Educational barriers, social isolation, and stable romantic relationships among pregnant immigrant Latina teens

Latina teen birth rates, particularly those of immigrant Latinas, surpass those of any major racial/ ethnic group. Little is known about how immigration experiences influence early childbearing. Fourteen pregnant Latina immigrant teens were interviewed regarding their feelings about pregnancy and birth control, educational and vocational expectations, and their partners' influences. Common themes included feelings of isolation, barriers to education and future opportunities, and a heavy reliance on partners as a stable source of emotional and financial support, all of which appeared to influence teens' desire for pregnancy. Findings suggest the need to help immigrant youth overcome barriers to education and work and to offer them culturally and linguistically appropriate clinical care including birth control information and services, preconception and prenatal care, and assistance navigating the system.

Enhancing service delivery through title x funding: findings from California

CONTEXT

The federal Title X grant program provides funding for family planning services for low-income women and men. In California, all clinics receiving Title X funds participate in the state's family planning program, Family PACT, along with other public and private providers. The relative extent to which Title X-funded clinics and other Family PACT providers have incorporated enhancements beyond their core medical services has never been studied.

METHODS

In 2010, a survey was sent to public- and private-sector Family PACT clinicians to assess whether funding streams were associated with the availability of special services: extended clinic hours, outreach to vulnerable populations, services for clients not proficient in English and use of advanced clinic-based technologies. Bivariate and logistic regression analyses controlling for potentially confounding factors were conducted.

RESULTS

Greater proportions of Title X-funded clinics than of other public and private providers had Spanish-speaking unlicensed clinical staff (89% vs. 71% and 58%, respectively) and Spanish-language signs (95% vs. 85% and 82%). Title X-funded providers were more likely than other public providers to offer extended clinic hours, provide outreach to at least three vulnerable or hard-to-reach populations, and use three or more advanced technologies (odds ratios, 2.0-2.9).

CONCLUSIONS

Compared with other Family PACT providers, clinics that receive Title X funding have implemented greater infrastructure enhancements to promote access and improve the quality of service for underserved populations. This may be because Title X-funded providers have more financial opportunities to provide the array of services that best respond to their clients' needs.

Observations of drinking water access in school food service areas before implementation of federal and state school water policy, California, 2011

Introduction

Recent legislation requires schools to provide free drinking water in food service areas (FSAs). Our objective was to describe access to water at baseline and student water intake in school FSAs and to examine barriers to and strategies for implementation of drinking water requirements.

Methods

We randomly sampled 24 California Bay Area public schools. We interviewed 1 administrator per school to assess knowledge of water legislation and barriers to and ideas for policy implementation. We observed water access and students’ intake of free water in school FSAs. Wellness policies were examined for language about water in FSAs.

Results

Fourteen of 24 schools offered free water in FSAs; 10 offered water via fountains, and 4 provided water through a nonfountain source. Four percent of students drank free water at lunch; intake at elementary schools (11%) was higher than at middle or junior high schools (6%) and high schools (1%). In secondary schools when water was provided by a nonfountain source, the percentage of students who drank free water doubled. Barriers to implementation of water requirements included lack of knowledge of legislation, cost, and other pressing academic concerns. No wellness policies included language about water in FSAs.

Conclusion

Approximately half of schools offered free water in FSAs before implementation of drinking water requirements, and most met requirements through a fountain. Only 1 in 25 students drank free water in FSAs. Although schools can meet regulations through installation of fountains, more appealing water delivery systems may be necessary to increase students’ water intake at mealtimes.

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.

Critical junctures: assuring healthy outcomes for adolescents in the new millennium

Adolescence represents one of the key transitional periods in the life course. During adolescence, individuals are particularly sensitive to environmental or contextual inputs and undergo tremendous physical, social, emotional, and cognitive growth and development, developing habits, behavior patterns, and relationships that influence their lifelong health outcomes. This article provides an overview of the current status of adolescent health in the United States, key examples of areas in which health improvements have been achieved over the past decade, and recent developments in adolescent health policy, including opportunities within health care reform and other federal efforts, that should serve to improve adolescent health over the next decade.

Latina adolescents' perceptions of their male partners' influences on childbearing: findings from a qualitative study in California

Teenage births among Latina women living in the USA remain higher than any other racial/ethnic group. This study explored the role that male partners play in the occurrence of pregnancy and their influence on teenage mothers' future plans in a sample of women pregnant with their first child. Qualitative analysis revealed that partners played a significant role in the use of contraception, timing and desire for pregnancy and young women's post-pregnancy plans for education, work and childrearing. Men's older age, concerns about contraceptive use and fertility, reluctance to use condoms, and readiness for parenthood put their partners at increased risk for pregnancy. More acculturated men were supportive of young women's educational goals in many cases, whereas less acculturated males subscribed to more rigid gender roles which required that their partners remain at home after the birth of their child. These findings have important implications for programmes that seek to reduce teenage pregnancy in the US Latino population.

