduate Equivalency Diploma Pretest/Graduate Equivalency Diploma
38.8
Postsecondary
6.6
Live in home with …
Mother
44.7
Stepmother
5.9
Father
16.2
Stepfather
7.1
Grandmother(s)
10.7
Grandfather(s)
4.6
Siblings
44.2
Father of baby
29.4
Parents of baby's father
7.1
Other relatives
11.2
Non-relatives
8.1
Live alone
5.6
Past sexual activity
Number of sexual partners (mean)
5.3
Number of times engaged in sexual intercourse in 3 months before pregnancy (mean)
21.5
Number of times had sexual intercourse in 3 months before pregnancy without using an effective method of birth control, among those who had sexual intercourse (mean)
17.4
Had sexually transmitted disease in past 12 months
18.2
Intentions for future sexual activity
Intention to have sexual intercourse in the next year
83.6
Intention for partner to use a condom, among those who intend to have sexual intercourse in the next year
81.0
Intention to use a hormonal birth control method (or non-hormonal intrauterine device) in the next year, among those who intend to have sexual intercourse in the next year
96.7
a Sample size for each question varies from 153 to 197, based on logical skips and item nonresponse. For some questions, not all response options are displayed. Data are based on enrollment in the first 20 months of a 36-month enrollment period.
AIM 4 Teen Moms is based on the Theory of Possible Selves, which posits that youth can be motivated in their present lives by images of their possible future selves [
]. Drawing on this theory and incorporating positive youth development principles, the CHLA team adapted an existing evidence-based program, Project AIM [
], to motivate teen mothers to delay repeat pregnancies by defining specific life aspirations and making the healthy life choices needed to achieve them. By engaging teens in positive future career and family planning, the program hopes to increase birth spacing and uptake of long-term contraception. In seven home visits and two community-based group sessions, trained program facilitators (advisors) with case management backgrounds guide participants through future-planning activities and facilitate discussion about career goals, birth spacing, reproductive life plans, communication skills, motherhood as an identity strength, and contraceptive use (Figure 3). The program provides transportation assistance, child care, and meals at group sessions. Participants obtain contraceptives through their medical providers, CHLA's onsite health center, or local clinics.
Figure 3AIM 4 Teen Moms curriculum. *Specific activities/content added to address family planning and contraception.
Children's Hospital Los Angeles's recruitment strategy relies primarily on referrals from two community-based programs serving teen parents: El Nido and Project NATEEN. Staff refers teens who are 15–19 years of age and have a child < 7 months of age. AIM 4 Teen Moms mostly serves Hispanic adolescents in urban Los Angeles, California (Table 2).
Table 2Key characteristics of AIM 4 Teen Moms participants
Sample size for each question varies from 95 to 211, based on logical skips and item nonresponse. For the question “Had sexually transmitted disease in past 12 months,” one person refused to answer. For the question “Highest grade completed,” two people refused to answer. For some questions, not all response options are displayed. Data are based on enrollment in the first 14 months of the 36-month program enrollment period.
Percentage of participants (unless otherwise noted)
Demographic and background characteristics
Age, years (mean)
17.3
Race
White Non-Hispanic
1.0
Black Non-Hispanic
11.9
Hispanic
85.2
American Indian or Alaskan Native
.5
Asian
1.5
Language spoken at home
Spanish
15.9
English
27.5
English and Spanish
56.5
Highest grade completed
7 or 8
8.5
9–11
77.7
High school/Graduate Equivalency Diploma Pretest/Graduate Equivalency Diploma
11.8
Postsecondary
.9
Live in home with …
Mother
73.0
Father
26.5
Grandmother(s)
7.6
Grandfather(s)
1.9
Siblings
59.2
Father of baby
18.0
Parents of baby's father
7.6
Aunts/uncles
9.0
Friends/roommates
2.4
Live alone
.5
Past sexual activity
Number of sexual partners (mean)
2.7
Percentage who had sexually transmitted disease in past 12 months
8.1
Percentage who had sexual intercourse in past 4 weeks
46.4
Number of times had sexual intercourse in past 4 weeks (mean)
2.1
Frequency of sex with no birth control, among those who had sex in past 4 weeks
None
51.6
One to five times
44.2
Six to 10 times
1.1
≥10 times
3.2
Intentions for future sexual activity
Intention to have sexual intercourse in the next year
71.0
Intention for partner to use a condom in the next year
92.9
Intention to use other birth control methods in the next year
95.3
a Sample size for each question varies from 95 to 211, based on logical skips and item nonresponse. For the question “Had sexually transmitted disease in past 12 months,” one person refused to answer. For the question “Highest grade completed,” two people refused to answer. For some questions, not all response options are displayed. Data are based on enrollment in the first 14 months of the 36-month program enrollment period.
