Did increasing use of highly effective contraception contribute to declining abortions in Iowa?

BACKGROUND: Between 2006 and 2008, Iowa increased access to family planning services through a Medicaid expansion and a privately funded initiative. During this same time, Iowa expanded access to abortion through telemedicine provision of medical abortion. Despite increased access to abortion services, abortions in Iowa have declined. This study assessed whether increased provision of long-acting reversible contraception (LARC) may have contributed to the abortion decline. STUDY DESIGN: We analyzed abortion data from Iowa vital statistics and LARC use data from 14 family planning agencies' records (N=544,248) for the years 2005 to 2012. Mixed-effects logistic regression analyses assessed whether changes in the percentage of LARC users were associated with subsequent reductions in abortion across the state. RESULTS: From 2005 to 2012, the number of family planning clients using LARC increased from 539 to 8603 (less than 1% to 15%); the number of resident abortions decreased from 5198 to 3887 (8.7 per 1000 women aged 15-44 to 6.7). There were reduced odds of abortion (adjusted odds ratio, 0.96; 95% confidence interval: 0.94-0.97) with increased LARC use. CONCLUSIONS: Declines in abortion followed increases in LARC use in Iowa.

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%).

A profile of sexually active male adolescent high school students in Lima, Peru.

To document knowledge and attitudes regarding sexuality and sexual practices of male adolescent high school students in Lima, Peru, a self-administered, anonymous survey was completed by 991 male adolescents aged 12-19 as part of a School-Based Sex Education Intervention model. Questions concerned sociodemographic information; family characteristics; personal activities; knowledge and attitudes regarding sexuality; sexual experience; and contraceptive use. Knowledge related to sexuality was limited. Males tended to mainly discuss sexuality with their male peers (49.8%). Attitudes towards sexual activity and condom use were largely positive, although some males expressed ambivalent feelings towards the latter. Of the sample, 43% had ever had sex; age at first sexual intercourse was 13 years. While 88% of the sample would use condoms, 74% also gave reasons for not using them. Sexual activity was related to age, ever having repeated a grade, living with only one parent or in a mixed family, activities such as going to parties, use of alcohol, tobacco, and drugs, and viewing pornographic videos or magazines. Many male adolescents were at risk of causing an unintended pregnancy or acquiring an STD.

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.

Adolescent health insurance coverage: recent changes and access to care.

OBJECTIVE: To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage. METHODS: We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey. RESULTS: An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased. CONCLUSIONS: This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Children's Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents.adolescents, health insurance, access, Medicaid, SCHIP.

A comparison study of an elementary school-based health center: effects on health care access and use.

OBJECTIVE: To assess the effects of an elementary school-based health center (SBHC) on access to and the use of physical and mental health services by children aged 4 to 13 years. STUDY DESIGN: A retrospective cohort analysis of parent surveys from a comparable intervention (SBHC) and a comparison of urban elementary schools. INTERVENTION: Elementary SBHC services, including preventive physical health care; the care of minor short-term illnesses, injuries, and stable ongoing medical conditions, dental screenings; and mental health counseling. PARTICIPANTS: All parents of students at both schools were asked to complete a survey. Return rates on the survey were 78.3% (570/728) and 77.0% (440/571) at the intervention and comparison schools, respectively. MAIN OUTCOME MEASURES: The use of health services, access to health services, and health service satisfaction. RESULTS: Compared with respondents at comparison schools, respondents whose children had access to an SBHC had less difficulty (P = .01) receiving physical health care for their children, ie, treatment of illnesses and injuries, immunizations, and physical examinations (odds ratio, 0.66; 95% confidence interval, 0.48-0.91). Access to an SBHC was independently and significantly related to less emergency department use (odds ratio, 0.63; 95% confidence interval, 0.40-0.99; P<.05), a greater likelihood of having had a physician's visit since the school year began (odds ratio, 1.92; 95% confidence interval, 1.39-2.65; P<.01), and a greater likelihood of having had an annual dental examination (odds ratio, 1.36; 95% confidence interval, 1.01-1.83; P<.05). Measured by a 12-item scale, respondents who reported the SBHC as their most-used health service were significantly more satisfied with their service than respondents who mostly used community clinics (z=-5.21; P<.01) or hospital clinics (z=-4.03; P<.01). CONCLUSIONS: Independent of insurance status and other confounding variables, underserved minority children with SBHC access have better health care access and use than children without SBHC access, signifying that SBHCs can be an effective component of health delivery systems for these children.

Pregnancies averted among U.S. teenagers by the use of contraceptives.

