Abstract
Purpose
The purposes of the study were to describe baseline data in the implementation of evidence-based clinical practices among health center partners as part of a community-wide teen pregnancy prevention initiative and to identify opportunities for health center improvement.
Methods
Health center partner baseline data were collected in the first year (2011) and before program implementation of a 5-year community-wide teen pregnancy prevention initiative. A needs assessment on health center capacity and implementation of evidence-based clinical practices was administered with 51 health centers partners in 10 communities in the United States with high rates of teen pregnancy.
Results
Health centers reported inconsistent implementation of evidence-based clinical practices in providing reproductive health services to adolescents. Approximately 94.1% offered same-day appointments, 91.1% had infrastructure to reduce cost barriers, 90.2% offered after-school appointments, and 80.4% prescribed hormonal contraception without prerequisite examinations or testing. Approximately three quarters provided visual and audio privacy in examination rooms (76.5%) and counseling areas (74.5%). Fewer offered a wide range of contraceptive methods (67.8%) and took a sexual health history at every visit (54.9%). Only 45.1% reported Quick Start initiation of hormonal contraception, emergency contraception (43.1%), or intrauterine devices (12.5%) were “always” available to adolescents.
Conclusions
The assessment highlighted opportunities for health center improvement. Strategies to build capacity of health center partners to implement evidence-based clinical practices may lead to accessibility and quality of reproductive health services for adolescents in the funded communities.
Keywords: Teen pregnancy, Adolescent reproductive health services, Evidence-based clinical practices, Youth-friendly reproductive health services
The 2014 United States (US) teen birth rate of 24.2 births per 1,000 females aged 15–19 years reflects over a 61% decline from 1991 [1]. Despite this trend, US teen birth rates remain higher than rates in other developed countries [2], and marked racial, geographic, and socioeconomic disparities persist [3,4]. In 2014, there were >249,000 births to teens aged 15–19 years, with the birth rate for African-American (34.9) and Hispanic (38.0) adolescents approximately double the rate of white adolescents (17.3) [1].
Observed differences in teen birth rates may be attributed in large part to disparities in access to and use of reproductive health services. Reproductive health services are defined as contraceptive services (provision of a method or prescription, a checkup, counseling, or pregnancy test), gynecologic services (a pelvic examination or Papanicolaou [Pap] smear), and sexually transmitted diseases (STD) counseling, testing, or treatment. Recent analyses of nationally representative data highlight that many adolescents are not receiving recommended preventive reproductive health services, with younger, Hispanic, underinsured, and undereducated adolescents less likely to report utilization of services [5]. During 2006–2010, approximately one in four (24%) sexually experienced females and more than one in three (38%) sexually experienced males aged 15–19 years did not receive a reproductive health service from a health care provider in the past year [5]. In addition, among sexually experienced female adolescents, 85% used contraception the last time they had sex; however, most used birth control pills (56%) and condoms (34%), which when not used consistently or correctly are less effective for pregnancy prevention [6]. Use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs) and implants, among teens remains low nationwide (<7%) [7–9], despite their effectiveness [10], safety [11], and ease of use. LARC are the most effective types of birth control for adolescents, with <1% of users becoming pregnant during the first year of typical use compared with birth control pills (9%) and condoms (18%), the two most common methods adolescents use most often [10]. Racial/ethnic disparities in use of highly effective methods (defined as IUD or hormonal methods) are evident among female teens aged 15–19 years. Overall, 66% of sexually experienced white female teens aged 15–19 years used a highly effective method as opposed to only 47% of African-American and 54% of Hispanic female teens [12]. Nonuse of any contraceptive method was significantly higher among sexually experienced African-American (26%) and Hispanic (24%) female teens aged 15–19 years than white teens (15%) [12]. Low use of highly effective methods may be related to lack of service utilization among sexually experienced teens.
