Repeat pregnancy prevention self-efficacy in adolescents: associations with provider communication, provider type, and depression.

OBJECTIVES: Among adolescent mothers, pregnancy prevention self-efficacy developed during pregnancy may predict the use of contraception following delivery. Communication between patients and their primary care providers (PCPs) is important for adherence to physician recommendations and may be associated with pregnancy prevention self-efficacy. Depression, which is common among adolescent mothers, has been associated with poor self-efficacy. The associations among pregnancy prevention self-efficacy, provider communication, provider type (PCP vs others), and depression are unclear. The objectives of the study were to determine the association of positive provider communication with pregnancy prevention self-efficacy, whether provider type or depression is associated with positive provider communication, and whether the association between provider communication and pregnancy prevention self-efficacy varies by provider type and depression. METHODS: Cross-sectional study of 164 third trimester Baltimore adolescents measuring pregnancy prevention self-efficacy, perceptions of the quality of provider communication (Ambulatory Care Experiences Survey), provider type, and depressive symptoms. RESULTS: Of 164 pregnant teens, 79% reported pregnancy prevention self-efficacy, 72% had a specific PCP, and 17% scored positive for depression. Positive provider communication was associated with pregnancy prevention self-efficacy (odds ratio 1.25; P = 0.04). Adolescents with PCPs had significantly higher communication scores (ß 0.90; P = 0.001). Depressed adolescents had significantly lower communication scores (ß -0.74; P = 0.03). The association between positive provider communication and self-efficacy was significant only for adolescents who reported having a PCP (P = 0.04) and those who were not depressed (P = 0.05). CONCLUSIONS: Having a PCP and favorable perceptions of provider communication are important for pregnancy prevention self-efficacy among adolescents. Depression negatively affects perceptions of provider communication, which may limit self-efficacy.

Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care.

BACKGROUND: Poor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) -which is associated with satisfaction and continued contraceptive use among various populations. OBJECTIVE: To examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas. PATIENT INVOLVEMENT: Formative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition. METHODS: Cross-sectional surveys were administered to Latinas ages 15-29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations. RESULTS: 103 Latinas (mean age = 21.4) participated. 33% of participants<21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants< 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively). DISCUSSION: Patient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those<21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population. PRACTICAL VALUE: Results from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.

Contraceptive Decision Making Among Latina Immigrants: Developing Theory-Based Survey Items.

BACKGROUND: Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations. AIM: This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas. METHOD: Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items. RESULTS: Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore. DISCUSSION: These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior-based interventions designed to improve the contraceptive counseling of Latinas.

Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial.

PURPOSE: One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes. METHODS: We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks' gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI-only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years' postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months' postpartum was measured with birth certificates. RESULTS: Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21-0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16-0.98) and CAMI-only (HR = 0.19; 95% CI, 0.05-0.69). CONCLUSIONS: Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.

Needs and preferences for receiving mental health information in an African American focus group sample.

The purpose of this study is to better understand the mental health/illness information and service delivery preferences among African American residents of Baltimore. We conducted four focus groups (n = 42) among African American adults currently unconnected with the mental health system. Participants expressed fear of stigma and perceptions of racism as major barriers to seeking information and/or services and discussed some normalizing strategies to address these barriers. African Americans harbor cultural and traditional beliefs regarding mental illness which could also act as barriers. Findings have implications for imparting acceptable and culturally sensitive mental health education and service delivery programs in community settings.

Bypass of local primary care in rural counties: effect of patient and community characteristics.

PURPOSE: This national study sought information from rural patients (1) to assess the prevalence of bypass, a pattern of seeking health care outside the local community; (2) to examine the impact of locally available primary care physicians (PCPs) and hospital size on the odds of bypass; and (3) to identify patient demographic and geographic factors associated with bypass. This study also ascertained the reasons patients give for bypass and their suggestions for how hospitals can retain patients locally. METHODS: We analyzed data from a 2005 telephone survey of 1,264 adults, aged 18 years or older, who lived within 20 miles of 25 randomly selected Critical Access Hospitals and were linked with a Health Professional Shortage Area and 2004 census data. Respondents were asked about demographic characteristics, travel time and distance to local hospitals, and insurance status, as well as for suggestions of what local hospitals could do to retain patients. RESULTS: Overall, 32% of respondents bypassed local primary care; the rate ranged from 9% to 66% across the Critical Access Hospital service areas. Factors associated with bypass included age, education, marital status, satisfaction with the local hospital, admission to a hospital in the past 12 months, hospital size, and local density of PCPs. Compared with residents in areas with a higher density of PCPs (=3,500 residents per PCP), residents in areas with a low density (>4,500 residents per PCP) were more likely to bypass local care (odds ratio, 1.58; 95% confidence interval, 1.02-2.46). Lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed local hospitals. CONCLUSIONS: The sizable variation in bypass rates among this sample of Critical Access Hospital service areas suggests that strategies to reduce bypass behavior should be directed at the local community or facility level. Changing rural residents' perception of their local care, helping them gain a better understanding of the function of primary care, and increasing the number of PCPs might help hospitals retain patients and rural communities stay healthy.

