Differences and similarities in sexual and contraceptive knowledge, attitudes, and behavior among Latino male adolescent students in California, United States and Lima, Peru

To identify the differences and similarities in sexual and contraceptive knowledge, attitudes, and behavior among Latino male adolescent students living in California and Lima. Self-administered, anonymous surveys were completed by Latino male students aged 12-19 participating in California, and by male adolescent students in four high schools in Lima. Both surveys contained similar questions allowing for comparisons regarding sexual activity and contraceptive behavior. The mean age of male students were 16 and 15 years, respectively. More California males reported having engaged in sexual intercourse (69% vs 43%. The sexual debut was 13 years in both samples. More students in California were aware of their risk of pregnancy at first sexual intercourse than in Lima (82% vs 50%). One-third of the California males reported communicating with their partner about sex and contraception to be "easy" as compared to 53% of males in Lima. More students in California reported knowing a place to obtain contraceptives if they need them (85% vs 63%), having ever gotten someone pregnant (29% vs 7%), and having fathered a child (67% vs 16%).

Informed policy making for the prevention of unwanted pregnancy. Understanding low-income women's experiences with family planning

California health and welfare officials asked the authors to identify ways that their programs could encourage service use among low-income women. The project posed a challenge: The clients wanted to identify supply-side barriers amenable to intervention, but prior research suggested other factors might be more influential. The approach was to examine service-related issues, but in the broader context of women's experiences. The authors identify factors amenable to intervention, including inaccurate beliefs about methods. Other important influences--such as instability of relationships, skepticism about planning, or unsatisfactory method experiences--may be beyond the reach of specific policies, but are nevertheless critical to understanding program context. Findings suggest that punitive messages and policies based on a simplistic model of behavior may be unrealistic and ineffective.

Building for the future: adolescent pregnancy prevention

Although almost 500,000 teenagers deliver babies every year in the United States, adolescent birth trends in the late 1990s clearly reversed the dramatic rise in rates of the previous decade. The US birth rate for teenagers in 1997 was 52.3 live births per 1,000 women age 15 to 19, a reduction of 16% from 1991. This results in part from two promising trends: Teenagers today are less likely to be sexually active, and sexually active teenagers are more likely to use contraception. Over the past two decades, a number of research studies have provided important insights that are useful for both individual clinical assessment and the development of interventions aimed at reducing the incidence of early childbearing. A number of key program factors can successfully reduce adolescent pregnancy. These include providing accurate information about the risks of unprotected intercourse and ways to avoid an unintended pregnancy; using a variety of teaching methods designed to involve the participants and have them personalize the information (with particular tailoring to appropriate age, gender, culture, and sexual experience); and providing models of and practice in communication, negotiation, and refusal skills. Resolving the problem of teenage pregnancy will require a major and coordinated effort aimed not only at adolescents themselves, but also at the political, economic, medical, educational, and religious institutions whose systems and policies profoundly influence the underlying conditions that lead to adolescent pregnancy and child-bearing.

Substance use and social outcomes among participants in perinatal alcohol and drug treatment

In recent years comprehensive, woman-centered alcohol and other drug (AOD) treatment programs for pregnant and parenting women have increased in number, despite a scarcity of information about their effectiveness. In response, an evaluation study was undertaken to document the behavioral and social outcome among a sample of women enrolled in AOD treatment through a California network of perinatal treatment services. A sample of 591 women were interviewed shortly before leaving treatment about their pretreatment and current treatment experiences, and 460 of them completed a follow-up interview 6 months later. Areas of positive change observed included reductions in AOD use, maintenance of some kind of treatment contact after discharge from the perinatal treatment program, reductions in criminal activity, and reductions in social problems. These findings suggest that comprehensive programs are effective at promoting recovery and positive social changes for pregnant and parenting women and their children.

