Choctaw Nation of Oklahoma Adolescent Family Life Care Program for 2007-08: ABSTRACT

Angela Dancer, B.S. in Sociology and Criminal Justice

Introduction

The pregnancy rate among 15-17 year-olds living in the Choctaw Nation of Oklahoma’s 11,000 square mile service area is 33.4 per 1,000. The Nation provides free health, education, counseling, and 77 other services for any member of a federally recognized Native American Tribe and/or for any non-Native teen whose child was fathered by a Tribal member. Since these pregnant and parenting teens receive little to no financial support from the fathers of their babies, achieving the goal of healthy outcomes for mothers and their children is largely dependent on their consistent use of the needed services. The purpose of the AFL Care Program is to identify the teens early in their pregnancies and successfully link each with all of the needed services. The staff fulfills this purpose by (1) coordinating efforts with Tribal, County, and State health and human services personnel to locate—and engage—all eligible teens in needed services, and by (2) conducting semi-monthly personal visits with all clients to provide counseling and instruction that will meet their need for knowledge regarding (a) maintenance of their own health and that of their babies and (b) healthy parenting and family relationship skills. A certified Counselor provides intensive case management to coordinate the medical services needed by each client. Three AFL Outreach Workers conduct the semi-monthly personal visits with each client—either at home, school, and/or at the Tribal medical facilities. The Project Staff conducts an AFL Retreat and many other events to provide additional instruction and family strengthening activities, encourages all clients to attend, and provides transportation when needed. Incentives (e.g., baby items and gasoline vouchers) are provided to encourage participation. In addition, the Director publishes (1) articles about AFL services in Bishinik, the Choctaw Nation’s newspaper that is distributed to all Tribal members, and (2) an AFL Quarterly Newsletter that is distributed to all current and former AFL participants. The Newsletter contains calendars of upcoming events, lists and descriptions of available health, counseling, and educational services (and contact information for accessing each), news items, and helpful articles about prenatal care and babies’ health and safety. The data over the past three years provide evidence of staff success in serving 111 pregnant teens, their family members, and the majority of their babies’ fathers in instructional sessions, thus significantly enhancing the potential for every client to achieve the desired positive outcomes. This plan is based on use of an intensive case management approach drawn from a combination of theories discussed in Precede-Proceed Model of Health Program Planning and Evaluation (Green & Kreuter, 1999) and Advanced Case Management (Shore & Raiff, 1993).

The Project Goals focus on achieving (1) reduction of unintended repeat pregnancies, (2) client success in writing personal goals and working to accomplish each, and (3) the clients’ demonstration of commitment to achieving their goals regarding continuing education, maintaining their own health and that of their babies, and working toward ensuring positive family relationships and outcomes. This Abstract focuses on those Outcome Objectives-based hypotheses that target clients’ accomplishments believed to be most critical to their future success and the resulting health and welfare of their children.

Methods

The Choctaw Nation AFL Project evaluation uses a quasi-experimental design that focuses on analysis of survey data gathered from two groups of 39 each—a group of AFL clients and a Comparison Group of pregnant and parenting teens who accessed the Choctaw Nation’s free prenatal, delivery, postpartum, and infant health services—but who declined participation following 2 to 3 one-on-one sessions that included descriptions of services and invitations to participate in AFL. Based on survey results, only one Comparison Group member gave lack of desire as her reason for non-participation in AFL. The remaining teens who were aware of AFL declined due to lack of time to participate in the semi-monthly instructional home visits and the other AFL activities provided. During 2007-08, 41% of Comparison Group members worked outside the home, 67% attended school, and 28% worked and attended school.

