Beth Barnet

Home visiting for adolescent mothers: Effects on parenting, maternal life course, and primary care linkage

PURPOSE Adolescent mothers are at risk for rapidly becoming pregnant again and for depression, school dropout, and poor parenting. We evaluated the impact of a community-based home-visiting program on these outcomes and on linking the adolescents with primary care. METHODS Pregnant adolescents aged 12 to 18 years, predominantly with low incomes and of African American race, were recruited from urban prenatal care sites and randomly assigned to home visiting or usual care. Trained home visitors, recruited from local communities, were paired with each adolescent and provided services through the child’s second birthday. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation. Research assistants collected data via structured interviews at baseline and at 1 and 2 years of follow-up using validated instruments to measure parenting (Adult-Adolescent Parenting Inventory) and depression (Center for Epidemiologic Studies Depression). School status and repeat pregnancy were self-reported. We measured program impact over time with intention-to-treat analyses using generalized estimating equations (GEE). RESULTS Of 122 eligible pregnant adolescents, 84 consented, completed baseline assessments, and were randomized to a home-visited group (n = 44) or a control group (n = 40). Eighty-three percent completed year 1 or year 2 follow-up assessments, or both. With GEE, controlling for baseline differences, follow-up parenting scores for home-visited teens were 5.5 points higher than those for control teens (95% confidence interval, 0.5–10.4 points; P = .03) and their adjusted odds of school continuation were 3.5 times greater (95% confidence interval, 1.1–11.8; P <.05). The program did not have any impact on repeat pregnancy, depression, or linkage with primary care. CONCLUSIONS This community-based home-visiting program improved adolescent mothers’ parenting attitudes and school continuation, but it did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care. Coordinated care may require explicit mechanisms to promote communication between the community program and primary care.

Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial.

PURPOSE One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes. METHODS We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks’ gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI−only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years’ postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months’ postpartum was measured with birth certificates. RESULTS Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21–0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16–0.98) and CAMI−only (HR = 0.19; 95% CI, 0.05–0.69). CONCLUSIONS Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.

Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers.

OBJECTIVE To examine whether depressive symptoms are a risk factor for a subsequent pregnancy in adolescent mothers. DESIGN Secondary analysis from a longitudinal risk-reduction intervention. SETTING Five community-based prenatal sites in Baltimore, Maryland. PARTICIPANTS Two hundred sixty-nine consenting teens, predominantly African American and with low income, who received prenatal care at any of the 5 community-based prenatal sites and completed follow-up questionnaires at 1 or 2 years post partum. Intervention Baseline depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale. Outcome Measure Occurrence of and time to subsequent pregnancy by 2 years post partum. RESULTS Among teens completing at least 1 follow-up questionnaire, baseline depressive symptoms were present in 46%. A subsequent pregnancy by 2 years post partum was experienced by 49%, with a mean (SD) time to first subsequent pregnancy of 11.4 (5.8) months. Depressive symptoms were associated with increased risk of subsequent pregnancy in both unadjusted models (hazard ratio, 1.44; 95% confidence interval, 1.01-2.03) and adjusted models (hazard ratio, 1.44; 95% confidence interval, 1.00-2.01). CONCLUSIONS Depressive symptoms may be an independent risk factor for subsequent pregnancy in African American adolescent mothers. Because depression is treatable, future studies should evaluate whether improved recognition and treatment of adolescent depression reduces the risk of rapid subsequent pregnancy.

Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care

PURPOSE To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based. METHODS Retrospective sohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents < or =18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SB-CAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics. RESULTS Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SB-CAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HB-CAPP: 2.31, 95% CI 0.65-8.24). CONCLUSIONS School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care.

Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics

PURPOSE This national study sought information from rural patients (1) to assess the prevalence of bypass, a pattern of seeking health care outside the local community; (2) to examine the impact of locally available primary care physicians (PCPs) and hospital size on the odds of bypass; and (3) to identify patient demographic and geographic factors associated with bypass. This study also ascertained the reasons patients give for bypass and their suggestions for how hospitals can retain patients locally. METHODS We analyzed data from a 2005 telephone survey of 1,264 adults, aged 18 years or older, who lived within 20 miles of 25 randomly selected Critical Access Hospitals and were linked with a Health Professional Shortage Area and 2004 census data. Respondents were asked about demographic characteristics, travel time and distance to local hospitals, and insurance status, as well as for suggestions of what local hospitals could do to retain patients. RESULTS Overall, 32% of respondents bypassed local primary care; the rate ranged from 9% to 66% across the Critical Access Hospital service areas. Factors associated with bypass included age, education, marital status, satisfaction with the local hospital, admission to a hospital in the past 12 months, hospital size, and local density of PCPs. Compared with residents in areas with a higher density of PCPs (=3,500 residents per PCP), residents in areas with a low density (>4,500 residents per PCP) were more likely to bypass local care (odds ratio, 1.58; 95% confidence interval, 1.02–2.46). Lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed local hospitals. CONCLUSIONS The sizable variation in bypass rates among this sample of Critical Access Hospital service areas suggests that strategies to reduce bypass behavior should be directed at the local community or facility level. Changing rural residents’ perception of their local care, helping them gain a better understanding of the function of primary care, and increasing the number of PCPs might help hospitals retain patients and rural communities stay healthy.