Creating an environmental justice framework for policy change in childhood asthma: a grassroots to treetops approach

OBJECTIVES

The Community Action to Fight Asthma Initiative, a network of coalitions and technical assistance providers in California, employed an environmental justice approach to reduce risk factors for asthma in school-aged children. Policy advocacy focused on housing, schools, and outdoor air quality. Technical assistance partners from environmental science, policy advocacy, asthma prevention, and media assisted in advocacy. An evaluation team assessed progress and outcomes.

METHODS

A theory of change and corresponding logic model were used to document coalition development and successes. Site visits, surveys, policymaker interviews, and participation in meetings documented the processes and outcomes. Quantitative and qualitative data were analyzed to assess strategies, successes, and challenges.

RESULTS

Coalitions, working with community residents and technical assistance experts, successfully advocated for policies to reduce children's exposures to environmental triggers, particularly in low-income communities and communities of color. Policies were implemented at various levels.

CONCLUSIONS

Environmental justice approaches to policy advocacy could be an effective strategy to address inequities across communities. Strong technical assistance, close community involvement, and multilevel strategies were all essential to effective policies to reduce environmental inequities.

Estimating the fertility effect of expansions of publicly funded family planning services in California

OBJECTIVE

To estimate the number of unintended pregnancies averted through the provision of family planning services to low income women in Family PACT, California's Medicaid waiver program.

STUDY DESIGN

We use a Markov model to estimate the number of pregnancies in the absence of Family PACT based on the contraceptive method mix used before program enrollment, and pregnancies in the presence of the program, based on method dispensing claims.

RESULTS

Nearly 1 million (998,084) women were provided with contraceptives in Family PACT in 2007. Contraceptive services averted over an estimated 286,700 unintended pregnancies including 122,000 abortions, 133,000 unintended births, and over 40,000 births among teens.

CONCLUSION

This conservative measure of the effect of Family PACT on unintended pregnancies indicates the benefit of expanding access to contraceptive services, an example for other states considering expanding access to family planning services through a state plan amendment under health care reform.

Willingness to have unprotected sex

Little is known about people's willingness to engage in sex without protection from unwanted pregnancy. This study surveyed 1,497 women and men at 75 clinics and physician offices across California after their reproductive health care visits in late 2007 and early 2008. When asked if they would have sex without contraception, 30% said definitively that yes, they would have unprotected sex, and 20% indicated they would "sometimes" or "maybe" engage in unprotected sex. In multivariate models, compared to non-Latino White respondents, Latinos who responded to the survey in English were 52% more likely and African Americans were 75% more likely to report willingness to have unprotected intercourse. Wanting a child within the next three years was associated with increased willingness to have unprotected sex. Age, gender, parity, and relationship status were not significant in multivariate models. A considerable proportion of women and men may be willing to have unprotected sex, even with access to subsidized contraceptive services and even when recently counseled about birth control. The dominant behavioral models of contraceptive use need to acknowledge the widespread likelihood of occasional unprotected sex, even among people motivated to usually use contraceptives. Findings underscore the need to make contraceptive methods accessible, easy to use, and even pleasurable.

Neighborhood poverty, aspirations and expectations, and initiation of sex

BACKGROUND

Cross-sectional research has demonstrated associations between neighborhood socioeconomic characteristics and adolescents' initiation of heterosexual intercourse. Prospective designs are needed to move toward causal inference, and to identify mediating and moderating influences to inform policies and programs.

METHODS

Among 5,838 nonsexually active participants in wave I (1994-1995) of the National Longitudinal Study of Adolescent Health, multilevel logistic regression analyses were used to predict initiation of sex by wave II (1996); models were stratified by gender and age group (11-14 and 15-17 yr). Predictors measured at wave I included census tract-level (neighborhood) poverty concentration, family-level income, parental education, race/ethnicity, and family structure. Adolescent college aspirations and life expectations were tested as possible mediators or moderators of the neighborhood poverty-sexual initiation association.

RESULTS

Neighborhood poverty concentration predicted older (15-17 yr) girls' and boys' sexual initiation, after considering individual-level covariates. However, adolescent college aspirations and life expectations were not found to mediate the prediction relationship. Moderating effects were identified for girls (college aspirations) and boys (positive life expectations) in high-poverty neighborhoods, paradoxically reflecting increased risk.

