PREVENTING TEEN PREGNANCY IN URBAN SCHOOL-BASED HEALTH CENTERS

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1 PREVENTING TEEN PREGNANCY IN URBAN SCHOOL-BASED HEALTH CENTERS Mark Hathaway, MD, MPH Medical Director, Family Planning Program Unity Health Care, Inc. Washington DC

2 Disclosures Consultant for Afaxys, Actavis, and ContraMed Speaker for Bayer Merck Nexplanon trainer

3 Learning Objectives 1. Apply promising practices for maintaining teen engagement in contraceptive and sexual health education 2. Illustrate strategies for delivering LARC services in a schoolbased primary care practice 3. Identify key program components that have successfully been used in a school-based context to keep teens pregnancy free

4 Case Example: Meet Claire 17 yo female with no regular source of care Presented to a Unity Health Care School-based Health Center (SBHC) as new patient S/P abortion 1 week ago History of seizure disorder, on Depakote Not aware of the risks of pregnancy, medication use and seizure disorder Currently using male condom as primary contraceptive method Met with Unity pediatrician at the SBHC

5 Case : Claire s Treatment Course Claire wanted to meet with OB/Gyn to get more information Saw OB/GYN in a Unity community health center the same week to discuss risks associated with Depakote use in pregnancy, managing a seizure disorder in pregnancy Claire elected to start Depo-Provera Received counseling about 100% condom use Continues on Depo-Provera after 1 ½ years; considering hormonal implant Graduating from high school this spring

6 Case : Highlights Teens can have complicated chronic medical problems These medical issues can be exacerbated by pregnancy Teens often have encounters with other providers and specialists that don t discuss family planning or sexual activity SBHC can be a point of entry and medical home for teens SBHC can play a valuable role family planning services and can reduce barriers for teens

7 Teen Birth Rates National Teen Birth Rate 26.6/1,000 (aged 15-19) National rate decreased 57% since 1991 Maryland, Delaware, Pennsylvania, teen birth rates significantly lower than national avg. DC and West Virginia in top ten highest teen birth rates

8 Teens in the District of Columbia 54 pregnancies/1,000 teens ages ( live births/1,000 teens ages 15-19; rank 10 (2012) Highest teen birth rate in country among year olds Chlamydia and gonorrhea increasing fastest among yr olds 70% of children < 18 on Medicaid Martin, J.A., Hamilton, B.E., Osterman, M.J.K., Curtin, S.C., & Matthews, T.J. (2013). Births: Final Data for 2012.National Vital Statistics Reports, 62(9). Retrieved from (HIV/AIDS, Hepatitis, STD and TB Administration. Annual Report District of Columbia: Department of Health; 2012)

9 DC Teens and Parents Speak Findings from DC Focus Group Research Teens environment is sexually charged Teens are focused on sex Gaps in contraceptive knowledge remain Parent conversations may not be happening Some see greater risk in pregnancy than others There is an uptown/downtown perception of inequality Perry Undem Research/Communication for DC Campaign (2013). 15 Years Later: Re-Examining Teen Pregnancy in the District of Columbia. Findings from Seven Focus Groups with DC Teens and Parents.

10 Why School-based Health Centers? SBHC reduce barriers for access Higher rate of contraceptive use* pregnancy rate Medical home for teens Entire clinic teen oriented Ease of confidential services * Smith,P. et al. Does Immediate Access to Birth Control Help Prevent Pregnancy? Journal of Applied Research on Children: Informing Policy for Children at Risk, no, 2 (2011): article 8

11 SBHC in DC Secondary school-based 7 total 4 operated by Unity Clinic enrollment 60-80% Approximately 3,000 patient encounters per year in SBHCs Minor Consent Law in DC In 2007, legislation passed to enable prescription med dispensing in SBHCs

12 Unity Health Care, Inc. Washington, DC About Unity One of the nations largest federally qualified health centers 29 health centers (5 school-based, 8 homeless sites) Over 200 clinicians Title X grantee for the District of Columbia Services 100,000 patients and > 500,000 visits annually Comprehensive primary care services Integrated family planning Specialty care & social services (OB/GYN, infectious disease, cardiology, dental, mental health)

13 Components of Adolescent Health at Unity Health Care School-Based STD Screening Program Youth and Families Initiative (YFI) Call Center Teen Line Adolescent-Friendly Policies School-Based Health Centers

14 History of Unity and SBHC 2000 Unity opens Eastern 2009 Approved regs for medications in schools March 2011 Unity opens Ballou July 2013 Unity opens Challenge 2006 Teen preg prevention program begins 2010 DC DOH announces support for SBHC with DCPS October 2012 Unity opens Woodson April 2014 Unity opens Cardozo