Teams of two researchers from the federal PPA study team visited Los Angeles and Columbus to collect in-depth implementation data on the planned intervention, staff training, and successes and challenges encountered during program implementation. Researchers collected qualitative data through semistructured interviews with program leadership and staff, partner organization staff, community stakeholders, and program developers. Evaluation of Adolescent Pregnancy Prevention Approaches staff observed two group sessions for AIM 4 Teen Moms. Quantitative data based on survey response and other program materials also informed the study. Program staff in each site conduct regular fidelity monitoring of program delivery by listening (with participant consent) to audio recordings of individual calls and sessions, documenting contacts and completed sessions, conducting in-person observations (where applicable), and offering targeted feedback to facilitators at regular one-on-one or group meetings.
After the site visits, PPA staff coded and analyzed the implementation data using qualitative analysis software, Atlas.ti [
], which facilitated thematic analysis and triangulation of data sources. Evaluation of Adolescent Pregnancy Prevention Approaches study methods and protocols were approved by the New England Institutional Review Board. Local institutional review boards associated with CHLA and OhioHealth also gave approval to site-specific methods and interview guides. Because data collection for the qualitative analysis of implementation occurred about midway through the sample enrollment period, the findings generalize only to the early implementation experience of each program.
Results
The analysis identified four main themes or lessons. These lessons center on (1) recruitment and retention; (2) staff capacity; (3) barriers to participation; and (4) participants' overarching service needs.
Recruiting and retaining parenting teen participants requires persistence, as well as buy-in from implementing partners
One of the biggest challenges for staff in both programs was recruiting and retaining program participants. To reach participants, both agencies developed linkages with local partners with community presence, but the initial step of getting staff buy-in, building trust, and overcoming logistical recruitment hurdles sometimes proved more challenging than expected. After participants were enrolled, sustaining contact and keeping them engaged in program activities was also difficult, despite the convenience of home visits or telephone appointments. Because of teens' competing priorities and parenting demands, scheduling difficulties and missed appointments were common in both sites.
Program implementation and scale-up required consistent access to potential participants and a well-managed recruiting effort. Establishing formal referral partnerships was important for successful recruiting. Staff found that any logistical hurdles and procedural challenges were more smoothly handled when partners were fully invested in the program and understood its intended approach and the value it brought to their communities. In Ohio, for example, some clinics were initially resistant to becoming a partner because they had concerns about T.O.P.P.'s inclusion of long-acting reversible contraceptives, such as intrauterine devices, in its list of possible contraceptive options. To get buy-in for the program, T.O.P.P. staff visited hospitals and clinics in person to provide more information and address questions and fears. T.O.P.P. staff noted that appointing one “on-the-ground” contact at each clinic or hospital made this relationship-building process easier.
Preparing backup plans for unexpected enrollment challenges was also critical. In Los Angeles, for example, state funding cuts forced staff to expand their outreach beyond their original plan of using existing case management clients referred by Project NATEEN and El Nido. Using existing relationships with community stakeholders, CHLA reached out to other sources to enroll teens. They established and advertised a hotline through flyers in target neighborhoods; recruited at health fairs, public events, and local Women, Infants and Children program offices; identified and partnered with an additional case management provider; and worked closely with staff at schools for pregnant and parenting teens. The program reported that designating outreach staff helped facilitate recruitment, rather than relying on referrals alone.
In working with teen mothers, staff emphasized that “the message and how you deliver it matters.” For example, because recruitment for T.O.P.P. happened just before or after giving birth (a sensitive and stressful time for new mothers), OhioHealth found that staff with postpartum nursing training could connect especially well with participants.
Facilitators also found it difficult to sustain regular contact with participants, especially because of participants' unstable living situations and competing demands on their time. As in most programs serving this population, staff had to be persistent and creative to schedule appointments. AIM 4 Teen Moms facilitators connected with participants primarily through texting and telephone calls. If the timing or location of the visits was not suitable for the facilitator or participant because of safety concerns or lack of privacy, staff offered to meet participants at another location. Similarly, T.O.P.P. nurses adapted their communication approaches to reach participants more efficiently. They tried texting, calling in the afternoon after school hours, and calling at the beginning of the month (before cell phone minutes had been depleted). In Ohio, staff members believed that more face-to-face contact was important, in addition to the telephone appointments. They reported that the home-visiting component of T.O.P.P. was not used as frequently as initially expected, which limited the personal interactions that facilitators viewed as being valuable. Going forward, OhioHealth decided to conduct home visits for all participants.