Facilitating adolescent access to and use of reproductive services is imperative for reducing disparities in teen birth rates [5,13–15]. Structural (i.e., poverty, inequity, oppression) and policy-level changes are needed to address the social determinants of teen pregnancy; however, changes at the health care delivery systems level that ensure provision of accessible, affordable, and evidence-based clinical practices are necessary to improve adolescents’ use of reproductive health services. Numerous professional organizations and governmental agencies, including the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Academy of Family Physicians, the Office of Population Affairs (OPA), and the Centers for Disease Control and Prevention (CDC), have issued recommendations for health centers and providers to facilitate increased adolescent access to reproductive health services and highly effective contraception [10–14] and guide health center implementation of evidence-based clinical practices in the provision of reproductive health services for adolescents [11–22]. Broadly, recommendations for increasing access include ensuring that reproductive health visits begin during early adolescence and include reproductive health counseling, screening for sexual activity, anticipatory guidance/delay counseling and/or provision of contraception as appropriate, and screening for STDs. Recommendations for health centers to implement evidence-based practices include the availability of a wide range of reproductive health services at reduced or no cost, providing services at locations and hours convenient to adolescents, ensuring protection of adolescent privacy and confidentiality, having separate waiting areas and examination rooms with age-appropriate educational materials, having staff trained to address the needs of adolescents of diverse backgrounds, and implementing systems and practices to ensure that the reproductive health care needs of adolescents are addressed in a timely manner [11,16–26].
Health centers that have incorporated evidence-based clinical practices and programs have achieved significant improvements in adolescent uptake of highly effective contraception and in satisfaction with services [15,27–35]. Initiatives to improve access to LARC [8,36–38] have facilitated use of LARC among reproductive-aged women, including teens, by underscoring the importance of educating providers that LARC is medically safe for teens [11], training providers on LARC insertion and use of a client-centered counseling approach that includes discussing the most effective contraceptive methods first [26], and providing contraception at reduced or no cost to the client. These efforts have increased the percentage of teens and young women selecting LARC as their preferred option for contraception and have been associated with declines in teen pregnancies, births, and abortions [36,37]. In addition, an evidence-based program that links at-risk youth to sexual and reproductive health services reported increases in female adolescents’ receipt of high-quality sexual and reproductive health care services, including receipt of birth control; increases in STD testing and/or treatment; and increases in ever receiving an HIV test [39]. However, recent research has also documented that these recommendations have been implemented inconsistently or not at all across a nationally representative sample of health centers [15,40].
The purposes of this article were to describe baseline data in the implementation of evidence-based clinical practices among health center partners as part of a multicomponent, community-wide teen pregnancy prevention initiative and, informed by findings from the baseline data, to identify opportunities for health center improvement.
Methods
A national demonstration project to reduce teen pregnancy was funded to implement a five component community-wide model; one component focuses on providing reproductive health care for adolescents. Before project implementation, two fundamental activities to identify opportunities for health center improvement included the following: (1) the identification of evidence-based clinical practices to assist health center partners in providing accessible reproductive services for adolescents and (2) the development of a needs assessment to measure the implementation of evidence-based clinical practices among health center partners and the capacity (i.e., health center infrastructure and staff skills and motivation) to provide reproductive health care for adolescents.
