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1 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 1 Reducing Teen Pregnancy in Utah: An Evidence-Based Approach NURS 3110

2 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 2 At a rate of about 43 pregnancies per 1,000 teenage girls, Utah has one of the lowest teen pregnancy rates in the United States (IBIS, 2009). Furthermore, a gradual overall decline in the number of teen births in the U.S. has been documented over the past 20 years (Guttmacher Institute, 2010). Without context, these figures may seem like cause for celebration. Unfortunately, the reality is that the United States has a national teen pregnancy rate that is significantly higher than that of other industrialized nations, at 52 per 1,000 compared to the next highest rate of 31 seen in the United Kingdom (Figure 1). While specific data sets used may vary, the overall picture is the same: current teen pregnancy reduction efforts in Utah are insufficient, resulting in a higher teenage pregnancy rate than that seen in any other industrialized nation. Any unwanted or unexpected pregnancy can tax the resources of an individual or family, and has the potential to result in an added burden on social support structures. Adolescents are especially at risk, since they are more likely to also experience multiple problems that may include poverty, domestic violence, poor birth outcomes, higher incidence of sexually transmitted diseases, lower education opportunity and attainment, and lower marriage rates (Sieving et al., 2011; Stanger- Hall & Hall, 2011; Utah Department of Health [UDOH], 2004, 2010). Each of these at-risk pregnancies has significant consequences for the mother and child, as well as costs for the general public. To community advocates, there is a clear connection between poverty and increased incidence of teen pregnancy (Theobold, personal communication, October 18, 2011). When basic necessities are a family s main priority there is little time for looking towards the future, including the prospect of further education. One study found that SES was the only significant participant-related characteristic that influenced the occurrence of teenage pregnancy (Corcoran & Pillai, 2007). Teens who give birth are less likely than their peers to finish high school, which leads to a decreased likelihood of getting a higher paying job (Kandakai & Smith, 2007). This in turn leads to increased incidence of poverty and therefore a greater reliance on social services like welfare. There are nearly as many programs for teen pregnancy prevention as there are stakeholders. Stakeholders are those with a vested interest in the policy or program (Schmeer, 2000). Since teens are a vulnerable population with a limited ability for self-representation, other adults must typically take the role of advocates, and there is disproportionate representation of particular stakeholders with power. In the case of teen pregnancy, the priority stakeholders include teens and parents, schoolteachers, local school boards and school administrators, nonprofit organizations (like the National Campaign to Prevent Teen and Unplanned Pregnancy), private businesses (including health insurance providers and some hospitals and clinics), and the public (via governmental agencies and legislation). While there is general agreement that teen pregnancy rates should be reduced, there is considerable disagreement about which methods to use (Sabia, 2006). Utah s school-based teen pregnancy programs are either abstinence-only until marriage or abstinence-promotion based. However there is no published evidence-based research that shows that these programs prevent teen pregnancy (UDOH, 1996). Analysis of state-reported data from 2005 (Stanger-Hall & Hall, 2011) demonstrated that abstinence-only programs correlated with higher rates of teenage pregnancy. Additionally, abstinence-only programs correlate with a greater incidence of sexually transmitted diseases than those that also provide comprehensive contraceptive and HIV education (Kirby, 2007; Stanger-Hall & Hall, 2011). Utah historical data also showed that the rate of chlamydia more than doubled among sexually active teens between 1988 and 1992 (Report on Adolescent Pregnancy in Utah, 1996). This data points to the ineffectiveness of Utah s abstinence-only school-based programs at addressing other risk factors that go hand and hand with teen pregnancy. The dramatic increase in