Building and improving staff capacity is integral to individualized service delivery models
T.O.P.P. and AIM 4 Teen Moms depended on trained facilitators to deliver important interventions to participants in challenging circumstances. Staff had to be comfortable discussing intimate information with teen mothers, able to adhere to the curriculum or prescribed method, and able to keep the teen participants engaged despite an often chaotic and distracting home environment.
Both organizations knew that it would be difficult to find applicants with all the required skills. Staff hired to deliver T.O.P.P. and AIM 4 Teen Moms had worked with vulnerable teens and were passionate about their roles; however, they did not always have the specialized skills required by the program model. Because of variation in staff skill levels, program leaders offered program-specific training before implementation and planned to assess the fidelity of program delivery regularly.
Staff members in both programs reported a significant learning curve in preparing to deliver the intervention. AIM 4 Teen Moms advisors had prior experience managing client relationships and three had facilitated support groups, but none had conducted scripted sessions. Delivering the program in a crowded and noisy home with other household members presented a further challenge. Staff indicated that more time for practice and feedback before implementation would help address this issue. In Ohio, the nurse educators delivering T.O.P.P. had medical training and experience, but becoming comfortable with a new, highly individualized technique such as MI required time and practice. In trying to help participants, they often felt tempted to revert to their roles as health professionals and be more directive than was appropriate in MI.
Both sites offered frequent technical assistance through conference calls and meetings, as well as targeted feedback. When regular monitoring revealed specific concerns about program delivery, sites provided additional training. For example, the AIM 4 Teen Moms developer conducted a supplemental facilitator skills training to provide feedback, reminded staff of the importance of allowing participants time to process information, and offered encouragement to build confidence. Additional practice, holding weekly discussions to address questions or problems, and shadowing more experienced facilitators (for new staff) also helped advisors become more adept at delivering lessons with fidelity but without reading verbatim. In Ohio, a nationally certified MI consultant who trained the T.O.P.P. educators provided them with ongoing supervision and technical assistance every week during the first year and every other week after that. Together, the educators and consultant listened to taped MI interactions, discussed the quality of the interactions, and attempted to troubleshoot challenges with the MI technique.
Overcoming participation barriers (such as lack of transportation) requires practical solutions that fit local context
Program staff and participating youth reported that lack of access to affordable transportation was a major challenge to program participation. According to program staff, most teens did not have access to cars, driver's licenses, or convenient nearby public transportation. Some teen mothers were responsible for siblings or other family members.
This issue affected participation for the two programs in different ways. In Ohio, although the MI component was offered by telephone, participants still needed transportation to visit clinics and obtain contraceptive services. For AIM 4 Teen Moms, lack of transportation was a significant impediment to group session attendance and participation, but not an issue for the individual home visits.
Both organizations developed strategies to address this challenge as part of their program model. The T.O.P.P. program originally included a mobile clinic staffed by nurses, a physician, and a social worker, to address transportation concerns and provide easy access to contraceptive services. The program design envisioned that this mobile clinic would park at community libraries and serve pregnant or parenting teens. In Los Angeles, staff members offered bus tokens to participants to attend the group sessions, as well as Target gift cards as incentives, and provided dinner and onsite child care at each group session.
Both programs soon realized that their plans to address this challenge were not yielding the desired results. In Ohio, the mobile clinic was discontinued owing to insufficient patient demand for contraceptive services in this type of setting; in addition, it was expensive (because of gas consumption and the need for a driver). In Ohio, staff did not want to interrupt the continuum of care of participants who would otherwise receive care from their existing doctor. In Los Angeles, staff realized that many teens lived in areas where bus service was unreliable or took too long. Group attendance was low, and a number of teens found it challenging to use public transportation to bring their infants (as well as other family members for whom they were responsible) to group sessions.
Sites looked for alternative solutions that could better meet the needs of their participants. T.O.P.P. staff decided to use their van to transport teens to and from the clinics where they were recruited. Staff could drive the van themselves (they would be covered under OhioHealth's insurance policy), and the time in the van with teens provided another opportunity to build rapport and use MI techniques. Staff explained, “It has been so helpful [and] valuable to get them to the appointment and sit in the car and talk to them. [You can say], ‘Pick a radio station. What do you want to listen to? What have you been up to?' [It] gives them a sense that [the nurse educator is] not intimidating, [and] gives the girl a sense of control.” In Los Angeles, staff also investigated renting a van to transport the teens to and from the groups; this was ruled out, however, because of legal and liability concerns. For teens without alternative transportation, the program used taxis to bring the participants and their babies to group sessions and El Nido staff offered rides whenever possible.
