1. Neighborhood-Based Public Health Program to Reduce Teen Pregnancy Disparities in NYC Allyna B. Steinberg, MPH Philip M. Alberti, PhD Bronx District Public Health Office Bureau of Maternal, Infant & Reproductive Health NYC Department Of Health & Mental Hygiene APHA November 2007

2. NYC Teen Pregnancy Rates: Declining, but still unacceptably high Bronx

3. In 2005, the South Bronx Teen Pregnancy Rate was the Highest in NYC

4. Health Disparities and District Public Health Offices (DPHOs)

6. Teen Pregnancy Prevention – Strategic Planning Process Guiding Principles 1.Consider context 2.Explore evidence-base 3.Identify intervention points Initial phase 1.Local epidemiology 2.“Market Analysis” 3.Published literature 4.Consult with local and national experts

7. 2005 Youth Risk Behavior Survey USNYC South Bronx Reported Condom Use 63%69%68% Reported Birth Control Pill Use 18%8%4%

8. Teen Pregnancy Prevention – Strategic Planning Process Guiding Principles 1.Consider context 2.Explore evidence-base 3.Identify intervention points Initial phase 1.Local epidemiology 2.“Market Analysis” 3.Published literature 4.Consult with local and national experts

9. Teen Pregnancy Prevention Strategic Plan – South Bronx Intervention Points - 3 1.Schools 2.Medical community 3.Public health message Components - 5 1.Create School-linked Health Care 2.Improve Adolescent Health Care 3.Create and Communicate the Public Health Message 4.Align Teen Pregnancy Prevention with NYC Priority Issues 5.Conduct Local Research to Improve Programs

10. 1. Create School-linked Health Care Criteria 1.Basic services 2.Dispense contraception 3.Regardless of ability to pay 4.Parental consent not required 5.Teen-friendly

11. 1. Create School-linked Health Care High Schools Clinic marketing material Condom distribution Positive clinic visits Outcomes --- # Condoms # Referral tickets Clinic data ---  Condom use  Birth control pill use ---  Teen Pregnancy Rate Local Clinics Training & TA DOH Healthy Teens Initiative Health Resource Room Staff DOH

12. 2. Improve Adolescent Health Care Starting with frontline medical practice staff HELP Teens Have a heart Explain Confidentiality, Parent involvement & Payment Link teens to care Practice using your HELP Teens! Card ANY QUESTIONS ???, PLEASE CALL BACK AppointmentReferral SOONw/o PARENT FREE 3-Payment 2-Parent Involvement 1-Confidentiality For Sexual & Reproductive Health Services HELP Teens!  $   

13. 3. Create and Communicate a Clear Public Health Message Stand (not Message) Choosing not to have sex is the surest way for teens to avoid getting pregnant or getting a sexually transmitted infection. Teens who have sex should use condoms and another form of birth control to prevent both pregnancy and STIs, including HIV.

14. 4. Align Teen Pregnancy Prevention with other NYC Priority Issues Education Economic Development Infant Mortality Reduction

15. 5. Conduct Local Research to Improve Programs Health care environment for teens seeking sexual and reproductive health care 1.“Mystery Shopper” Phone Calls 2.Clinic Administrator Phone Survey 3.Medical Provider Mail Survey

16. Evaluation Strategic Plan 1.Create School-linked Health Care 2.Improve Adolescent Health Care 3.Create and Communicate the Public Health Message 4.Align Teen Pregnancy Prevention with NYC Priority Issues 5.Conduct Local Research to Improve Programs Outcomes 1.Condom Distribution 2.Referral Tickets 3.Clinic Data

17. Total Condoms Distributed By Quarter And Cumulating Totals (January 2004 – June 2007)

18. How Many Condoms are Enough? Session 4215.0 (tomorrow) “NYC Department of Health high school condom availability program: How many condoms are enough?”NYC Department of Health high school condom availability program: How many condoms are enough? For All South Bronx Teens For Teens at our 17 High Schools 100% Target 584,071104,106 68% Target 397,16870,792 2006-2007 Distribution -53,262

19. School-linked Health Care Referrals (48% Successful Referral Rate Over 8 Months)

20. Number of 12 – 18 Year Old Pregnancy Tests (Jan-04 – Jun-07) Post- intervention

21. Number of 12- 18 Year Old Contraception Visits (Jan-04 – Jun-07) Post- intervention

22. Local Research Strategic Plan 1.Create School-linked Health Care 2.Improve Adolescent Health Care 3.Create and Communicate the Public Health Message 4.Align Teen Pregnancy Prevention with NYC Priority Issues 5.Conduct Local Research to Improve Programs Methods 1.“Mystery Shopper” Phone Calls 2.Clinic Administrator Phone Survey 3.Medical Provider Mail Survey

23. “Mystery Shopper” Phone Calls Scripted phone interview Callers posed as 15 year old girls seeking birth control pills 2 rounds of phone calls to all 93 clinics Focus: –“Disclosure”: Did frontline staff discuss issues of confidentiality, parent involvement, payment, etc.? –“Come Across”: Was the frontline staff knowledgeable, comforting and friendly?

24. “Disclosure” (α =.65, mean = 2.6)

25. “Come Across” (α =.83, mean = 6.3)

26. “If you needed reproductive health care, would you seek care from this clinic based upon this phone call?”

27. Clinic Administrator Phone Survey

28. Policy Regarding Prescription of Hormonal Contraception (n=68) Does your clinic have a policy regarding which tests or procedures are absolutely required before prescribing hormonal contraception to a teen?

29. Policy Contents (n=39) Which of the following does that policy include? That is to say, if a teen presents requesting hormonal contraception only, which tests are required in order for her to receive it?

30. Provider Practices Mail Survey

31. Methodology and Estimated “Provider Universe” 1 st Mailing = 450 surveys 2 nd Mailing (3 weeks later) = 357 surveys –152 Total Surveys Returned –6 = “Return to Sender” –27 = Reported that they did not treat patients aged 17 and under We estimate there are 314 providers who see teens for sexual and reproductive health care in the SBX. Final sample = 119 Est. Response Rate = 38%

32. Providers Are Most Likely to Prescribe OC All paired comparisons significant at the p <.01 level

33. Percent of Physicians who ‘Usually’ or ‘Always’… During PhysicalDuring Sick Visit Ask the parent / guardian to leave 92%44% Initiate discussion about contraception with female teen patients 94%42% Ask female teen patients if they are sexually active 98%50% All paired Physical/Sick Visit comparisons significant at the p <.001 level

34. Provider Concerns About Hormonal Contraceptives and Teens Significantly more concern about the Patch and Depo than about the Ring or OC. Patch concerns: –Hypercoagulability & Side effects Depo concerns: –Decreased bone density & Side effects OC concerns: –Teen’s ability to use correctly Ring concerns: –Teen’s ability to use correctly

35. If ‘Yes’, What do those Policies Require?

36. Summary Guiding Principles 1.Consider context 2.Explore evidence-base 3.Identify intervention points Strategic Plan 1.Create School-linked Health Care 2.Improve Adolescent Health Care 3.Create and Communicate the Public Health Message 4.Align Teen Pregnancy Prevention with NYC Priority Issues 5.Conduct Local Research to Improve Programs