Development of a national demonstration project to prevent teen pregnancy using the integration of services, programs, and strategies through community-wide initiatives
Under the President’s Teenage Pregnancy Prevention Initiative (http://www.cdc.gov/teenpregnancy/preventteenpreg.htmhttp://www.cdc.gov/teenpregnancy/preventteenpreg.htm), the CDC partnered with the Office of Adolescent Health to fund a national demonstration project to implement community-wide initiatives to reduce teen pregnancy in 10 intervention communities across the United States [41]. Briefly, nine state- and community-based organizations were funded: eight by Office of Adolescent Health and one jointly by CDC and the OPA. Five national organizations were also funded by the CDC to provide technical assistance and training (TTA) to the funded state- and community-based organizations with the purpose of building their capacity to implement a five-component model to prevent teen pregnancy. Each of the funded state- and community-based organizations were then required to work with community partners (e.g., health centers, youth-serving organizations, faith-based organizations, schools) to implement the five key components of the teen pregnancy prevention community-wide initiative model: (1) mobilizing necessary resources, disseminating information, generating support, and fostering cooperation across public and private sectors in the community; (2) providing teens with evidence-based teen pregnancy prevention programs, including youth development and curriculum-based programs that reduce teen pregnancy and associated risk factors; (3) ensuring clinical partners are providing teen friendly, culturally competent reproductive health care services that are easily accessible to all youth in the community and establishing linkages between teen pregnancy prevention program partners and clinics that serve at-risk youth from the target community; (4) educating civic leaders, parents, and other community members about evidence-based strategies to reduce teen pregnancy and improve adolescent reproductive health, including needs and available resources in the target community; and (5) raising awareness of community partners about the link between teen pregnancy and social determinants of health and ensuring culturally and linguistically appropriate programs and reproductive health care services are available to youth.
Implementation of the key component to improve adolescent reproductive health care services
One of the five key components of the teen pregnancy prevention community-wide initiative model is to improve adolescent reproductive health care services. Each of the 10 intervention communities were required to partner (i.e., signed memorandum of agreement) with a minimum of five health centers (i.e., 51 health center partners at baseline) with the goal to establish a coordinated health care delivery systems for adolescents to increase access to and use of reproductive health care services. The role of the funded state- and community-based organizations were to leverage existing and new resources to increase access to reproductive health care for adolescents and to build the capacity of the health center partners to implement evidence-based clinical practices. To build the capacity of health center partners, a funded national organization provided TTA on: (1) establishing linkages between health care and other service area systems (e.g., primary care, education, social services, juvenile justice, foster care) to enhance the coordination of reproductive health care for adolescents; (2) increasing number of adolescents from the target community served at partner health centers; (3) increasing access to and use of highly effective contraception, including LARC by sexually active adolescent females; (4) providing anticipatory guidance and support to adolescents who choose to delay sexual activity; (5) increasing the implementation of evidence-based clinical practices for the delivery of reproductive health care for adolescents among health center partners; (6) ensuring the delivery of culturally, age-, and gender-appropriate health care among health center partners; and (7) measuring and monitoring the impact of activities to improve access to and use of reproductive health care by the target community.
Identification of evidence-based clinical practices
In 2011, before project implementation, we used the rapid synthesis and translation process [42] to facilitate rapid translation of professional recommendations and evidence from the literature to develop a standardized checklist of evidence-based clinical practices to assist our health partners in providing accessible reproductive services for adolescents. The rapid synthesis and translation process is a six-step process that includes the following: (1) soliciting suggested topics by end users (i.e., health center partners); (2) scanning for findings; (3) sorting for relevance; (4) synthesizing results; (5) translating for end user; and (6) review by end user and experts [42]. Resulting products are intended to inform the field and stimulate action.
Briefly, we systematically scanned both professional organizations’ and governmental agencies’ recommendations (e.g., American Academy of Pediatrics, Society for Adolescent Health and Medicine, American College of Obstetricians and Gynecologists, American Medical Association, American Academy of Family Physicians, CDC, OPA), and peer-reviewed scientific articles that focused on the provision of reproductive health services for adolescents based on developed search strategies for electronic databases, retrieval and inclusion criteria, and quality assessment. To determine which literature is most relevant to clinical practice needs, we sorted evidence-based clinical practice findings related to adolescent reproductive health from the initial literature review scan based on relevance. To narrow the literature focus to discrete, actionable information, we synthesized recommendations from professional organizations and governmental agencies to develop a list of evidence-based clinical practices in service delivery, whereas scientific articles on teen-friendly health care and access to services informed the development of evidence-based clinical practices related to clinic environment and infrastructure [43].