Effect of partner relationship on motivation to use condoms among adolescent mothers.

PURPOSE: Adolescent mothers have high rates of repeat pregnancy and sexually transmitted infections (STIs). We sought to identify factors associated with their consistent condom use. METHODS: Data for 107 urban adolescent mothers enrolled in a longitudinal computer-assisted motivational interviewing (CAMI) intervention were analyzed. The intervention aimed to motivate and instill confidence in using condoms consistently. DATA SOURCES: 1) structured interviews during the third trimester of pregnancy (baseline), 2) CAMI responses at 9-12 months postpartum. Outcomes were dichotomized as: consistent condom users and inconsistent condom users. RESULTS: At baseline, mean age was 17 (1.1 SD) years, 96% African American, and 26% reported always using condoms. At 9-12 months postpartum, 33 (31%) used condoms consistently. Consistent condom users were less likely to report having sex with their baby's father (61% vs. 81%; p = 0.05). Adolescent mothers who used condoms consistently experienced greater self-efficacy in the prevention of STIs and recognized the importance of preventing STIs with a new boyfriend (p = 0.006). Consistent condom users held the opinion that it was more important to use condoms with a new boyfriend than with their baby's father regardless whether their main partner was the father of their baby or a new boyfriend. CONCLUSIONS: Level of motivation, belief in the importance of condom use and self-efficacy to use condoms with a new boyfriend regardless of actual sexual partner relationship were the strongest predictors of consistent condom use among adolescent mothers. Future interventions aimed at improving condom use should focus on motivation and to different views held by teens regarding their partner-specific condom use.

Home visiting for adolescent mothers: effects on parenting, maternal life course, and primary care linkage.

PURPOSE: Adolescent mothers are at risk for rapidly becoming pregnant again and for depression, school dropout, and poor parenting. We evaluated the impact of a community-based home-visiting program on these outcomes and on linking the adolescents with primary care. METHODS: Pregnant adolescents aged 12 to 18 years, predominantly with low incomes and of African American race, were recruited from urban prenatal care sites and randomly assigned to home visiting or usual care. Trained home visitors, recruited from local communities, were paired with each adolescent and provided services through the child's second birthday. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation. Research assistants collected data via structured interviews at baseline and at 1 and 2 years of follow-up using validated instruments to measure parenting (Adult-Adolescent Parenting Inventory) and depression (Center for Epidemiologic Studies Depression). School status and repeat pregnancy were self-reported. We measured program impact over time with intention-to-treat analyses using generalized estimating equations (GEE). RESULTS: Of 122 eligible pregnant adolescents, 84 consented, completed baseline assessments, and were randomized to a home-visited group (n = 44) or a control group (n = 40). Eighty-three percent completed year 1 or year 2 follow-up assessments, or both. With GEE, controlling for baseline differences, follow-up parenting scores for home-visited teens were 5.5 points higher than those for control teens (95% confidence interval, 0.5-10.4 points; P = .03) and their adjusted odds of school continuation were 3.5 times greater (95% confidence interval, 1.1-11.8; P <.05). The program did not have any impact on repeat pregnancy, depression, or linkage with primary care. CONCLUSIONS: This community-based home-visiting program improved adolescent mothers' parenting attitudes and school continuation, but it did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care. Coordinated care may require explicit mechanisms to promote communication between the community program and primary care.

How can Primary Care Physicians Best Support Contraceptive Decision Making? A Qualitative Study Exploring the Perspectives of Baltimore Latinas.