Analysis of AFL and Comparison Group (CG) characteristics yielded no significant differences in regard to age range (AFL=16-21 & CG=15-20) and means of ages (AFL=18.5 & CG=18.3), mean ages of the babies’ fathers (AFL=22.6 & CG=22.2), eligibility for Choctaw Nation free services (all were eligible), residence (all live in the service area), dates of services received (all accessed the Choctaw Nation clinic and hospital services during the 2007-08 school year), average number of children previously born to mothers (AFL=1.3 and GC=1.2), racial balance (% minority: AFL=85% and CG=73%, the majority of whom are Native American), and average grade completed by respondents (AFL=10.8 and CG=11.1).

A 55-item Choctaw Nation AFL Objectives Achievement Survey was designed to measure the degree of objectives achievement and to provide data for the AFL vs. Comparison Group Study. Survey item readability was controlled at ≤Grade 7. The survey was administered using methods that ensured respondents’ privacy (i.e., personal delivery with instructions to read and complete each item, with stamped, self-addressed envelopes provided for survey return). No signatures were required.

For this Abstract, the Outcome Objectives are stated in simple null hypothesis form. The relevant survey data were analyzed using the z-Test for Hypotheses About Proportions (i.e., with proportions being the percent of specified item responses for each group), and alpha was set at .01 for all tests. (Power analyses were conducted using 2006-07 data. The results are included in the Evaluation Report.)

Results

(Note: AFL references the AFL Participant Group and CG references the Comparison Group)

• Goal 1 is focused on avoidance of unintended repeat pregnancies. The hypotheses of ¹no difference in repeat pregnancies and ²those using birth control since the birth of their last baby were not rejected ¹(AFL=10% and CG=23%; z = 1.54) and ²(AFL=80% and CG = 72%; z = .82). However, the null hypothesis regarding percent of teens receiving instruction in birth control methods via a Choctaw Nation source was rejected (AFL=100% [all of whom indicated AFL staff] and CG=69%; z = 3.59).
• Goal 2 focuses on clients’ demonstration of commitment to achieving their goals regarding their own health, that of their babies, and positive family outcomes. The following hypotheses of no difference were all rejected: (a) percent of ¹teens and ²their babies’ fathers participating in Injoy prenatal are instruction ¹(AFL=100% and CG=13%; z = 7.72), ²(AFL= 49% and CG=10%; z = 3.77), and (b) percent of teens participating in Positive Indian Parenting (AFL=97% and CG=5%; z = 8.10), and Prevention Relationship Enhancement Program instruction (AFL=97% and CG=2.6%; z = 8.28).
• Goal 3 is focused on achieving client success in writing and working to accomplish their personal goals. The null hypotheses regarding percent of teens ¹writing personal goals, their ²receipt of information regarding needs-based continuing education sources, and ³receipt of assistance with enrollment in appropriate classes by a Choctaw Nation source were all rejected: ¹(AFL=91% and CG=29%; z = 5.34), ²(AFL=97% and CG=13%; z = 7.29), and ³(AFL=90% and CG=10%; z = 7.37).

Discussion

The evaluation data suggest that the Choctaw Nation AFL Care Project staff is effective in ensuring that all clients receive instruction in birth control methods and their use, the Injoy curriculum (Prenatal Care, Birth & Delivery, and Postpartum Care), the Positive Indian Parenting concepts and skills, and the Prevention Relationship Enhancement Program. (AFL clients’ pre/post test score comparisons that demonstrate significant learning progress in each of these skills areas are displayed in the Evaluation Report.) The AFL Outreach Workers effectively taught each client how to write goals in seven critical life skills areas, ensured that each succeeded in writing her goals, and reviewed her achievement progress quarterly. The data also indicate staff success in assisting clients with enrollment in the continuing education programs desired by each (public school, GED, Technology Center, and/or college classes).

Implications

Provision of home instructional visits as the major method for delivery of targeted interventions appears to bring success in achieving the desired behavioral change. Lessons learned: That doubling the home visit frequency (i.e., from monthly in Year 1 to semi-monthly for Years 2 and 3) has enabled the staff to achieve significant improvement in accomplishing the Project Outcomes Objectives.

Contact Information

Telephone: (580) 326-7758
Email: angelad@choctawnation.com