3 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 3 adolescent sexually transmitted diseases results in higher long-term healthcare costs for teens that are already at risk, and therefore higher societal costs via public funding. School-based programs are not the only option for teen pregnancy prevention: there are many effective community and family-based programs, and nonprofit organizations that target their interventions towards particular ages, genders, or regions. Nurses are other healthcare providers are positioned to provide information both about pregnancy prevention and prenatal through postpartum care to the most at-risk teenage populations. Kirby (2007) provides a rigorous summary of primary prevention programs that have demonstrated effectiveness and organized a 17-point table of program characteristics that align well with program success (Table 1). As there are many programs that have already been through these testing phases, an effective strategy would be to implement with fidelity programs that have been demonstrated to be effective in other places with similar young people (Kirby, 2007, p.187). One program that is applicable to at-risk Utahan teens is Cuídate!, an after-school program for urban Latino teens in grades The CDC identifies Cuídate! as a best-evidence risk reduction program, with teens in the intervention group reporting more consistent condom use and fewer sexual partners. The intervention is delivered over two sessions, one week apart, and requires purchase of a facilitator curriculum, an implementation manual, and a training manual. Therefore, although fairly modest, the limiting factors for implementing this program are both time and money. Another specific program is Wyman s Teen Outreach Program (TOP), which effectively reduced teen pregnancies in the intervention group to half that of the control group among 9 th through 12 th graders. The Salt Lake Planned Parenthood Clinic is already certified as a TOP replication partner, which costs $26,000 the first year and $6,000 every subsequent year. This means that a significant portion of the monetary expense for the program has already been secured, and that the ability to train additional facilitators is already in place in Utah County. By using this program in a school-based model it may be possible to tap into this already functional community resource and expand its capacity to serve many more at-risk teens. The Tooele County Health Department s Teenage Pregnancy Prevention Project promotes abstinence-only until marriage. But while the project s website touts its national and state recognition for its positive open, honest communication with teens ( Teen Pregnancy Prevention, n.d.), the rate of teenage pregnancies in Tooele County is higher than Utah s average, and nearly rivals the overall U.S. teen pregnancy rate. Moreover, the racial and ethnic diversity of Tooele County is very limited: almost 90% of the population is white (IBIS, 2009). While this particular program may open communication lines with teens, it does not prevent teen pregnancy on a county level. This may be due to poor targeting of the local at-risk teen populations (Herrman & Waterhouse, 2011), or it may be the abstinence-only message is proving ineffective. Attention must certainly be paid to the specific programs that are implemented to effectively reduce teen pregnancy, but these decisions can often be made on a smaller scale within communities, school districts, or small group populations. For example, professional nurses are uniquely positioned to facilitate delivery of Wyman s TOP program for teen pregnancy prevention. The intervention has proven efficacy and the framework for the program already exists in our community. On a larger scale it is important to set aside resources for these communities and schools to draw upon when the best-fit teen pregnancy prevention program has been selected. In the absence of public and private funding, it is impossible to sustain an evidence-based intervention with significant positive results. However when this cost is weighed against the long-term social expense of pregnant teenagers reliant on public welfare services, or the loss of human capital from education termination, compromised health, and poor employment outlook, it is a small investment for significant individual and community return.

4 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 4 Figure 1: A national rate comparison of births to year old women, (Unicef, 2001)

5 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 5 Table 1: 17 curriculum characteristics that contribue to development of a successful teen pregnancy reduction program. (Kirby, 2007)

6 An Evidence-Based Approach to Reducing Teen Pregnancy in Utah 6 References Corcoran, J., & Pillai, V.K. (2007). Effectiveness of secondary pregnancy prevention programs: A meta-analysis. Research on Social Work Practice 17(1): doi: / Guttmacher Institute. (2010). In Brief. Retrieved from Herrman, J.W., & Waterhouse, J.K. (2011). What do adolescents think about teen parenting? Western Journal of Nursing Research 33(4): doi: / Kandakai, T.L., & Smith, L.C.R. (2007). Denormalizing a historical problem: Teen pregnancy, policy, and public health action. American Journal of Health Behavior 31(2): Kirby, D. (2007). Emerging Answers 2007: Research findings on programs to reduce teen pregnancy. Washington, D.C.: The National Campaign to Prevent Teen Pregnancy. Sabia, J.J. (2006). Does sex education affect adolescent sexual behaviors and health? Journal of Policy Analysis and Management 25(4): doi: /pam Schmeer, K. (2000). Stakeholder Analysis Guidelines. In Policy Toolkit for Strengthening Healthcare Reform. World Bank. Sieving, R.E., Resnick, M.D., Garwick, A.W., Bearinger, L.H., Beckman, K.J., Oliphant, J.A., Rush, K.R. (2011). A clinic-based, youth development approach to teen pregnancy prevention. American Journal of Health Behavior 35(3): Stanger-Hall, K.F., & Hall, D.W. (2011). Abstinence-only education and teen pregnancy rates: Why we need comprehensive sex education in the U.S. PloS ONE 6(10): e doi: /journal.pone Tooele County Health Department, Department of School and Family Health. (n.d). Teen Pregnancy Prevention. Retrieved from Page.html UNICEF, Innocenti Research Centre. (2001). A league table of teenage births in rich nations. Retrieved from Utah Department of Health, Division of Community and Family Health Services. (1996). Report on Adolescent Pregnancy in Utah. Retrieved from health.utah.gov/mihp/pdf/1997report.pdf Utah Department of Health, Division of Community and Family Health Services. (2004). Update on Adolescent Pregnancy in Utah. Retrieved from health.utah.gov/mihp/pdf/update_teen_preg.pdf Utah Department of Health, Center for Health Data, Indicator-Based Information System for Public Health. (2009). Utah pregnancy risk assessment monitoring system. Retrieved from Utah Department of Health, Division of Community and Family Health Services. (2004). Update on Adolescent Pregnancy in Utah. Retrieved from health.utah.gov/mihp/pdf/update_teen_preg.pdf Utah Department of Health, Maternal and Infant Health Program, Division of Family Health and Preparedness. (2010). Utah adolescent reproductive health report. Retrieved from health.utah.gov/mihp/pdf/2010_adolescent_health_update.pdf

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