Teen mothers' overarching service needs require a broad service delivery framework
Teen mothers' risks and circumstances led to a variety of service needs. Participants struggled with issues such as substance use, poverty, depression, violence, interpersonal conflict, parental conflict, and poor nutrition.
The one-on-one facilitation model offered through both programs provided some level of social and emotional support to teen mothers who might not have received it from families, parents, and friends. Through AIM 4 Teen Moms and T.O.P.P., participants were able to share their experiences and life challenges with someone who was willing to listen and provide educational support. At the end of one program cycle, AIM 4 Teen Moms participants noted the close positive relationships they had developed with their advisors. In Ohio, staff members said that MI gave the adolescents more control over their life choices, as well as someone with whom to talk over an extended period of time, and that most participants really looked forward to the monthly telephone calls.
Programs such as AIM 4 Teen Moms and T.O.P.P. do not operate in isolation; inevitably, they encounter these additional needs among the teen mothers they serve. Because the two programs offered the support of a trusted adult, it is natural that participants would seek help from the program facilitator for other service needs, as well. T.O.P.P. educators had the benefit of working with participants over an 18-month period, and the program included the offer of service referrals and support from a social worker, as needed. AIM 4 Teen Moms participants also had access to referrals, but the home visits and their relationships with their advisors ended after the 12-week program period. According to program staff, this loss was especially critical for participants not connected to any case management program or other service provider. They agreed that many participants would have liked to continue these relationships beyond the 12 weeks. Staff in both sites reported feeling challenged by their work with a population that had so many needs, some of which were outside the scope of the programs they were trying to deliver.
Discussion
Drawing on data collected as part of the PPA study, this article discusses challenges and lessons learned from the early implementation experiences of two new and innovative programs for teen mothers: AIM 4 Teen Moms, in Los Angeles County, California, and T.O.P.P., in Columbus, Ohio. Both programs aimed to increase contraceptive use and delay repeat pregnancy by providing targeted interventions to at-risk teen mothers in their homes or community locations, or by telephone. In doing so, they also sought to overcome common obstacles teen mothers often face in seeking and receiving needed social services.
The lessons learned in addressing these challenges provided useful guidance to program developers, providers, policy makers, and stakeholders working with high-risk teen mothers. To efficiently enroll hard-to-reach participants, program staff had to get early buy-in from implementing partners, establish organizational supports such as referral mechanisms and coordination agreements early in the partnership, hire or designate staff for conducting outreach, and show persistence through specific outreach strategies targeted to the teen population. To ensure strong engagement, programs had to be designed to minimize transportation limitations and other common barriers to participation (for example, by replacing group sessions with one-on-one sessions offered in the home or by telephone, and offering viable transportation options, child care, and other necessary services). Programs had to prepare early to build the necessary staff capacity, with ample opportunity for training and practice. After the program started, staff had to continue to receive regular support and individualized feedback.
Programs for teen mothers must recognize and be embedded in the broader service delivery context necessary to help this population. Teen mothers have many and unique long-term needs that cannot be addressed by one program alone. Providers must consider how best to link participants with necessary support during program delivery and after it ends (for instance, by creating formal service and referral networks, or incorporating into a broader community-based program) so participants receive more seamless and sustained support.
These early findings will be useful in interpreting results of the ongoing impact studies for each program and will provide an important context for future replications. Results of the impact evaluations will be released after data collection is completed in 2015 and 2016.
Acknowledgments
The authors are grateful for the valuable input, assistance, and cooperation provided by Dr. Leslie Clark (Children's Hospital, Los Angeles), Mona Desai (Children's Hospital, Los Angeles), Dr. Pamela Drake (ETR Associates), Robyn Lutz (OhioHealth), and Dr. Jack Stevens (Nationwide Children's), as well as the program staff members who were integral to delivering the two programs in Los Angeles and Columbus. The authors would also like to acknowledge the valuable support and guidance from PPA project directors Alan Hershey (Mathematica), Dr. Brian Goesling (Mathematica), and Dr. Chris Trenholm (Mathematica).
Funding Sources
This research was conducted under contract to the Office of Adolescent Health in the U.S. Department of Health and Human Services (Contract number HHSP23320082911YC).
References
Martin JA, Hamilton BE, Ventura SJ, Osterman MJK. Births: final data for 2011. Hyattsville (MD): National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed on July 8, 2013.
Adolescents and long-acting reversible contraception: Implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists.
Conflicts of Interest: The authors declare no conflicts of interest.
Disclaimer: Publication of this article was supported by the Office of Adolescent Health, U.S. Department of Health and Human Services. The opinions or views expressed in this paper are those of the authors and do not necessarily represent the official position of the Office of Adolescent Health, U.S. Department of Health and Human Services.
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