CONTEXT: The personal and social costs associated with teenage pregnancy in the United States concern many policymakers and researchers, yet the role of contraception in preventing these pregnancies has not been adequately quantified. METHODS: Published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices in order to estimate the number of pregnancies averted through the use of contraceptives by U.S. teenagers. Four scenarios of contraceptives access--from current levels of access to highly restricted access--and teenagers' sexual and contraceptive practices in response to such restrictions are used to project the potential impact on pregnancies among teenagers. RESULTS: Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15-19-year-old women in the United States during 1995. If these young women had been denied access to both prescription and over-the-counter contraceptive methods, an estimated one million additional pregnancies (ranging from 750,000 to 1.25 million) would have occurred, assuming some decrease in sexual activity. These pregnancies would have led to 480,000 live births, 390,000 abortions, 120,000 miscarriages, 10,000 ectopic pregnancies and 37 maternal deaths. CONCLUSIONS: Contraceptive use by teenage women prevents pregnancies and negative pregnancy-related health consequences that can disrupt the lives of adolescent women and that have substantial societal costs. Continued and expanded access to contraceptives for adolescents is a critically important public health strategy.

PIP: An analysis of the number of adolescent pregnancies and pregnancy outcomes that are averted in the US each year by contraceptive use highlighted the importance of continued and expanded access on the part of young people to contraception. In this analysis, published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices among US teenagers. Four scenarios of contraceptive access--from current levels to highly restricted access--and sexual and fertility control practices in response to such restrictions were constructed. The 651 sexually active female adolescents enrolled in the national survey had used contraception during 80% of the times in which they were at risk of pregnancy. Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15- to 19-year-old US women in 1995. If these adolescents had been denied access to prescription and over-the-counter contraceptive methods, an estimated 750,000 to 1.25 million additional pregnancies would have occurred, assuming some decrease in sexual activity. These pregnancies would have resulted in 480,000 live births, 390,000 induced abortions, 120,000 miscarriages, 10,000 ectopic pregnancies, and 37 maternal deaths. The prevalence of adolescent sexual activity would have to decrease by 83% over current levels to avert the same number of pregnancies that are presently prevented by contraceptive use.

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.

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.

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.

PIP: Traditional methods of identifying areas in need of adolescent pregnancy prevention programs may overlook small localities with high levels of adolescent childbearing in communities and counties where this is not a universal problem. The present study assessed the potential of a "geomapping" approach based on measurement of the number of births occurring to teens 15-17 years old in each California (US) zip code in 1992-94. A total of 415 zip codes with teen birth rates in excess of the state's 75th percentile cut-off point (62.8 births/1000) were identified. 210 of these zip codes, accounting for 96% of all births to 15-17 year olds in the 75th-percentile zip codes, differed significantly (p 0.01) from the state average of 44.5 births/1000 15-17 year olds. 178 (85%) of these 210 "hot spots" also included birth rates exceeding the third quartile among teens 10-14 and/or 18-19 years old. Panels of local experts reviewed these "hot spots" for accuracy and grouped them into 82 potential project areas on the basis of demographics, geography, and political infrastructure. Although there was substantial variation, localities with the highest teen birth rates tended to be characterized by minority overrepresentation, poverty, and poor prenatal care coverage. In addition to identifying areas with unmet need, this approach encourages community participation in program development.

Redesigning a school health workforce for a new health care environment: training school nurses as nurse practitioners.

Diminishing financial resources for school health dictate the most efficient possible deployment of the school health workforce. School nurses trained as nurse practitioners could help resolve the common problems of ready access to and appropriate use of primary care, early detection of potentially costly medical problems, and efficient use of school health staff. To determine how best to use existing resources to meet the increasingly varied and complex health care needs of children and adolescents, a pilot project was conducted in Denver from 1994 to 1996. With physician back-up and health aide support, school nurses were trained as nurse practitioners to provide in-school diagnostic and treatment services. Based on their evaluation study of this pilot project, the authors suggest ways to solve problems in role transition, including well-balanced training; clear role definition and assignment of responsibilities; appropriate back-up and mentoring support; and issues of sustaining long-term programs.

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.

Evaluating community efforts to decategorize and integrate financing of children's health services.

Publicly funded categorical programs for children often differ in eligibility rules, allowable services, and criteria for provider participation, making it necessary for families to navigate through several programs to piece together care for their children. Recognizing these problems, the Robert Wood Johnson Foundation launched a national demonstration project in 1991 with the goal of decategorizing children's health services in nine communities. It was hoped that by releasing funds from categorical restrictions on their use, scarce public resources could be directed where they might have the greatest impact. However, the demonstration sites confronted a number of challenges in designing and implementing decategorization strategies: an absence of existing models and effective technical assistance; political hurdles in gaining cooperation from the multiple local agencies engaged in service provision; and difficulties in carrying out major programmatic changes when the health care system itself was rapidly being transformed. The proposition that decategorization holds promise as a tool for improving access to health care deserves further investigation.

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.