The Prevention Minimum Evaluation Data Set (PMEDS). A tool for evaluating teen pregnancy and STD/HIV/AIDS prevention programs

This article presents the Prevention Minimum Evaluation Data Set (PMEDS), a ready-to-use questionnaire or tool for evaluating teen pregnancy prevention and teen STD/HIV/AIDS prevention programs. Recognizing the diversity of approaches taken by these programs, PMEDS has two parts. Part 1 contains a primary questionnaire applicable to all programs. Part 2 consists of 15 additional supplementary modules for optional use by programs with a more specific target population or intervention approach that matches the module's content. It is hoped that PMEDS will facilitate the conducting of high-quality evaluations, first by highlighting important aspects of a program model that should be included in an evaluation, such as the demographic profile of the target population, the specific aspects of the intervention or treatment received by each participant, and the short-term outcomes and long-term goals that the program is trying to affect; second, by presenting measures for these evaluation constructs that have been extensively pretested and used in large-scale national studies and for which national comparison norms and data exist.

Small-area analysis: targeting high-risk areas for adolescent pregnancy prevention programs

CONTEXT

Traditional methods of identifying areas in need of adolescent pregnancy prevention programs may miss small localities with high levels of adolescent childbearing.

METHODS

Birthrates for 15-17-year-olds were computed for all California zip codes, and the zip codes with birthrates in the 75th percentile were identified. Panels of local experts in adolescent pregnancy reviewed these "hot spots" for accuracy and grouped them into potential project areas, based on their demographics, geography and political infrastructure.

RESULTS

In all, 415 zip codes exceeded the 75th-percentile cut-off point of 62.8 births per 1,000, and 210 of them differed significantly from the state average of 44.5 per 1,000 for 15-17-year-olds. While all had high adolescent birthrates, they varied greatly in racial and ethnic mix, poverty and educational attainment, and certain perinatal measures such as inadequate prenatal care and repeat pregnancy.

CONCLUSIONS

The use of zip code-level data holds promise for more effective program planning and intervention.

Community health monitoring: taking the pulse of America's children

OBJECTIVE

To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991-1996).

METHODS

A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-person and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting.

RESULTS

All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children.

CONCLUSIONS

Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.

Elementary school-based health center use

BACKGROUND

The number of school-based health centers (SBHCs) has grown from 40 in 1985 to >900 in 1996. During the 1996-1997 school year there were 914 SBHCs, 32% of which were located in elementary schools. Despite the relatively large number of elementary SBHCs in existence, SBHCs serving elementary-aged students are not adequately represented in the literature.

OBJECTIVE

To analyze physical and mental primary health care utilization in a comprehensive elementary SBHC for an underserved Hispanic population.

DESIGN

Retrospective analyses of services used at an elementary SBHC during the 1995-1996 school year. We describe physical and mental health services utilization provided by SBHC staff who offered a range of primary medical and mental health services.

PATIENTS

The study population was predominately Hispanic, and comprised of 811 elementary school students (grades preschool through fifth) registered for SBHC use. Analyses were conducted on 591 students who used the SBHC.

RESULTS

The 591 SBHC users made 2443 visits, ranging between 1 and 54 visits/individual; mean 4 visits/student. Two thirds of visits (1638) were medical provider visits, and 33% (798) were mental health provider visits. Most students (75%) saw a medical provider exclusively, 9% saw a mental health provider exclusively, and 16% of students were seen by both. Mean duration of medical provider visits +/-SD was 15 +/- 13 minutes, mean for mental health provider visits +/-SD, 37 +/- 16 minutes. Of the 3035 diagnoses, 64% were medical and 36% were mental health diagnoses. These diagnostic frequencies are grouped as follows: acute medical (31%), health maintenance (22%), depression (10%), non-Diagnostic and Statistical Manual of Mental Disorders-IV mental health diagnoses (8%), conflict disorder/emotional disturbance (8%), chronic medical (8%), academic/learning disorder (7%), anxiety disorder (3%), and other (4%).

CONCLUSIONS

High rates of SBHC utilization by this population and the range of diagnoses recorded suggest health care delivered in a comprehensive, culturally-sensitive SBHC has the potential for impacting the health and well-being of underserved elementary-aged students.