CONCLUSIONS

In this longitudinal study, moderating effects generally considered protective against sexual initiation were not protective or were harmful for adolescents living in high-poverty neighborhoods. Subsequent research to understand how to reduce the health risks of living in poor neighborhoods must examine an even wider range of variables and/or use different methodologies.

The role of school health centers in health care access and client outcomes

OBJECTIVES

We describe the impact of school health centers in Alameda County, California, on adolescents' access to care and their mental and physical health outcomes.

METHODS

We used a multimethod evaluation of 12 school health centers to track data on clients (n=7410), services, and provider-reported outcomes; client pre-post surveys (n=286); and student focus groups (n=105 participants).

RESULTS

School health centers were the most commonly reported source of medical (30%), family planning (63%), and counseling (31%) services for clients. Mental health providers reported significant improvements (P<.05) from baseline to follow-up in clients' presenting concerns and resiliency factors. Medical providers and clients also reported general improvements in reproductive health, particularly in the use of birth control other than condoms. Student focus group participants noted that school health centers helped improve access to services students might not seek out otherwise, particularly counseling and family planning services. Furthermore, students noted that they liked school health centers because of their confidentiality, free services, convenience, and youth-friendly staff.

CONCLUSIONS

School health centers increase access to care and improve mental health, resiliency, and contraceptive use.

Factors Associated With Delayed Childbearing: From the Voices of Expectant Latina Adults and Teens in California

There has been limited research on the protective factors that help Latinas delay childbearing until adulthood. In-depth interviews were conducted with 65 pregnant Latina teenage and adult women in California who were about to have their first child. Lack of or inconsistent birth control use as teens was attributed to wanting or ambivalence toward childbearing, concern about contraceptive side effects and infertility, and/or inadequate contraceptive information. Parental influence was cited as the primary reason for avoiding teen childbearing, as well as the feeling that a baby would have interfered with life plans. Close parental supervision and positive relationships with parents appeared to protect some adults from teen childbearing. The findings from this study point to the need to improve Latinos’ birth control knowledge and strengthen parents’ ability to establish supportive relationships with their children.

Gender, culture and reproductive decision-making among recent Mexican migrants in California

This study of the experiences of recent Mexican immigrants living in California explores the changing perceptions of sexual and societal norms, including gender roles and resulting reproductive decision-making, that appear to accompany the migration process. These norms are compared to those held by migrants' families of origin in Mexico. We analysed 44 semi-structured interviews conducted with a client-based population in order to identify reproductive perceptions and practices that appear to be influenced by recent migration. Using a grounded theory approach, 26 women and 18 men's narratives were analysed to understand the complexity of changing expectations and resulting reproductive health practises. The social marginalisation and isolation of immigrants' experiences, the challenges of new socio-economic factors and access to health services appear to reshape views on reproductive decisions. While traditional gender roles and large families remain a spoken ideal, in practice these reproductive patterns are changing. Our analysis suggests that the migration process does alter relationships, reproductive decisions and contraceptive use among recent Mexican immigrants. The public health goal should be to provide an array of accessible and affordable services, tailored to the needs of this increasingly larger population of recent Mexican migrants in California and throughout the USA.

Trends in adolescent and young adult health in the United States

This review presents a national health profile of adolescents and young adults (ages 10-24). The data presented include trends on demographics, mortality, health-related behaviors, and healthcare access and utilization, as well as the most significant gender and racial/ethnic disparities. Although the data show some improvement, many concerns remain. Encouraging trends-such as decreases in rates of homicide, suicide, and some measures of reproductive health-appear to be leveling off or, in some cases, reversing (e.g., birth and gonorrhea rates). Large disparities, particularly by race/ethnicity and gender, persist in many areas. Access to quality healthcare services remains a challenge, especially during young adulthood. Policy and research recommendations to improve health during these critical periods in the lifespan are outlined.

The role of policy advocacy in assuring comprehensive family life education in California

As part of their 10-year $60 million Teenage Pregnancy Prevention Initiative, The California Wellness Foundation funded 18 state and local organizations to conduct policy advocacy to strengthen teen pregnancy prevention policies. This article describes how some of these grantees accomplished noteworthy goals, including the passage of the California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act (SB71), the prevention of the state's pursuit of federal "abstinence-only-until-marriage" funding, and the passage of a local school district FLE policy. Grantee progress is presented through a five-stage policy change framework: Institutional Capacity and Leadership Building, Policy Issue Recognition, Policy Prioritization, Policy Adoption, and Policy Maintenance. Implications are shared for advocates, policy makers, and funders who are developing initiatives aimed at improving the health of adolescents.