Social Determinants of Breast Cancer Screening in Urban Primary Care Practices: A Community-Engaged Formative Study

BACKGROUND The recent decline in the breast cancer mortality rate can be attributed to intensive screening and early detection efforts. However, studies have documented a decline in self-reported recent mammography use and interventions to enhance mammography utilization have yielded modest improvements. To address the root causes of breast cancer disparities and improve mammography use, interventions need to address multiple layers of patient, provider, and health system factors. OBJECTIVE Using community-based participatory research principles, we sought to learn from women receiving care through urban primary care practices about issues surrounding mammography screening and strategies to increase screening. METHODS We conducted five focus groups among 41 eligible women who were predominantly African American, recruited using nonprobability purposive sampling methods from urban community health centers in Baltimore, Maryland. Data are reported from three focus groups (n = 28) that provided usable data. We used the social determinants of health perspective to conduct a qualitative content analysis and interpretation of the data. RESULTS Major obstacles to obtaining a screening mammogram were individual-level (i.e., pain from the procedure) and structural-level factors (i.e., cost, geography, convenience). Strategies to overcome obstacles could include the creation of structural mechanisms whereby women can receive a host of services during one visit to a healthcare professionals office. Important promoters of screening behavior included social-level factors such as social support, hope, and positive treatment outcomes. CONCLUSION The social determinants of health perspective provided a unique perspective to frame barriers and promoters of mammography utilization and insights to develop interventions aimed at improving cancer control among women receiving care at urban primary care health centers.

Engaging hard-to-reach patients in patient-centered outcomes research

AIMS This study aimed to identify methods to engage hard-to-reach patients in the research process. MATERIALS & METHODS With funding from the Patient-Centered Outcomes Research Institute (Washington, DC, USA), the University of Maryland (MD, USA) conducted 20 focus groups and one individual interview. The sample consisted of six groups of hard-to-reach patients, two groups of healthcare providers who work with hard-to-reach patients and two groups of surrogates of hard-to-reach patients. RESULTS & CONCLUSION In order to make patient-centered outcomes research more meaningful to patients and their caregivers, patient-centered outcomes research should be conducted with a focus on building and maintaining trust, which is achieved via pre-engagement with communities and continuous engagement of study participants and their communities.

Cost-effectiveness of a Motivational Intervention to Reduce Rapid Repeated Childbearing in High-Risk Adolescent Mothers A Rebirth of Economic and Policy Considerations

OBJECTIVE To determine the cost-effectiveness of an intervention that successfully reduced rapid repeated births within 2 years of an index birth to adolescent mothers. DESIGN Randomized, controlled trial conducted from February 2003 to October 2007. SETTING Home-based intervention with participants recruited from 5 urban clinics that provide care to low-income African American communities. PARTICIPANTS Two hundred thirty-five pregnant teenagers (n = 235) aged 18 years or younger who were at 24 or more weeks of gestation at recruitment were followed up for 27 months. INTERVENTIONS Participants were randomly assigned to usual care (n = 68) or 1 of 2 home-based interventions conducted by community outreach workers: (1) computer-assisted motivational intervention (CAMI) conducted quarterly with additional visits (CAMI+ [n = 80]) or (2) CAMI only (n = 87), a single-component motivational intervention conducted quarterly. MAIN OUTCOMES Additional births by 24 months post partum determined from birth certificates, total and weighted mean intervention costs, cost per participant, and incremental cost-effectiveness ratios, defined as cost per prevented repeated birth. RESULTS Relative to usual care, CAMI significantly reduced repeated births (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-0.97). Mean intervention costs per adolescent were

Repeat pregnancy prevention self-efficacy in adolescents: associations with provider communication, provider type, and depression.

2064, with incremental cost-effectiveness ratios per prevented repeated birth of

Double Jeopardy : Depressive Symptoms and Rapid Subsequent Pregnancy in Adolescent Mothers

21 895 (unadjusted),