A profile of the adolescent male family planning client

CONTEXT

Family planning programs and policies increasingly focus on the male partner's roles and responsibilities in contraceptive decision-making and use. To effectively tailor services for males, policymakers and providers must refine their understanding of men's psychosocial and reproductive health needs.

METHODS

Using self-administered questionnaires, 1,540 sexually active males aged 19 and younger who attended family planning clinics in California provided information about their sexual behavior, contraceptive use, pregnancy and parenting history, and psychosocial characteristics. Logistic regression was used to examine factors that contributed to effective contraceptive use.

RESULTS

Although 73% of participants reported having used a birth control method at first intercourse, only 59% said that they or their partner had used an effective method at last intercourse, and 35% had used no method. If the client was uncomfortable with his method, the odds that he had used an effective method at last intercourse were reduced (odds ratio, 0.4). The likelihood of use at last intercourse was increased among males who agreed with their partner about their method and those who had never impregnated a partner (1.4 and 1.9, respectively).

CONCLUSIONS

To adequately serve young males, clinics must take into account their sexual and contraceptive histories. But screening should go beyond traditional family planning techniques to discuss how to improve communication with partners and other lifestyle issues that may interfere with consistent use.

The use of formative evaluation to assess integrated services for children. The Robert Wood Johnson Foundation Child Health Initiative

This article describes the use of formative evaluation in assessing the feasibility of implementing a new service integration effort. The Child Health Initiative, a nine-site, national demonstration project funded in 1991 by the Robert Wood Johnson Foundation, sought to implement systemic change through the creation of new mechanisms for spending service dollars more flexibly at the local site. The Child Health Initiative called for developing local child health-monitoring systems, a care coordination mechanism, and a program for decategorizing the myriad of restrictive categorical public programs serving children. Most demonstration communities experienced some degree of success in achieving the first two components, but none was able to implement decategorization during the 3- to 5-year funding period. Key lessons for evaluators include the need for (a) a flexible evaluation design that can sequentially adapt to changes in program implementation, (b) repeated longitudinal data collection measures to document changes over time, (c) avoidance of a premature focus on program outcomes, and (d) methods to establish attribution of outcomes.

Integrating children's health services: evaluation of a national demonstration project

OBJECTIVES

Increasingly, the public and private sectors are turning to "service integration" efforts to reduce, if not eliminate, barriers to needed care created by categorical programs. In 1991, the Robert Wood Johnson Foundation established a new national demonstration project, called the Child Health Initiative, intended to test the feasibility of developing mechanisms at the community level to coordinate the delivery of health services and to pay for those services through a flexible pool of previously categorical funds. This article presents the findings of an independent evaluation of the Child Health Initiative.

METHOD

The evaluation utilized a combination of qualitative methods to assess and describe the experiences of the communities as they developed and implemented integrated health services. It used a repeated measures design involving two site visits and interim telephone interviews, as well as review of documents.

RESULTS

Overall, the demonstration project achieved mixed success. Both care coordination and the production of community health report cards were found to be achievable within the relatively short life of the foundation grant. However, many sites experienced significant delays in the production of report cards and implementing care coordination plans because the sites largely did not benefit from the successful models already in existence. Little clear progress was made in implementing the decategorization component of the project. Sites experienced difficulties due to lack of previous experience with this new undertaking, the inability to secure active cooperation from local, state, and federal agencies, the relatively short duration of the project, and other factors.

CONCLUSIONS

A number of lessons were learned from this project that may be useful in future decategorization experiments, including (1) a clear understanding of the concept and its applications among all parties is essential, (2) high-level political commitments to the effort are needed between all levels of government, (3) adequate technical assistance should be provided to surmount technical considerations in establishing a workable approach to decategorization, and (4) decategorization and service integration efforts should focus on both the health and social sectors.

Social HMOs and other capitated arrangements for children with special health care needs

OBJECTIVE

Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs.

METHOD

We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly.

RESULTS

Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged.

CONCLUSIONS

With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.