PIP: Findings are reported from 1780 young male clients of the California Office of Family Planning's Expanded Teen Counseling Program's (ETCP) family planning clinics during 1992-94 on their sexual behavior, contraceptive use, pregnancy and parenting history, and psychosocial characteristics. 37% were Hispanic, 30% White, 18% Black, 12% Asian, and 6% members of other racial or ethnic groups. 14% were aged 14 years or younger, 50% were aged 15-17, and 36% were aged 18-19. 9% reported having Medicaid insurance and 3% received Aid to Families with Dependent Children. 31% of the young men reported going to the clinic in search of a birth control method, 27% to determine whether they were infected with an STD, 26% for a physical exam, 22% because their partner or girlfriend wanted them to, and 15% for information or someone to talk to. 88% reported recent episodes or symptoms of depression and 23% were having problems in school. 86% were currently sexually active, with 48% of those sexually active being age 14 or younger when they had their first sexual encounter. 73% reported using a condom at first sexual intercourse, while 12% had never used a contraceptive method. 50% reported using a condom the last time they had sexual intercourse, 71% of condom users reported being comfortable with the method, 21% had impregnated a partner and 8% were parents, and 25% reported having 4 or more sex partners during the past 6 months. 9% reported ever having an STD, 31% reported being always or sometimes high on alcohol or drugs during sex, and 6% reported having been forced or tricked into having sex. The odds were reduced that a client had used an effective method at last intercourse if he was uncomfortable with that method. The likelihood of contraceptive use at last intercourse was increased among males who agreed with their partner about their method and those who had never impregnated a partner.

Substance use among pregnant adolescents: a comparison of self-reported use and provider perception.

PURPOSE: This study describes, from both client and provider perspectives, the ethnic differences (African-American and white) in cigarette, alcohol, marijuana, and other drug (cocaine and crack) use among pregnant adolescents attending public prenatal clinics in one county. METHODS: Client information was based on a cross-sectional survey of 248 consecutive adolescent, public prenatal clients. The sample represented 79% of pregnant adolescents in the country at the time of the study. Ethnic groups were compared through the use of appropriate bivariate statistics regarding (a) number, type(s), and frequency of substance(s) used; (b) mean age of first use; (c) change in use 6 months prior to pregnancy and first trimester; and (d) use among family and friends. Provider information was based on open-ended interviews among 23 individuals (91% of all providers) covering the same themes. RESULTS: The majority of clients were African-American (61%), single (81%), and primaparous (72%). Many reportedly used at least one substance prior to pregnancy (79%) and during their first trimester (49%). The most common substances were cigarettes and alcohol. Overall, use of each substance during both time periods was higher among whites; yet African-Americans were more likely to report discontinued use. Substance use was common among adolescents' family members and friends. The provider survey revealed a wide range of perceptions about substance use among pregnant adolescents. CONCLUSIONS: Pregnant adolescents' self-reported substance use patterns differed by ethnicity, and providers' perceptions of substance use among their adolescent prenatal population differed from what was obtained from patients' self-reports. Additional research is needed to understand the role ethnicity plays in high-risk behaviors among adolescent prenatal clients, as well as its role in client-provider communication.

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.

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.

Perceptions of motivators and barriers to public prenatal care among first-time and follow-up adolescent patients and their providers.

OBJECTIVES: To compare perceptions of the motivators and barriers to obtaining public prenatal care from the perspectives of pregnant adolescents coming for first-time and follow-up appointments, as well as among those of their prenatal care providers. METHOD: The patient sample consisted of 250 consecutive, adolescent, public prenatal patients coming to one of the 5 prenatal clinics in one county in Arkansas. Patient responses were analyzed by appointment status (first-time vs. follow-up visitors). Sixteen providers at the same public prenatal clinics were also interviewed using the same survey instrument. RESULTS: We observed striking differences between patients and providers with respect to their perceptions of both the motivators and barriers to prenatal care. Adolescents reported "concern over the health of their baby" as a primary motivation, while providers identified adolescents' "concern over their own health" as the most important reason. With regard to barriers, adolescents were more likely to identify system-related barriers (e.g., lack of finances and transportation, and waiting time for appointments), while providers were more likely to identify personal barriers (e.g., feeling depressed, fear of procedures, and needing time to deal with problems at home). Patients and providers agreed, however, that fear of procedures and not wanting to be pregnant were important barriers to care. CONCLUSIONS: The differences in perceptions between adolescents and their prenatal care providers suggest that poor patient-provider communication may represent one of the single most important nonfinancial barriers to care. Possible explanations for inadequate patient-provider communication as well as solutions to improve their clinic interactions are discussed.

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.

The state of adolescent health: looking back and planning ahead.

PURPOSE: A decade has passed since the 1986 Health Futures of Youth policy-making conference was held. The present study aimed to examine perceived changes in the field of adolescent health since this conference, as a basis for further planning in adolescent health and consideration of a possible follow-up conference. METHODS: The study included two parts: (a) a mailed survey which was completed by 68 of 90 conference participants; and (b) telephone interviews with a sample of leaders from federal agencies and major foundations and one professional organization serving youth in the United States. RESULTS: Respondents perceived that small to moderate improvements have occurred for 10 key recommendations made at the 1986 conference. There appears to be increased recognition of the special needs of youth and a greater understanding of the period of adolescence. Improvements in health-related activities and in research of health behaviors have occurred. However, perceived setbacks have occurred at the intersection of health and social welfare. The conference was viewed by respondents as having had a moderate influence on the field of adolescent health and on the participants' own work and working relationships. In addition, policy-making conferences were listed as the strongest source of influence on the agenda of national agencies and foundations serving youth. CONCLUSION: A follow-up conference is recommended and should focus on both health-related topics and issues of social welfare.