This synthesis resulted in the identification of 31 evidence-based clinical practices [43], which were grouped into the following eight domains: (1) contraceptive access; (2) quick start method to initiate hormonal contraception and IUDs (i.e., begin contraception at the time of the visit rather than waiting for next menses if the health provider can reasonably be certain that the client is not pregnant) [44]; (3) emergency contraception (EC); (4) cervical cancer screening; (5) HIV/STD testing; (6) confidentiality and consent; (7) youth-friendly health center environment; and (8) cost and billing practices to facilitate both provision of and access to adolescent reproductive health services. None of the recommendations obtained from our review of the literature directly conflicted with the guidelines issued by another agency, which likely reflects similarities and consistency in the evidence base related to adolescent reproductive health or mutual recognition of guidance by multiple entities [43]. To determine usability, actionable knowledge, and applicability to practice, we obtained feedback from experts and health center partner staff on the use of plain language, usability, and applicability of the synthesized list of 31 evidence-based clinical practices. The checklist was disseminated to funded state- and community-based organizations and their health center partners [43].
To support health center efforts to ensure consistent implementation of evidence-based clinical practices to increase youth access to, provision of, and appropriate use of reproductive health services, a health center needs assessment, relevant tools and resources, and targeted capacity–building TTA were provided to health center partners. The targeted capacity building focused on systems related to access; processes for the delivery of care; implementation of evidence-based practices; cost, confidentiality, and supportive infrastructure; and the health care delivery environment. Technical assistance, informed by the needs assessment, focused on strategies for addressing the identified gaps to ensure that the health center’s ability to implement evidence-based clinical practices improved over the course of the initiative.
Development of the clinic partner needs assessment
The clinic partner needs assessment is a comprehensive assessment tool that was developed during the first year of the community-wide initiative. It is used to examine health center practices and capacity in provision of reproductive health care for adolescents by obtaining data on health center type, funding sources, and staff training needs. In addition, it is used to collect information annually to measure the implementation of evidence-based clinical practices among health center partners in each intervention community.
Data collection and analysis
Health center partner baseline data were collected at the end of the first year (2011) and before implementation of the 5-year community-wide teen pregnancy prevention initiative (the first year was a planning year; program implementation and TTA for health center partners began in the second year). Baseline data from the clinic partner needs assessment included information on the health center setting and funding, processes for referrals and linkages, billing practices and revenue, staff training, implementation of evidence-based clinical practices, accessibility of services for adolescents, health center environment and infrastructure, and the use of health care services by adolescents. Data were collected in 2011 from 51 health center partners in 10 intervention communities in Alabama, Connecticut, Georgia, Massachusetts, New York, North Carolina, Pennsylvania, South Carolina (two communities), and Texas. These data were collected by a multidisciplinary team of health center staff, including providers, administrators, and billing and information technology staff. This team approach facilitated more accurate reporting of health center capacity and practices, as appropriate staff were tasked with completing sections of the data entry form most relevant to their disciplinary roles (i.e., billing staff completed sections relevant to billing codes and practices, information technology staff completed sections on electronic medical record utilization).
All data were entered and maintained on a secure, password-protected server. Descriptive statistics were calculated to summarize health centers practices, by setting, implementation of evidence-based clinical practices, and demographics of the target population. All quantitative data were analyzed using Stata 10 statistical analytic software.
Institutional review board approval was not needed for this project because CDC determined that this project was public health practice.
Results
Clinic type, client demographics, and contraceptive coverage
The most commonly reported health center practice setting was family planning clinics (45.1%), followed by school-based health centers (13.7%) and obstetrician/gynecologist clinics (11.7%). Of the 51 health centers, 33 (64.7%) reported receiving Title X funding, in which Title X funded health centers are mandated to provide reproductive health services that are confidential regardless of a client’s ability to pay and serve disproportionately high numbers of young clients [24] (Table 1).
Table 1.