At the crossroads: options for financing college health services in the 21st century

At a time when increasing numbers of uninsured and underinsured students are attending college, many college health programs face formidable challenges in their efforts to sustain services. As financial pressures increase, college health programs must revisit their funding options, including (1) maintaining the current level and source of funding but requiring additional out-of-pocket fees for certain services from students, (2) establishing their own insurance plans, (3) qualifying as a preferred provider organization, or (4) some combination of the above. Whatever strategies are selected and pursued, college health programs must continue to try to provide quality services at a reasonable cost while maintaining an emphasis on prevention, health education, and the provision of services most needed by the college population, including mental health and substance abuse services.

Benchmarking the perioperative process. I. Patient routing systems: a method for continual improvement of patient flow and resource utilization

The article presents an overview of the design and application of a real-time patient routing system, based on barcode and local area network technology, that was designed to track the progress of patients during the perioperative process. We present data on all patients undergoing ambulatory surgery. Patients' progress during their surgical stay was recorded at 17 strategic events using this real-time patient tracking technology. These times were used to identify inefficiencies in the perioperative process by identifying bottlenecks and areas of high variation. We found that both raw and actual operating room (OR) utilization efficiency was less than 50%. Points of high variation in a patient's progress occurred during the time from admit to the hospital until the patient was ready for the OR; the time from when a patient was ready for the OR until they were called for; and the time a patient spends in the OR preoperative holding room. Causes for variation were identified and traced back to individual procedures, activities, and work processes. Multidisciplinary improvement teams were created to improve the pinpointed problem areas. The real-time patient routing system is a process that has proven to be highly valuable to all participants in the surgical process in bringing about rational, data driven efficiencies in perioperative services. This process has the potential to facilitate multidisciplinary cooperation in efforts to contain and reduce costs of perioperative services.

Using a multimethod approach to measure success in perinatal drug treatment

In the evaluation study of Options for Recovery (OFR), a comprehensive statewide initiative to promote perinatal drug and alcohol recovery, a critical step in the design and implementation of the research was to define and operationalize indicators of success. Rather than rely on any single evaluation method, a number of different data-gathering strategies were used to illuminate and provide a context for data that pertained to a given indicator. Qualitative information, derived from the interviews with staff and clients, yielded a set of treatment success indicators that was used to guide the selection of quantitative variables, as well as provide a contextual understanding of the quantitative findings. The quantitative findings helped to objectify the qualitative information. This article discusses the practical application of this multimethod approach and its effectiveness in measuring client success and illuminating the complexities of perinatal substance use treatment and recovery.

The interplay of national, state, and local policy in financing care for drug-affected women and children in California

Recent prevalence studies in California indicate that perinatal alcohol and other drug use remains a serious issue for large numbers of women and their children. In response, national, state and local policymakers have taken steps to address the problem, including increasing funding for treatment services. To gauge the impact of policy attention to this problem, the Center for the Vulnerable Child at Children's Hospital, Oakland, California, surveyed state and local administrators of programs that serve drug-affected women and children in California. Information collected included the scope of program services, indicators of access, and sources of program funding. Surveyed programs were funded through federal, state, county, and foundation sources. Despite new policy and funding initiatives to serve this population, the study found wide gaps between the kinds of services that are believed to be appropriate for drug-affected women and children and the service system that currently exists. Problems in access to care included long waiting times, exclusion of women from programs based on their pregnancy or parenting status, and exclusion of drug-exposed children from programs with medically based eligibility criteria. Program funding sources appeared to impede access, as traditional federal, state, and county funding sources do not support programs that are comprehensive, family-centered, and easily accessible to these women and children. Analysis of the study data suggests that policymakers consider new approaches to promote access to care for these underserved women and children, particularly now as Congress and the states redesign health and social service funding mechanisms and delivery systems.