OBJECTIVES: U.S. Latinas experience disproportionately high rates of unintended pregnancy and low rates of consistent contraception use. Not well known are Latinas' perspectives about how primary care physicians (PCPs) might facilitate or deter contraceptive decision making. The theory of planned behavior has been used previously to explain contraceptive behaviors. This study used the theory of planned behavior as a guide to help describe Latinas' perspectives regarding specific factors that influence their contraceptive decision making and to describe their perspectives about the role of PCPs in the decision making. STUDY DESIGN AND METHODS: We conducted focus groups (n = 3) and interviews (n = 8) of Latinas ages 15 to 24 years, recruited from urban primary care sites in Baltimore, Maryland. Concepts from the theory of planned behavior were used to develop a coding scheme and guide identification of themes. RESULTS: Sixteen Latinas participated; all were immigrants. THEMES: The desire to avoid unintended pregnancy is dominant and, not surprisingly, is the main driver of contraceptive intentions. The role of PCPs in contraceptive decision making is to build strong patient relationships through heightened communication and trust. PCPs should develop trust and foster communication by using a shared decision-making approach in contraceptive counseling. Religious norms rarely operate as barriers to contraceptive use, yet positive reinforcement from family, friends, and schools is viewed as supportive. CONCLUSIONS AND IMPLICATIONS: For this group of young, immigrant Latinas, there is a pervasive desire for effective communication and trusting relationships with PCPs. Findings suggest that providers can facilitate contraceptive decision making for this population by using a shared decision-making approach to contraceptive counseling.

Processes for effective communication in primary care.

Communication in the delivery of health care services occurs along 2 axes: between providers and patients and among several providers. In primary care, a principle objective in the provider-patient relationship is facilitating whole-person care, which is care provided in the context of family and community. In addition, primary care emphasizes communication between the primary care physician and other providers with the goal of integrated care, or care provided in the context of a patient's overall health care needs. However, considering both the U.S. health care delivery system and medical education programs, several obstacles interfere with the necessary processes of communication. This paper addresses those obstacles with a conceptual framework for effective communication in primary care. Recommendations propose formalizing requirements for the exchange of information among providers, enhancing communication training, disseminating information technology, and mitigating external factors that disrupt communication in primary care.

The effect of volunteer home visitation for adolescent mothers on parenting and mental health outcomes: a randomized trial.

BACKGROUND: Children of adolescent mothers may suffer because of parenting inadequacies. The use of volunteer home visitors to enhance parenting skills has not been well studied. OBJECTIVE: To evaluate the effect of a volunteer model home visitation program on adolescent parenting outcomes. DESIGN: Randomized trial with assignment to home visitation or control group. SETTING: Urban, African American community. PARTICIPANTS: Adolescents aged 12 to 18 years at 28 or more weeks' gestation or who had delivered a baby in the past 6 months were recruited between February 1996 and August 1999. INTERVENTION: Volunteers were recruited from the community and trained to implement a parenting curriculum during weekly home visits. Each volunteer was paired with one teenager. MAIN OUTCOME MEASURE: Validated instruments measuring parenting stress, parenting behaviors, and mental health. RESULTS: A total of 232 teenagers were successfully randomized to home visitation and control groups. At baseline, the groups were comparable on demographic, social support, and mental health measures. Almost half the teenagers had poor mental health at baseline, and high rates persisted at follow-up in both groups. In multivariate models, the home visitation group demonstrated significantly better parenting behavior scores at follow-up than did the control group (P =.01) but showed no differences in parenting stress or mental health. CONCLUSIONS: The volunteer home visitation program significantly improved some parenting outcomes but not parental distress or poor mental health. Volunteers may be an effective means of providing parenting education, but interventions that include specific means of addressing poor mental health are likely to have greater effects.

Reduced school dropout rates among adolescent mothers receiving school-based prenatal care.

BACKGROUND: Adolescent pregnancy is associated with increased school dropout rates. Dropping out amplifies the probability of persistent social and economic disadvantage. Whether school-based health centers might help reduce school absenteeism and dropout rates in this group has not been well studied. OBJECTIVE: To examine the association of school-based prenatal services on school attendance and dropout rates. METHODS: In this retrospective cohort study, using school rosters from an alternative school, we identified adolescents aged 18 years or younger who delivered a baby between July 1, 1995, and August 30, 1997, in Baltimore, Md. We linked school records spanning 3 years with medical records and birth certificates. School variables such as attendance and dropout rates were examined in relation to the teen's year of pregnancy and prenatal care setting (school-based vs non-school-based). Hierarchical logistic regression was used to examine effects of school-based prenatal care on dropout and promotion or graduation rates, with adjustment for baseline group differences. RESULTS: We identified 431 predominantly African American, low-income adolescents who attended the alternative school in their pregnancy school year. In the year prior to pregnancy, most performed poorly in school and had significant absenteeism. During their pregnancy school year, teens receiving school-based prenatal care were absent 12 fewer days, as compared with those receiving non-school-based care (P =.001), and their dropout rate was half that of those receiving non-school-based care (6% vs 15%; P =.02). Hierarchical logistic regression analyses, with adjustment for baseline prepregnancy differences, demonstrated that teens receiving school-based prenatal care were less likely to drop out of school during the pregnancy year (adjusted odds ratio, 0.39; 95% confidence interval, 0.15-0.99; P =.048). CONCLUSIONS: Absenteeism and dropout rates were reduced for pregnant adolescents receiving prenatal care at a school-based health center in an urban alternative school. Findings underscore the importance of funding and evaluating school-based health centers and other interventions that may ameliorate negative outcomes among childbearing adolescents.

Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care.

PURPOSE: To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based. METHODS: Retrospective sohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents < or =18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SB-CAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics. RESULTS: Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SB-CAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HB-CAPP: 2.31, 95% CI 0.65-8.24). CONCLUSIONS: School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care.

Is depression associated with contraceptive motivations, intentions, and use among a sample of low-income Latinas?

BACKGROUND: Latinas in the United States experience high rates of unintended pregnancy and low rates of contraception use, yet reasons are not completely understood. Depression is common among pregnant and nonpregnant Latinas; its influence on contraceptive motivations, intentions, and use is understudied. OBJECTIVES: We sought to 1) describe Latinas' contraceptive motivations, intentions, and use; 2) use structural equation modeling to test associations between depression and contraceptive self-efficacy/motivations/intentions/use; and 3) determine whether associations differ by pregnancy status. METHODS: This cross-sectional study included Latinas ages 15 to 45 recruited from an urban Federally Qualified Health Center in Baltimore, Maryland. Structured surveys were used to collect data regarding depressive symptoms measured using the PHQ-9. All other constructs were measured with previously validated questions. Constructs included contraceptive self-efficacy, positive and negative contraceptive motivations (perceived advantages and disadvantages of using contraception), contraceptive intentions to begin or continue contraception use, and contraceptive methods currently used. RESULTS: Among pregnant Latinas, depression was associated with negative motivations (ß = 0.16; p < .05), negative motivations were associated with intentions (ß = -0.22; p < .01), and contraceptive self-efficacy was associated with intentions (ß = 0.43; p < .001). Among nonpregnant Latinas, contraceptive self-efficacy was associated with intentions (ß = 0.78; p < .001) and intentions were associated with use (ß = 0.40; p < .05). CONCLUSIONS: Among pregnant Latinas, negative motivations intervene in the association between depression and contraceptive intentions. For nonpregnant Latinas, intentions intervene in the association between self-efficacy and contraceptive use. This study underscores the importance of depression screening during pregnancy and encourages practitioners to target contraceptive motivations to improve contraceptive use.

Engaging hard-to-reach patients in patient-centered outcomes research.

AIMS: This study aimed to identify methods to engage hard-to-reach patients in the research process. MATERIALS & METHODS: With funding from the Patient-Centered Outcomes Research Institute (Washington, DC, USA), the University of Maryland (MD, USA) conducted 20 focus groups and one individual interview. The sample consisted of six groups of hard-to-reach patients, two groups of healthcare providers who work with hard-to-reach patients and two groups of surrogates of hard-to-reach patients. RESULTS & CONCLUSION: In order to make patient-centered outcomes research more meaningful to patients and their caregivers, patient-centered outcomes research should be conducted with a focus on building and maintaining trust, which is achieved via pre-engagement with communities and continuous engagement of study participants and their communities.

Social determinants of breast cancer screening in urban primary care practices: a community-engaged formative study.

BACKGROUND: The recent decline in the breast cancer mortality rate can be attributed to intensive screening and early detection efforts. However, studies have documented a decline in self-reported recent mammography use and interventions to enhance mammography utilization have yielded modest improvements. To address the root causes of breast cancer disparities and improve mammography use, interventions need to address multiple layers of patient, provider, and health system factors. OBJECTIVE: Using community-based participatory research principles, we sought to learn from women receiving care through urban primary care practices about issues surrounding mammography screening and strategies to increase screening. METHODS: We conducted five focus groups among 41 eligible women who were predominantly African American, recruited using nonprobability purposive sampling methods from urban community health centers in Baltimore, Maryland. Data are reported from three focus groups (n = 28) that provided usable data. We used the social determinants of health perspective to conduct a qualitative content analysis and interpretation of the data. RESULTS: Major obstacles to obtaining a screening mammogram were individual-level (i.e., pain from the procedure) and structural-level factors (i.e., cost, geography, convenience). Strategies to overcome obstacles could include the creation of structural mechanisms whereby women can receive a host of services during one visit to a healthcare professional's office. Important promoters of screening behavior included social-level factors such as social support, hope, and positive treatment outcomes. CONCLUSION: The social determinants of health perspective provided a unique perspective to frame barriers and promoters of mammography utilization and insights to develop interventions aimed at improving cancer control among women receiving care at urban primary care health centers.

Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions.

This qualitative study sought to explore facilitators and barriers to adherence to multiple medications among low-income patients with comorbid chronic physical and mental health conditions. The 50 focus group participants identified personal/contextual and health system factors as major impediments to adherence to multiple medications. These factors included medication side effects, fear of harm from medication, fear of dependence on medication, complex instructions, suboptimal communications with doctor, suspicion about doctors' and pharmaceutical companies' motives in prescribing medication, and the high cost ofmedications. Participants also identified motivators, both internal (self-initiated) and external (initiated by family, doctor, support groups),to ensure adherence to multiple medications. These motivators included self-discipline, sense of personal responsibility, faith, support from family members and doctors, and focused health education and self-management support. Three themes emerged that enhanced understanding of the complexity of adherence to multiple medications: (1) reaching one's own threshold for medication adherence, (2) lack of shared information and decision making, and (3) taking less than the prescribed medication. Further analysis of the data revealed that the patients perceived a lack of shared decision making in the management of their comorbid chronic conditions and their medication regimen.

Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: a rebirth of economic and policy considerations.

OBJECTIVE: To determine the cost-effectiveness of an intervention that successfully reduced rapid repeated births within 2 years of an index birth to adolescent mothers. DESIGN: Randomized, controlled trial conducted from February 2003 to October 2007. SETTING: Home-based intervention with participants recruited from 5 urban clinics that provide care to low-income African American communities. PARTICIPANTS: Two hundred thirty-five pregnant teenagers (n = 235) aged 18 years or younger who were at 24 or more weeks of gestation at recruitment were followed up for 27 months. INTERVENTIONS: Participants were randomly assigned to usual care (n = 68) or 1 of 2 home-based interventions conducted by community outreach workers: (1) computer-assisted motivational intervention (CAMI) conducted quarterly with additional visits (CAMI+ [n = 80]) or (2) CAMI only (n = 87), a single-component motivational intervention conducted quarterly. MAIN OUTCOMES: Additional births by 24 months post partum determined from birth certificates, total and weighted mean intervention costs, cost per participant, and incremental cost-effectiveness ratios, defined as cost per prevented repeated birth. RESULTS: Relative to usual care, CAMI significantly reduced repeated births (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-0.97). Mean intervention costs per adolescent were $2064, with incremental cost-effectiveness ratios per prevented repeated birth of $21 895 (unadjusted), $17 388 (adjusted), and $13 687 for a high-risk subgroup termed newly insured (eligible for but not enrolled in public insurance). CONCLUSIONS: The CAMI costs and cost-effectiveness compare favorably with other effective programs aimed at preventing repeated teenage births. Replication of these results in broader samples of adolescents would provide policy guidance for what works, for whom, and at what cost.

Double jeopardy: depressive symptoms and rapid subsequent pregnancy in adolescent mothers.

OBJECTIVE: To examine whether depressive symptoms are a risk factor for a subsequent pregnancy in adolescent mothers. DESIGN: Secondary analysis from a longitudinal risk-reduction intervention. SETTING: Five community-based prenatal sites in Baltimore, Maryland. PARTICIPANTS: Two hundred sixty-nine consenting teens, predominantly African American and with low income, who received prenatal care at any of the 5 community-based prenatal sites and completed follow-up questionnaires at 1 or 2 years post partum. Intervention Baseline depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale. Outcome Measure Occurrence of and time to subsequent pregnancy by 2 years post partum. RESULTS: Among teens completing at least 1 follow-up questionnaire, baseline depressive symptoms were present in 46%. A subsequent pregnancy by 2 years post partum was experienced by 49%, with a mean (SD) time to first subsequent pregnancy of 11.4 (5.8) months. Depressive symptoms were associated with increased risk of subsequent pregnancy in both unadjusted models (hazard ratio, 1.44; 95% confidence interval, 1.01-2.03) and adjusted models (hazard ratio, 1.44; 95% confidence interval, 1.00-2.01). CONCLUSIONS: Depressive symptoms may be an independent risk factor for subsequent pregnancy in African American adolescent mothers. Because depression is treatable, future studies should evaluate whether improved recognition and treatment of adolescent depression reduces the risk of rapid subsequent pregnancy.