Number and percentage of health center partners in the Centers of Disease Control and Prevention/Office of Adolescent Health teen pregnancy prevention community-wide initiative by practice setting and Title X funding status, 2011
| Practice setting | Total = 51, N (%) |
|---|---|
| Family planning clinic | 23 (45.1) |
| School-based health center | 7 (13.7) |
| Obstetrician/gynecologist | 6 (11.7) |
| Adolescent subspecialty | 5 (9.8) |
| Multiple practice settinga | 4 (7.8) |
| Primary care | 4 (7.8) |
| Pediatric | 2 (3.9) |
| Title X fundedb | |
| Yes | 33 (64.7) |
| No | 18 (35.2) |
Percentages may not add to 100 because of rounding.
Multiple practice setting includes health centers that have more than one type of practice within their setting (e.g., a health department may have a family planning clinic, primary care and pediatric clinic).
The Title X National Family Planning Program provides cost-effective and confidential family planning and related preventive health services for low-income women and men; it serves approximately one million teens each year.
Of the 51 health centers, 35 (68.6%) provided information on the demographics of their adolescent clients for the baseline analysis. The health centers served a total of 48,850 adolescent clients in 2011; of whom, 70.1% were female. Among females, health centers provided services to an equal proportion of 15- to 17- (40.9%) and 18- to 19-year olds (40.9%); among males, health centers provided services a near equal proportion of <14-year olds (35.0%) and 15- to 17-yearolds (39.9%; Table 2). Most clients served were youth from racial/ethnic minority groups; more than half of the adolescent males (55.9%) and females (56.0%) served by these health centers were African-American, and 28.9% of adolescent males and 19.9% of adolescent females were Hispanic (Table 2).
Table 2.
Number and percentage of unduplicated adolescent clients and contraceptive coverage by health center partners in the Centers for Disease Control and Prevention/Office of Adolescent Health teen pregnancy prevention community-wide initiatives, 2011
| N | % | |
|---|---|---|
| All clients | 48,850 | |
| Male clients | 14,608a | 29.9 |
| Age ≤14 years | 5,113 | 35.0 |
| Age 15–17 years | 5,843 | 39.9 |
| Age 18–19 years | 3,652 | 25.0 |
| Hispanic | 4,236 | 28.9 |
| African-American | 8,180 | 55.9 |
| White | 1,315 | 9.0 |
| Female clients | 34,242 | 70.1 |
| Age ≤14 years | 6,164 | 18.0 |
| Age 15–17 years | 14,039 | 40.9 |
| Age 18–19 years | 14,039 | 40.9 |
| Hispanic | 6,848 | 19.9 |
| African-American | 19,176 | 56.0 |
| White | 5,136 | 14.9 |
| Female clients receiving | ||
| Hormonal contraceptionb | 11,189 | 32.7 |
| Intrauterine devices or implantc | 925 | 2.7 |
The total adolescent client number may not equal the adolescent client numbers for sex, age, and race/ethnicity because of missing data for demographics.
Hormonal contraception includes the pill, patch, ring, and injectable contraception.
Intrauterine devices or implant is also know as long-acting reversible contraception.
Analyzing contraceptive coverage, 32.7% of adolescent female clients between the age of 15–19 years were using hormonal contraception, and 2.7% were using an LARC method at the time of their last visit (Table 2).
Implementation of evidence-based clinical practices
Overall, health centers inconsistently implemented evidence-based clinical practices in the provision of reproductive health care services for adolescents (Table 3).
Table 3.