Options for recovery: promoting success among women mandated to treatment

In recent years imprisonment has been used increasingly for a wide range of nonviolent and petty offenses committed by women. Among incarcerated women, particularly those who are pregnant or parenting, substance use and its deleterious consequences are often exacerbated by imprisonment. Women who have been identified as chemically dependent are also at high risk for losing custody of their children. In California, the Options for Recovery (OFR) treatment program provided an alternative to incarceration or relinquishment of custody of children for chemically dependent pregnant and parenting women. This three-year pilot project offered alcohol and other drug abuse treatment and case management to these women, and included special training and recruitment of foster parents for their children. Findings from a three-year, multimethod evaluation study showed that women who were mandated to OFR treatment programs were more likely to successfully complete treatment than women who had enrolled in OFR voluntarily. An economic analysis of the costs associated with women in OFR compared with the combined costs of incarceration and alcohol and other drug abuse treatment produced a ratio in favor of OFR. Additionally, some innovative service alternatives for women mandated to treatment were developed during the project. The impact of such changes have implications for improving women's and family health.

Promising approaches for adolescent reproductive health service delivery. The role of school-based health centers in a managed care environment

Within the arena of adolescent health care, the most critical service delivery issue is access to care. Efforts to contain health care expenditures through managed care plans inevitably conflict with efforts to deliver truly comprehensive preventive services to all adolescents. Because of the substantial increase in risk behaviors, prevention efforts require frequent contacts if interventions are to be made before risk behaviors occur or soon after their onset. In addition, yearly screening for all adolescents is likely to identify many teens who could benefit from early interventions. Enabling school-based health centers to provide services in coordination with managed care systems would go far to ensure access to care, as well as appropriate attention to the special needs of adolescents, in a timely and cost-effective way. Furthermore, that access would not be tied solely to the family's choice of provider or to the provider mandated by the adolescent's insurance plan. Underlying any approach to coordination of services, however, is the need for managed care providers to understand and affirm a preventive care investment in young people as a means of reducing health care expenditures, an investment that would pay dividends not only during the adolescent years but into adulthood as well. Whether the willingness exists to make this investment, when the cost savings may not directly accrue to the adolescent's current HMO, presents a conflict between the present interests of the HMO and the future interests of whatever provider the adolescent sees as an adult. As managed care systems are more widely adopted, it will be important to ensure that they adequately incorporate the service delivery components that have been found to be efficacious in serving adolescents. Given the leading role school-based health centers can play in providing preventive health care and health promotion, managed care providers should be encouraged to develop strong partnerships with such centers, so that the dual goals of high-quality care and cost containment can be achieved.

The associations between immigrant status and risk-behavior patterns in Latino adolescents

PURPOSE

The purpose of this study was to identify differences in patterns of risk-taking behavior among Latino adolescents with respect to immigrant status and in comparison to their native non-Hispanic white counterparts.

METHODS

In fall of 1988 and spring of 1989 a confidential Teen Health Risk Survey was administered to 1,789 students at two high schools in northern California, both of which have a school health center on-site, and which had large numbers of Latino students enrolled. We divided the Latino adolescent population into two groups: Latinos who were born in the United States (native-born Latinos) and Latinos who had immigrated to the United States (Latino immigrants). Eight different risk-taking behaviors were identified for this study: alcohol, cigarette, marijuana, illicit drug use, self-violence, drunk driving, unintended pregnancy, and violence.

RESULTS

We found that in general, Latino students engaged in a greater number of risk-taking behaviors than native non-Hispanic whites. The mean number of risk behaviors was highest for Latino immigrants (1.78), followed by native-born Latinos (1.71), and native non-Hispanic whites (.99). A t-test revealed that non-Hispanic whites were statistically different from both Latino populations in either level of risk-taking behavior (p < 0.05).

CONCLUSIONS

This sample of immigrant Latino students appeared to be vulnerable to engaging in risk-taking behaviors and did not exhibit the anticipated cultural protective factors associated with recent immigrants. The extent and variety of risk-taking behaviors clearly call for the development of culturally sensitive and accessible health education and health care services within a broader array of social, educational and support services.

The impact of health insurance status on adolescents' utilization of school-based clinic services: implications for health care reform

PURPOSE

1) To examine variations among students with different health insurance coverage in their use of school-based clinics (SBCs), reasons for not receiving health care when needed, and reasons for using or not using SBCs, and 2) to determine if insurance status is a significant factor in predicting SBC use, after controlling for demographic variables and health status.