15 Unity SBHC Services Full range of primary and preventive services offered Immunizations, acute illness management, medications Family Planning Services (on-site) Contraceptive provision (all methods and EC available since 2010) STI/HIV testing and treatment Pregnancy testing and options counseling One-on-one health education/life skill counseling Group workshops (Wise Guys, RAP) Social services and case management Provider mix Pediatricians, Family Medicine, PA/NP

16 Unity Teen-Friendly SBHC Services Teen-friendly environment Parental consent form for advance services except for confidential services No explanation of benefits in DC sent home, (only with private) Extended hours for teens at other Unity centers Teen appointment line

17 SBHC Funding Sources Insurance reimbursements Federal 330 grant DC Department of Health Title X Private foundations

18 Key Program Components Teen Pregnancy Prevention Initiative (began in 2006) GOAL: Decrease the number of unintended pregnancies (primary and secondary) among girls aged through: 1) one-on-one contraceptive counseling with a health educator and/or provider 2) onsite provision of all contraceptive methods, including LARC 3) weekly group workshops for males and females that integrate life-skills and reproductive health topics (WISE GUYS/RAP) 4) social work services to assess and address individualized risks for teen pregnancy and sexually transmitted infection.

19 Tiered Counseling

20 Onsite Methods and Resources

21 Teen-Wellness and Life Skills Workshops Adapted from Wise Guys for Females year old girls girls /workshop session Based on Wise Guys Responsibility Curriculum year old boys boys /workshop session ** Wise Guys curriculum shown to: - improve teen male knowledge of sexual behavior and STI transmission - change sexual behavior among participants - increase condom use and contraception among sexually active males Source: Gruchow HW, Brown RK, (2011). Evaluation of the Wise Guys Male Responsibility Curriculum: participant-control comparisons. J Sch Health Mar:81(3):152-8.

22 Workshop Topics Gender roles in relationships and sex Dating and relationships Teen pregnancy and life goals Teen parenting The cost of teen pregnancy Family Planning services and methods Birth control and menstruation Communication skills Reproductive anatomy and physiology STI Awareness and protection

23 Summary Evaluation Teen Pregnancy Prevention Program 1,199 total participants had four or more program encounters annually ( ) Pregnancies 95% of participants remained pregnancy free in each year of program Teen pregnancies decreased 50% at Ballou SBHC in 2014 compared to previous year Current pregnancy rate 4.4% (all students seen at SBHCs)

24 Summary Evaluation Contraceptive Use Indicator Result Data timeframe % of students on moderate or highly effective method % of contraceptors using a LARC method 93% % (increase from 11.5% ) % of new contraceptive initiations that are LARCs % increase in contraceptive use (all methods) 30% >100%

25 School-Based STD Screening Program Partnership between DC Department of Health, DC Public Schools, and Unity Health Care; Started in 2010 to screening for Gonorrhea and Chlamydia in every DC public high school A Unity provider from a nearby health center administers treatment for STDs HIV testing Pregnancy testing Contraceptive counseling Collaboration with other community partners (Metro Teen Aids)

26 US Select Practice Recommendations

27 Adolescent Recommendations LARC methods are appropriate for most women, including adolescents and nulliparous women Adolescents may benefit from more frequent follow-up after contraceptive provision The recommendations within the report refer to all females of reproductive age, including adolescents

28 National Family Planning Guidelines

29 Adolescent Recommendations 16 Core QFP Recommendations Six Adolescent Service Recommendations 1. Youth-friendly 2. Confidential 3. Offer comprehensive information about pregnancy and STD prevention discuss contraceptive options include abstinence as an option for prevention 4. Educate about IUD/Implants being safe and effective for adolescents 5. Promote family-child communication about sexual and reproductive health 6. Refer pregnant and parenting adolescents to home visiting and other support programs

30 Resources Resource Description Website Association of Reproductive Health Professionals Contraceptive Choice Project LARC First Guttmacher Institute Centers for Disease Control and Prevention National Campaign To Prevent Teen and Unintended Pregnancies Resources for reproductive health education Resources for LARC service delivery - providers and patients Research, policy, and public education US Medical Eligibility Criteria for Contraceptive Use, 2010 US Selected Practice Recommendations for Contraceptive Use, 2013 Quality Family Planning Services Patient contraception education materials

31 Conclusions SBHCs and Title X make a great combination! Teens are receptive to family planning services, particularly when provided in the context of on-site primary care services Critical to have all staff trained on different birth control methods uniform messaging In the school setting, teens are opting for LARCs Pregnancy prevention possible with increased number of faceto-face program encounters (provider and NON-provider) For some teens- SBHC services may be the only opportunity to receive sexual and reproductive health services

32 Health education initiatives at Ballou SBHC

33 THANK YOU! Questions?

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