Cost savings from the provision of specific methods of contraception in a publicly funded program

OBJECTIVES

We examined the cost-effectiveness of contraceptive methods dispensed in 2003 to 955,000 women in Family PACT (Planning, Access, Care and Treatment), California's publicly funded family planning program.

METHODS

We estimated the number of pregnancies averted by each contraceptive method and compared the cost of providing each method with the savings from averted pregnancies.

RESULTS

More than half of the 178,000 averted pregnancies were attributable to oral contraceptives, one fifth to injectable methods, and one tenth each to the patch and barrier methods. The implant and intrauterine contraceptives were the most cost-effective, with cost savings of more than $7.00 for every $1.00 spent in services and supplies. Per $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contraceptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34; and emergency contraceptives, $1.43.

CONCLUSIONS

All contraceptive methods were cost-effective-they saved more in public expenditures for unintended pregnancies than they cost to provide. Because no single method is clinically recommended to every woman, it is medically and fiscally advisable for public health programs to offer all contraceptive methods.

Empowerment and Physical Violence Throughout Women's Reproductive Life In Mexico

This article analyzes intimate partner violence (IPV) against women aged 15 to 21, 30 to 34, and 45 to 49, based on the 2003 National Survey on the Dynamics of Household Relationships (in Spanish, ENDIREH) in Mexico. The authors examined the degree of women's empowerment and autonomy in relation to their partners. Logit regression analyses showed that variables significantly associated with physical violence varied between the three age groups, suggesting that women followed specific trajectories throughout their reproductive lives. Some dimensions of empowerment reduced the risk of violence (women's ability to decide whether to work, when to have sexual relations, and the extent of their partners' participation in household chores). Other dimensions (women's decision making regarding reproductive matters) increased such risk. Thus, access to resources meant to empower women did not automatically decrease the risk of violence. The authors recommend specific interventions tailored to each age group, aimed at breaking the cycle of violence.

Innovations in preventive mental health care services for adolescents

PURPOSE

This descriptive study examined programs designed to provide mental health-related preventive services to at-risk adolescents.

METHODS

Qualitative interviews were conducted with state and local program directors and key personnel in public health and mental health departments and academic researchers who have initiated preventive services.

RESULTS

States and local communities offer varied mental health-related preventive services for high-risk adolescents in diverse settings. Services include public education, screening, early intervention for adolescents, and educational programs for primary care providers. Funding mechanisms include state general funds, foundation grants, and Medicaid and the State Children's Health Insurance Program dollars. Evaluation is essential to maintain services and to persuade funders and other stakeholders to sustain these efforts.

CONCLUSIONS

State and local prevention-related mental health programs have been implemented with limited funding, but significant local advocacy and community support. More extensive evaluation and cost effectiveness studies may encourage policymakers to expand services. Further data are necessary to determine how prevention-related mental health programs can best serve vulnerable youth.

A midcourse review of the healthy people 2010: 21 critical health objectives for adolescents and young adults

As part of Healthy People 2010, a national consensus panel identified 21 Healthy People 2010 objectives as critical to adolescent and young adult health. These objectives span six areas: mortality, unintentional injury, violence, mental health and substance use, reproductive health, and the prevention of chronic disease during adulthood. Progress on these objectives was reviewed as part of the Healthy People 2010 Midcourse Review. The review found little or no improvement on most objectives. Expert recommendations call for broad, population-based efforts to improve adolescent health. However, changes in health policy are largely issue-based and occur incrementally.

Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California

OBJECTIVE

To assess the short-term economic savings associated with the prevention of unintended pregnancies through California's Medicaid family planning demonstration project.

DATA SOURCES

Secondary data from health and social service programs available to pregnant or parenting women at or below 200 percent of the federal poverty level in California in 2002 and data on the quantity and type of contraceptives dispensed to clients of California's 1115 Federal Medicaid demonstration project.

STUDY DESIGN

The cost of providing publicly funded family planning services was compared with an estimate of public savings resulting from the prevention of unintended pregnancies.

DATA COLLECTION

To estimate costs and participation rates in each health and social service program, we examined published program reports, government budgetary data, analyses conducted by federal and state level program managers, and calculations from national datasets.

FINDINGS

The unintended pregnancies averted by California's family planning demonstration project in 2002 would have incurred $1.1 billion in public expenditures within 2 years and $2.2 billion within 5 years, significantly more than the $403.8 million spent on the project. Each dollar spent generated savings of $2.76 within 2 years and $5.33 within 5 years.

CONCLUSIONS

The California 1115 Medicaid family planning demonstration project resulted in significant public cost savings. The cost of the project was substantially less than the public sector health and social service costs which would have occurred in its absence.