METHODS

Confidential questionnaires were administered to 2,860 adolescents attending 3 urban high schools with on-site SBCs. Chi-square and multiple logistic regression analyses were used to assess differences among insurance groups in patterns of SBC use and reasons for clinic use/nonuse.

RESULTS

Students with private insurance or HMO coverage had the highest rates of SBC utilization (67% & 66%) and students without health insurance and with Medicaid had the lowest (57% & 59%) (p < 0.01). While there was no difference among adolescents according to insurance group membership in their use of SBC medical services, a significantly higher proportion of students with Medicaid coverage used SBC mental health services. Students without health insurance were less likely to receive health care from any source when it was needed. After controlling for demographic variables and health status, no insurance factors remained significant.

CONCLUSIONS

SBC users represent a variety of insurance groups. Health care reform efforts need to take into account the special needs of adolescents and the challenges they face in accessing care that go beyond financial barriers to care. SBC have been shown to provide a convenient and acceptable source of care, as well as offering the opportunity to provide preventive and primary care services to at-risk youth. As the country moves to a managed care environment potential partnerships with SBCs represent a unique opportunity to improve the delivery of care to adolescents, assuring increased access to a package of health services that they need.

Decategorizing health services: interim findings from the Robert Wood Johnson Foundation's Child Health Initiative

Although results from the evaluation are preliminary thus far, certain tentative conclusions can be reached. First, both care coordination on a small scale and the production of community health report cards are achievable within the relatively short life of a foundation grant. Moreover, both efforts can result in tangible improvements for children and their families. Report cards associated with the initiative have made children's issues more prominent and appear to have led many community leaders to focus greater attention on children's needs. Likewise, many of the care coordination systems developed under the initiative have produced real change for children and their families by guiding them to needed health care and other services. It is important, however, to keep these accomplishments in perspective. While of significant benefit to demonstration communities, the monitoring and care coordination components of this initiative are not unique. A large number of communities have adopted monitoring and reporting programs in recent years. Similarly, care coordination efforts are well established in many communities. What is unique about the RWJF initiative is its attempt at decategorization, and much less progress has been demonstrated for this component. The less-than-hoped-for progress in implementing decategorization at the original sites appears to be the product of a number of interrelated factors. These include an absence of existing models and appropriate technical assistance; political difficulties in gaining cooperation from multiple local agencies involved in service provision; limited progress in establishing needed connections with the state and federal agencies that have authority over categorical programs; and difficulties in implementing major programatic changes when the health care system itself is undergoing rapid change. In combination, these barriers have proven to be largely insurmountable for the originally funded sites, although it is too early in the project to determine which of these factors is predominantly responsible for the lack of success. Whether the newer sites can learn from the experience of the first group and adapt strategies to overcome the multiple hurdles involved remains to be seen. Decategorization is a tool that has the potential to rationalize a fragmented service system by facilitating the coordination of services, especially for children and families with multiple needs. The need for decategorization of funds will not disappear, even if the federal government chooses to combine more of its grant programs to the states into block grants.(ABSTRACT TRUNCATED AT 400 WORDS)

Characteristics associated with contraceptive use among adolescent females in school-based family planning programs

Among 162 young female family planning clients at four school-based health centers, a step-wise regression analysis shows that students' consistency of contraceptive use is associated with only a few specific service and provider characteristics. For example, clients who have more contacts with the family planning program use contraceptives more consistently than those with fewer contacts. On the other hand, young women whose follow-up visits are scheduled to occur within one month of their previous visit are less consistent contraceptive users than other clients. Contraceptive use is not related to whether contraceptives are dispensed on site, whether health education and counseling are provided by a health educator, whether contraceptive services are part of a comprehensive array of services that include medical or counseling services, or whether a family planning visit results in the dispensing of contraceptives or a prescription for contraceptives.