Percentage of health center partners implementing the synthesized list of 31 evidence-based clinical practices for adolescent clients in the Centers for Disease Control and Prevention (CDC)/Office of Adolescent Health teen pregnancy prevention community-wide initiatives, 2011
| Evidence-based clinical practices | Percentage (%) of health centers implementing the practice (n = 51 health centers) |
|---|---|
| Contraceptive access | |
| 1. Offers same-day appointments | 94.1 |
| 2. Offers after–school hours appointments | 90.2 |
| 3. Offers appointments during the weekend | 23.5 |
| 4. Take/update sexual health history at every visit | 54.9 |
| 5. Offers a wide-range of contraception (via prescription and/or dispensed on-site) | 67.8 |
| 6. Offers hormonal contraception or IUD at every visit to the clinical provider regardless of reason for visit (e.g., urgent, preventive, school health, sports physical, pregnancy testing, emergency contraception, STD testing, HIV testing) to ensure that there are no missed opportunities | –a |
| 7. Prescribes hormonal contraception without prerequisite examinations or testing (i.e., without first requiring any of the following: Pap smear, pelvic examination, breast examination, or STD testing) | 80.4 |
| Quick start method for initiation of hormonal contraception and IUD | |
| 8. Hormonal contraception is initiated utilizing the quick start method | 45.1 |
| 9. Quick start initiation of hormonal contraception after client has had a negative pregnancy test | 46.0 |
| 10. Quick start initiation of hormonal contraception when client is provided with emergency contraception where a pregnancy test is negative | 43.1 |
| 11. Quick start insertion of IUD | 12.5 |
| Emergency contraception | |
| 12. Emergency contraception is available to females | 88.1 |
| 13. Emergency contraception is provided to females for future use (advance provision) | 25.5 |
| 14. Emergency contraception is provided to males for future use (advance provision) | 14.3 |
| Cervical cancer screening | |
| 15. Adhere to current cervical cancer screening (Pap smear) guidelines (i.e., initiative Pap screening at age 21 years) | 84.3 |
| STD and HIV testing | |
| 16. Chlamydia screening is provided at least annually, or based on diagnostic criteria, consistent with USPSTF and CDC recommendations | —a |
| 17. Chlamydia screening is available for females using a urine or vaginal swab specimen | —a |
| 18. Chlamydia screening is available for males using a urine specimen | —a |
| 19. Gonorrhea screening is available for both females and males | —a |
| 20. HIV rapid testing is available for females and males per CDC recommendations | 63.6 |
| 21. Expedited patient delivered partner therapy is available as an option for the treatment of uncomplicated chlamydial infection | —a |
| Cost, confidentiality, and consent | |
| 22. Low cost or no cost contraceptive and reproductive health care services are provided | 63.3 |
| 23. Confidential contraceptive and reproductive health care is available without need for parental or caregiver consent | 70.5 |
| Infrastructure | |
| 24. Participate in the federal 340B drug discount purchasing program | 91.1 |
| 25. Utilize electronic medical records (e.g., eClinical Works, Centricity, Epic, NextGen) | 84.8 |
| 26. Have systems in place to facilitate billing third party payers for contraceptive and reproductive health care services provided | 100 |
| Environment | |
| 27. Has a counseling area that provides both visual and auditory privacy | 74.5 |
| 28. Has an examination room that provides visual and auditory privacy | 76.5 |
| 29. Has teen-focused materials in waiting room or examination areas | 49.0 |
| 30. Displays information on issues related to adolescent sexual health | 48.0 |
| 31. Has brief evidence-based or evidence-informed video interventions designed for adolescents | 29.4 |
IUD = intrauterine devices; STD = sexually transmitted disease; USPSTF = U.S. Preventive Services Task Force.
Health center data are not available. The initial version of clinic partner needs assessment, which was used for the baseline data, did not include questions to assess the implementation of evidence-based clinical practices related to contraceptive access in nonreproductive health care visits and STD testing. Before project implementation (Year 2), the assessment was modified to include questions to assess contraceptive access in nonreproductive health care visits and STD testing. The total may not equal to 100 because of missing data.
With respect to practices that increase access to contraception, approximately 94.1% of health centers offered same-day appointments and 90.2% offered after school hours. In addition, 80.4% prescribed hormonal contraception to adolescent female clients without prerequisite examinations or testing (i.e., without first requiring any of the following: Pap smear, pelvic examination, breast examination, or STD testing), and 67.8% of health centers offered a wide-range of contraceptive methods (i.e., IUD, hormonal implant, hormonal injection, hormonal contraceptive pills, patch, ring, EC, and condoms). However, only 54.9% of health centers reported taking or updating a sexual health history at every visit for adolescent clients, and only 23.5% offered weekend appointments for adolescents.
