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标题：The Adolescent Family Life Program: A Multisite Evaluation of Federally Funded Projects Serving Pregnant and Parenting Adolescents
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作者：Marni L. Kan ; Olivia Silber Ashley ; Kathryn L. LeTourneau 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2012
卷号：102
期号：10
页码：1872-1878
DOI：10.2105/AJPH.2012.300836
语种：English
出版社：American Public Health Association
摘要：Objectives. We evaluated the effectiveness of care demonstration projects supported by the Title XX Adolescent Family Life (AFL) program, which serves pregnant and parenting adolescents in an effort to mitigate the risks associated with adolescent childbearing. Methods. This cross-site evaluation involved 12 projects and 1038 adolescents who received either enhanced services funded by the AFL program or usual care. We examined the effects of enhanced services on health, educational, and child care outcomes approximately 6 months to 2 years after intake and explored moderation of program effects by time since intake and project characteristics associated with outcomes. Results. The odds of using long-acting reversible contraception (odds ratio [OR] = 1.58) and receiving regular child care (OR = 1.50) in the past month were higher in the intervention group than in the comparison group. Odds of a repeat pregnancy were lower (OR = 0.39) among intervention group adolescents than among comparison group adolescents within 12 months of intake. Several project characteristics were associated with adolescent health outcomes. Conclusions. These projects show promise in improving effective contraceptive use, increasing routine child care, and yielding short-term decreases in repeat pregnancy. Enhancements to supportive services targeting pregnant and parenting adolescents can improve maternal and child outcomes, including repeat pregnancy, educational attainment, and child well-being. 1,2 The disadvantages faced by adolescent mothers and their children 3,4 can be mitigated by providing high-quality programs at school or home visits, case management, and mentoring. 2,5,6 One such program, the Title XX Adolescent Family Life (AFL) program, was established to support demonstration projects in developing, implementing, and evaluating innovative strategies to serve pregnant and parenting adolescents, their infants, male partners, and family members. The goals of the AFL program include reducing the number of repeat adolescent pregnancies and increasing educational attainment. 7 The program also targets contraceptive use and receipt of child care ( Figure 1 ). This study involved a multisite evaluation to assess effectiveness of selected AFL care demonstration projects in achieving these goals. Open in a separate window FIGURE 1— Conceptual model of the Adolescent Family Life (AFL) program cross-site evaluation, 2009. Prior efforts to improve outcomes for pregnant and parenting adolescents—repeat pregnancy and birth, contraception, and educational attainment—have had mixed results. Some individual randomized controlled trials of home visiting and family support programs have found no effect on repeat pregnancy or birth, 8–10 but other randomized controlled trials of motivational interviewing, home-based monitoring, and multicomponent interventions have shown promising effect. 11–13 Two individual studies reported intervention group repeat birth rates (13.8% and 11%) that were about half the control group rates (25% and 24%). 11,12 A meta-analysis of 16 experimental and quasi-experimental evaluations that were diverse with regard to sample and interventions found moderate effects on repeat pregnancy over approximately 18 months of follow-up that disappeared at later follow-up. 1 Fewer studies have examined program effects on contraception, but 1 posttest-only quasi-experimental study of a comprehensive school-based program found higher rates among intervention than among comparison group respondents for current use of contraception (86.7% vs 77.4%) and ever use of Depo-Provera (56.9% vs 45.8%). 14 For educational outcomes such as preventing dropout and increasing school attendance or graduation, a review 2 and individual randomized controlled trials 8,13,15 indicated that program models involving peer support groups, community-based home visiting, or comprehensive case management showed promising evidence. One individual randomized controlled trial of a home visiting program found that the odds of school continuation were 3.5 times higher among intervention than among control group respondents 8 ; another randomized controlled trial that tested a peer support prenatal care intervention found that intervention group respondents completed 0.5 year more school by 12 months postpartum than did control group respondents. 15 However, 2 home-visiting programs did not affect graduation rates in separate randomized controlled trials. 9,16 Despite the emerging base of randomized controlled trials of pregnant and parenting adolescent programs, limitations such as small sample sizes and high attrition persist. 1,5 These studies often examine a limited number of outcomes, and some outcomes of importance have not been investigated. For instance, no rigorous studies have evaluated program effect on long-acting contraceptive use, which is linked to reduced risk for repeat or unintended pregnancy. 17,18 Receipt of regular child care, which may enable adolescent mothers to advance their education or seek employment and may improve child development, also has not been examined as a program outcome. Limited information is also available about the project characteristics associated with program effectiveness in this population. Programs that have been successful in postponing additional births have initiated services during the prior pregnancy and continued to the end of the child’s second year. 5 For example, effective home-visiting programs initiated services early and sustained the length of service delivery with specially trained nurses who followed a regular schedule and discussion protocol at each visit. 19,20 More broadly, effective curriculum-based adolescent pregnancy prevention programs use activities, instructional methods, and behavioral messages that are appropriate to adolescents’ culture, developmental age, and sexual experience. 21 Although local evaluations of AFL demonstration projects have yielded some evidence of individual project effectiveness, 8,11,22–24 no multisite evaluations of programs for pregnant and parenting adolescents have been conducted to examine effects across program models and with diverse populations. This national cross-site evaluation provided an opportunity to understand, through rigorous evaluation, the overall effect of 12 AFL demonstration projects on repeat pregnancy, educational attainment, contraceptive use, and child care receipt, as well as project characteristics associated with effectiveness. We hypothesized that odds of repeat pregnancy and school dropout would be lower, and educational attainment and odds of using long-acting contraception and receiving regular child care would be higher, among intervention than among comparison group adolescents. Given prior evidence of diminishing program effects on repeat pregnancy over time 1 and the variation in intervention duration across projects, the evaluation examined the extent to which intervention effects and effects of project characteristics varied as a function of time since intake.