[The reproductive characteristics of adolescents and young adults in Mexico City]

This article presents the preliminary findings of the Survey on Teenagers and Youth Reproductive Behavior in the Metropolitan Area of Mexico City, which contains information on 1,010 teenagers and young adults from 10 to 25 years of age interviewed in 1987. The average age was 17 years; 51.7 per cent of those interviewed were male and 48.3 per cent were female. A total of 14.6 per cent were married, being the average age at marriage 19.2 years for males and 17.8 years for females. Menarche occurred at an average age of 12.4 years, and spermarche at 14. Of those interviewed, 32.7 per cent have had sexual intercourse at least once in their lives. The average age at which sexual activity had begun, in the case of males, was 16 years and for females, 17 years. Of this group, 33.8 per cent stated that they had used some form of contraception during the first sexual intercourse; the contraceptive methods used most often were rhythm and withdrawal. The main source of supply of other methods is the pharmacy, in 67 per cent. 18.4 per cent of women had been pregnant, and 20.4 per cent of men's partners had presented this same condition. The first pregnancy occurred at 17.8 years for women and 18.7 for men. Of those men and women with a pregnancy experience 66.1 per cent and 57.3 per cent, respectively, stated that their first pregnancy was an unplanned one. Also, first pregnancy was related to their first marriage in 48.1 per cent of women and 82.4 per cent of male. The data presented here will reinforce current knowledge and will enable us to obtain a profile of the reproductive behavior of teenagers and young adults in the metropolitan area of Mexico City.

Health policy reform and comprehensive school health education: the need for an effective partnership

This article offers a framework for considering how health care reform issues will impact the success of any national movement to implement Comprehensive School Health Education and the potential role that CSHE proponents can play in advocating reforms congruent with CSHE goals. The effectiveness of the CSHE movement within this arena will depend largely on its ability to critically self-diagnose its potential contributions to short-term and long-term positive health outcomes, and on its ability to join forces in ensuring that a variety of health, educational, and social services are made available in nontraditional sites--particularly schools--that are able to reach children and their families. An important step will be to expand the availability of Comprehensive School Health Education throughout the country: only one-half of all states currently mandate Comprehensive School Health Education programs, and implementation is spotty in some of these states. Another boost for the potential role of CSHE proponents can be found in the Year 2000 health objectives, of which more than one-third of 300 objectives geared to promoting health and disease prevention are devoted to the health behavior of school-age children and youth. Many of these objectives can be achieved directly or indirectly in schools, contingent upon appropriate financing and the establishment of CSHE goals as priorities at the policymaking level. An important factor will be the ability of the CSHE movement to provide its programs in the most cost-effective and cost-efficient manner, possibly including redeployment of staff and relocating resources as needed.(ABSTRACT TRUNCATED AT 250 WORDS)

Financing health care for adolescents: problems, prospects, and proposals

Currently, one in every seven adolescents, aged 10-18, is uninsured. This translates to nearly 5 million uninsured adolescents nationwide. Uninsured adolescents, as opposed to insured adolescents, are more likely to be members of poor and minority families. In addition, adolescents without health insurance use fewer health services than their insured counterparts even after controlling for health status differences. Improving the health insurance status of adolescents is becoming an important public policy objective, although Congress recently rejected legislation that would have expanded Medicaid coverage for poor adolescents. Despite this setback, legislators and child health associates are increasingly striving for public and private insurance expansions for adolescents. These efforts are described, and the prospects for future improvements in health insurance coverage of adolescents are discussed.

Trends in rates of live births and abortions following state restrictions on public funding of abortion

Abortion rates rose following the expanded legalization of abortion by the Supreme Court decision in Roe v. Wade. As a result, the impact of the restriction on Federal funding of abortions under the Hyde Amendment in 1977 was not clear. However, abortion rates had plateaued by 1985, when State funding of Medicaid abortions was restricted in Colorado, North Carolina, and Pennsylvania. Analysis of statewide data from the three States indicated that following restrictions on State funding of abortions, the proportion of reported pregnancies resulting in births, rather than in abortions, increased in all three States. In 1985, the first year of State restrictions on the use of public funds for abortion, Colorado, North Carolina, and Pennsylvania recorded 1.9 to 2.4 percent increases in the proportion of reported pregnancies resulting in live births, after years of declining rates. With adjustments for underreporting of abortion, there was an overall 1.2 percent rise in the proportion of pregnancies resulting in live births in those States. Nationally the proportion rose only 0.4 percent. By 1987, the three States had experienced increases above 1984 levels of 1.6 to 5.9 percent in the proportion of reported pregnancies resulting in live births. The experiences of the three States can be used in projecting an expected increase in the proportions of reported pregnancies resulting in live births, rather than in abortions, for similar States. A projection for California, for example, showed that an increase could be expected in the first year of restrictions on the use of public funds for abortion of at least 4,000 births, which could be expected largely to affect women of low income.