For quick start initiation, less than half of health centers offered this method to adolescents for hormonal contraception (45.1%), EC (43.1%), or insertion of IUDs (12.5%). Similarly, a low proportion offered advance provision of EC for female adolescent clients (25.5%) and for male adolescent clients (14.3%).
Overall, health centers reported adherence to guidelines for cervical cancer screening (i.e., initiative Pap screening at age 21; 84.3%) and HIV rapid testing for adolescent clients per CDC recommendations (63.6%).
With respect to containing costs and providing confidential services, most health centers participated in the 340B drug discount purchasing program (i.e., a federal program that enables health care organizations that care for underserved people to purchase outpatient drugs at discounted prices; 91.1%), provided confidential contraceptive and reproductive health care for adolescents without need for parental or caregiver consent (70.5%), and provided low cost or no cost contraceptive and reproductive health services to adolescents (63.3%); all had an infrastructure in place to reduce cost barriers for adolescent clients.
Finally, results were diverse in regard to the health center environment. With respect to providing privacy for adolescents, only 76.5% and 74.5% of health centers reported areas with visual and auditory privacy for examinations and for providing counseling, respectively; 49.0% reported having teen-focused materials in waiting or examination room areas; and 48.0% reported displaying information on adolescent sexual health.
Continuous quality improvement and staff training
To ensure consistent implementation of evidence-based clinical practices, most health centers (90.0%) regularly used continuous quality improvement (CQI) processes. Health center partners reported their staffs were trained on CQI processes (41.3%) and cultural competency (41.3%) in the past 2 years. Fewer staff, however, had received training on topics specific to adolescent clients, including provision of youth friendly services (20.5%) and addressing the needs of lesbian, gay, bisexual, transgender, and questioning youth (10.4%; Table 4).
Table 4.
Number and percentage of health center partners implementing continuous quality improvement and providing staff training in the Centers for Disease Control and Prevention/Office of Adolescent Health teen pregnancy prevention community-wide initiatives, 2011
| Continuous quality improvement and staff training | All health centers (n = 51) |
|---|---|
| CQI | |
| Regularly utilize CQI processes | 90.0 |
| Staff training—all staff | |
| CQI | 41.3 |
| Cultural competency | 41.3 |
| Youth-friendly services | 20.5 |
| Addressing the needs of LGBTQ youth | 10.4 |
| Staff training—clinical staff only | |
| CQI | 41.7 |
| Contraceptive services for adolescents | 56.2 |
| IUD insertion for adolescents | 36.2 |
| Youth-friendly services | 25.5 |
CQI = continuous quality improvement; LGBTQ = lesbian, gay, bisexual, transgender, and questioning; IUD = intrauterine device.
Discussion
Despite declines in the U.S. teen birth rate, recent analyses of nationally representative data highlight that many adolescents are not receiving recommended preventive reproductive health services [5]. Of particular concern are observed socioeconomic disparities in receipt of services, in which underinsured, African-American, and Hispanic adolescents report significantly lower rates of service utilization than their insured, white counterparts [12–14].
Recent transformations in the health care delivery system associated with the Affordable Care Act have presented health care providers with new opportunities to meet the reproductive health care needs of historically underserved populations and communities [45]. A first step in meeting these needs is to conduct an assessment of the current capacity of providers to deliver health care services to the underserved and the subsequent identification of opportunities for improving the accessibility and quality of service provision.
Our findings indicate that across the 10 communities funded through the initiative, implementation of evidence-based clinical practices critical to increasing adolescent access to and use of reproductive health care services is inconsistent. However, our findings speak to larger gaps in accessibility of reproductive health services within communities suffering the greatest disparities in teen birth rates; among the funded communities, the assessment identified limited capacity of health center partners and inconsistent or no implementation of evidence-based clinical practices among health center partners to serve adolescents in communities with disproportionately high rates of teen births.
