Promise Place Program: Using Case Management to Prevent Subsequent Pregnancies among Parenting and Pregnant Adolescents

Eleni  L. Tolma, MPH, Ph.D., Valerie Skaggs, Ph.D., Tracey D. Douglas, MS; LPC  

Introduction

Oklahoma has one of the highest teen-pregnancy rates in the country. The North Care Promise Place Program (PPP) is one of the few programs that provides a holistic approach to teen parents by providing an array of services to them with a core service of case management by a Family Advocate.  Research has shown that programs that are comprehensive, incorporating a case-management component are more likely to be successful in achieving their health, educational, and social outcomes.

The priority population consists primarily of 200 parenting or pregnant female students from a diverse ethnic background 11-19 years old. Approximately 50 male students who are teen fathers will also participate in the PPP.    Enrollment in the program is continuous. The program goals are: a) to increase the number of pregnant and parenting adolescents who delay subsequent births until after high school graduation; b) to increase the number of pregnant and parenting adolescents who graduate from high school; c) to increase the number of pregnant and parenting adolescents who experience healthy pregnancy outcomes; and d) to increase the number of pregnant and parenting adolescents who have the parenting skills necessary to create a healthy, nurturing family unit. The aims of the evaluation are: a) to assist the project director to continually improve quality of the project implementation; and b) to assess whether the Promise Place Program has been effective in making a positive impact on the students’ lives.

The main hypothesis that will be tested is that teen parents or pregnant teens who have been participating in the Promise Place program for at least 12 months are more likely to graduate from high-school, enhance their parenting skills necessary to create a healthy nurturing family, and delay subsequent births until after high school graduation, compared to teens parents who have not participated in the Promise Place program.

Methods

The evaluation takes place at two levels; process evaluation and impact evaluation. During process evaluation the research team monitors the percentage of services utilized by the participants on a monthly basis through a service tracking log. It also monitors the quality of the family advocate service through logs review, which documents the average amount of time each family advocate spends with a student, and by assessing the degree of satisfaction with the PPP through qualitative research.  Finally, fidelity of the program implementation is assessed through periodic review of the Logic Model and degree of achievement of the process objectives.

Impact evaluation is conducted through the administration of the following surveys: a) core baseline questionnaire for parenting teens; b) core baseline questionnaire for pregnant teens; c) core follow-up survey for all clients; d) parenting-sense competency scale and e) child birth and parenting knowledge test. The research design consists of a combination of quasi-experimental and time series designs.  Students (females who attend grades 7th-12th) from Emerson High School (EHS) serve as the intervention school whereas students (females who attend grades 7th-12th) from Capitol Hill High School  ( CHHS) serve as the comparison group. Students from CHHS are being recruited with the help of a teacher at the school and are not being exposed to any intervention. A recruitment protocol has been developed for students from both schools. Due to their small numbers, male students from EHS are only included in focus group research.

Data collection has already begun for both the comparison and intervention groups.  Surveys were administered at baseline ( upon entry to the program). The data collection will continue with a follow-up at the childbirth -for pregnant teens only- and then at 1 year interval follow-up for all teens. In addition, teens who participate in the PPP will receive the client evaluation services form at the end of the participation of 2 semesters in the program. Formative research has also been conducted. 

The data analysis consists of univariate, bivariate (e.g. Kruskal-Wallis ANOVA, t-test for independence between groups), and multivariate analysis. This will allow us to get descriptive statistics, as well as test for associations and differences between groups. We will also be able to model what factors are impacting the dependent variables. The dependent variables include those related to the goals of the study (e. g decrease of the number of repeat pregnancies) and those related to the intermediate outcomes such as increasing the number of pregnant teens who intend not to have a pregnancy before school graduation. Independent variables include demographics or the services the youth receive during the intervention.  The study has been approved by the University of Oklahoma Health Science Institutional Review Board.

Results

The formative research cohort consisted of 12 teens from EHS and 11 students from CHHS at baseline (January-February 2008). At the post assessment (May 2008) only 5 students from EHS and 6 from CHHS have participated. Due to the small sample sizes we did not control for potential confounders. Moreover, power analyses were not performed as it was expected that the power would be very low. The formative research focused on the achievement of intermediate outcomes. The bivariate analysis compared both school changes from baseline to follow-up.  The answers to only one question (“how sure they were that they could resist sexual intercourse if a partner did not want to use some form of birth control”) was found to have changed statistically significantly (p=0.0941) in favor of the intervention group at an alpha level of 0.1.  There was no mean difference between the schools in regards to the changes between the baseline and post-childbirth related knowledge (p=0.6565). In addition, neither school had a statistically significant mean change between the baseline and post childbirth related knowledge. However, the trend was in the positive direction for the teens at EHS.  During the focus group research teen-fathers (n= 3) felt very positive regarding the parenting class they have received and were satisfied with the family advocate services. Similarly, teen-mothers (n=3) indicated that overall they were satisfied with the family advocate services they have received. However, they did not use extensively other services offered by the PPP and thus did not feel that they have benefited from the program.  

Process evaluation has indicated that the program is taking place as originally planned with an emphasis on providing high quality Family Advocate services as it has been assessed through focus group research and review of the Family Advocates logs. In addition, 80 % of the process objectives set to be accomplished have been completed as of May 2008.

Discussion

The results of the quantitative research indicated a slightly better performance among the students of the intervention school versus the students at the comparison school since two outcomes (ability to resist sexual intercourse if the partner does not want to use birth control and knowledge about childbirth) out of the 13 examined indicated a more positive trend within the intervention group than the comparison group. Two limitations of the quantitative formative research that need to be mentioned are: a) the follow-up was done approximately three months after the baseline which could be a short period of time to allow us to detect any differences; b) the sample size was small and thus the students did not provide variability of answers.  

The qualitative research has given us mixed results. One reason for that as mentioned earlier was that three months is perhaps an insufficient period of time for the students to be exposed in the program and thus benefit from it. In addition, due to the small sample size we were not able to capture a variety of experiences and views regarding the PPP.

One of the challenges that we have encountered in the formative research was the lack of firm policies in both schools regarding student attendance or absenteeism. This has resulted numerous times in students not showing- up during an established date for data collection despite the fact that the students were reminded about it the day before. We will work closely with the school authorities to make the data collection process as efficient as possible.

Implications

Based on our formative research we can conclude that the PPP is in place and it is effective in terms of achieving some immediate outcomes. Family Advocacy at a school setting could be a promising strategy toward preventing subsequent pregnancies among youth.  However, collaborating effectively though the school systems could be challenging.  

Contact information

Eleni  L. Tolma, MPH, Ph.D 
College of Public Health
University of Oklahoma Health Science Center
801 NE 13th street,
Oklahoma city, OK 73126  

Valerie Skaggs, Ph.D
College of Public Health
University of Oklahoma Health Science Center
801 NE 13th street
Oklahoma city, OK 73126

Tracey D. Douglas, MS; LPC  
North Care Promise Place
720 N. Dewey
Oklahoma City, OK 73102