Birth weight outcomes in a teenage pregnancy case management project

While many comprehensive health care programs for pregnant adolescents are designed to improve the birth weights of the babies born, few provide statistical evidence that they were able to do so. In this study, information was gathered prospectively on 411 mothers in a Teenage Pregnancy and Parenting Program (TAPP) that coordinated medical, educational, and social services through individual case management and agency-level coordination, information on the mothers, their pregnancy, and services received. The low birth weight rate for TAPP participants was significantly lower than the rate for San Francisco teens prior to the establishment of the program (8.1% versus 12.0% p less than 0.05). The mean weights of babies born to teens in TAPP were significantly higher than those in San Francisco after controlling for differences in the race, infant gender, parity, and age (p less than 0.0001). Participation in the TAPP program prior to delivery was more strongly associated with better birth weight outcomes than was race, age, parity, or gender. Participation in the TAPP program was associated with significantly better birth weights independent of receiving a minimal number of prenatal medical visits adequate for the gestational age of the baby at birth. Our results provide evidence of better health outcomes for the babies of teens who had case management that included continuous individual counseling and coordination of health, education, psychosocial, and nutrition services.

High fertility among Indochinese refugees

From 1975 to 1988, nearly 900,000 Indochinese refugees were resettled in the United States. This paper examines patterns of fertility among these refugees from Cambodia, Laos, and Vietnam who have exhibited high levels of reproduction since their arrival. Data are drawn from sample surveys in San Diego and San Francisco, CA. Fertility levels were found to exceed five children per ever-married woman, a level that is consistent with perceptions of ideal family size in the homeland. Fertility levels were significantly higher among rural second-wave refugees than in the more urban first-wave groups. One explanation for the high fertility is that couples have migrated from areas where fertility is high, and they have not yet adapted their reproductive behavior to the low fertility environment of the United States. This possibility is reinforced by a general gender preference for boys and exacerbated by the fact that, while a majority of women are aware of methods of fertility control, access is still limited by cultural and financial barriers, and the motivation to use family planning still appears to be relatively low. The data suggest that this refugee population will continue to put pressure on maternal and child health resources, and that continued residence in the United States could lead to desires to limit family size, thus increasing demand for methods of fertility control.

Family planning among Southeast Asian refugees

Five different Southeast Asian groups were studied to document family planning knowledge, attitudes, and practices, and to identify current barriers to care. Significant differences exist among ethnic groups in their knowledge and use of effective methods of contraception, as well as variations in the timing of when to adopt family planning practices and in the preferred number of children. Nearly 70% of the sample had experienced barriers to services, including language, transportation, and a lack of awareness of available services.

Pew Memorial Trust policy synthesis: 3. Adolescent pregnancy: the responsibilities of policymakers

In recent years, adolescent pregnancy and childbearing have emerged as major health and social policy issues, sparking debates in local and national forums. The concern is a response to rates of adolescent sexual activity, pregnancy, and out-of-wedlock childbirth that have risen sharply in the past 20 years. The deleterious effects of early parenthood, especially in poor communities, have been amply documented; education, future employment, and health status are among the areas affected. Efforts at intervention have ranged from preventing pregnancy by encouraging celibacy to trying to enhance the options available to those who are already parents. Many of these efforts have fallen short, proving unequal to the complexity of the issues being tackled. Relatively successful approaches have also been developed, however, and the synthesis describes several. Strategies addressing the needs of adolescents comprehensively and involving a multiplicity of concerned players appear to be most effective in the long term. There is a pressing need for more program documentation to substantiate this and other promising strategies.