Our study is not without limitations. Data on implementation of evidence-based clinical practices were collected via self-report and not verified using clinic records. Also of note, the sample of health centers for this analysis is not representative of all health centers with 31% submitting insufficient demographic data to be included in the baseline analysis. However, in spite of this limitation, we identified important areas for improvement in communities with high rates of teen births and were able to highlight the need for targeted efforts at the health systems level to support the work of all health centers in meeting the reproductive health care needs of adolescents. At the health systems level, future efforts may consider focusing on supporting the development of systems and processes to regularly collect, monitor, and report data to assess the consistency and quality with which reproductive health services are provided to adolescents. Where gaps existed, improvement efforts were focused on strategies to build the capacity of health center partners to ensure that the evidence-based clinical practices are implemented, thus enhancing the overall accessibility and quality of reproductive health services for adolescents in the initiative.
Additional efforts at the health systems level may focus on building the knowledge and skills of health center staff to implement evidence-based clinical practices consistently. Of particular importance is implementation of practices to facilitate access to highly effective contraception, including LARC, which have the potential to significantly reduce rates of unintended pregnancy among adolescents [7,15]. These efforts included improving contraceptive access by providing appointments at times that adolescents can access services, working with health care providers to create a health care experience for adolescents that ensures their reproductive health care needs are assessed and addressed every time they visit a health center, and providing a tiered, client-centered counseling approach in which the most effective contraceptive methods (LARCs) are discussed first among the range of methods that meet priorities expressed by the client.
These findings also point to the need to align strategies and resources at the policy level to support the work of health centers in meeting the reproductive health needs of adolescents. Opportunities for partnership are a critically important part of the service delivery infrastructure to address youth-friendly reproductive health services. For example, with almost 65% of the initiatives health center partners receiving Title X funding, active partnership with the national Title X program is important to coordinate TTA activities, CQI efforts, performance measurement related to the implementation of evidence-based clinical practices and to ensure strategies to increase access to and use of contraception and reproductive health care services for adolescents are aligned with the national quality family planning recommendations [26].
Finally, more research is needed to further highlight opportunities for improving access to and use of youth-friendly reproductive health services in communities with disproportionately high rates of teen births. It is important to identify the barriers and facilitators to implementation of the evidence-based clinical practices to facilitate improvement efforts (e.g., support from health center leadership and providers, communication between leadership and staff overseeing implementation, the use of data for CQI, and attitudes and beliefs among providers to address the reproductive health needs of adolescents). It is also important to evaluate community-wide initiatives such as this study to further understand the impact of whether and how community partnerships and initiatives are facilitating adolescent access to and use of reproductive health services. To improve adolescent access to and use of reproductive health services and ultimately decrease the teen pregnancy and birth rates, it is important to support health center capacity and systems needs to ensure consistent and quality implementation of evidence-based clinical practices.
Our results highlight the importance of using a clinic assessment to examine health center practices and capacity in the provision of reproductive health care for adolescents with the purpose to identify opportunities for health center improvement. Specifically, information collected was used to identify where targeted improvement efforts were needed for adherence to evidence-based clinical practices, including access, processes for the delivery of care, utilization of cost, confidentiality, supportive infrastructure, and the health care delivery environment. These findings suggest the need to focus on strategies to build the capacity of health center partners to ensure that the evidence-based clinical practices are implemented, thus enhancing the overall accessibility and quality of reproductive health services for adolescents in the initiative.
IMPLICATIONS AND CONTRIBUTION.
This study highlights the importance of using an assessment to identify opportunities for health center improvement. Strategies to build the capacity of health center partners to ensure that evidence-based clinical practices are implemented may enhance the overall accessibility and quality of reproductive health services for adolescents.
Footnotes
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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