Effects of Enhanced Mental Health and Youth Asset Development Interventions on a Home Visiting Program for Pregnant and Parenting Teens

Danell Weese, RN, BSN, Lizelle Lirio, RN, MS, Anand Chabra, MD, MPH, and
Katie DellaMaria, RN, MSN (San Mateo County Health Department, San Mateo, CA)
Xiaojing Wang, MMP, Nancy Latham, PhD and India Alarcon, BS
(LaFrance Associates, LLC, San Francisco, CA)

Introduction

The Adolescent Family Life Program (AFLP) serves pregnant and parenting Latina, African American, and Filipina teens, ages 13-19, and their male partners. In addition, high risk siblings receive case management and youth asset development services. Interventions include intensive case management and home visiting services, mental health treatment, and social support and youth asset development groups, and are provided to the teens primarily in the home, clinic, or school settings.

The research follows two pathways:  Research Evaluation and Program Evaluation. The Research Evaluation Pathway objectives are:  (1) young parents with access to mental health counseling through AFLP will show decreased depression and increased functioning over the course of the treatment; and (2) young parents with access to mental health counseling through AFLP will show reduced social isolation over the course of treatment.  The Program Evaluation Pathway objectives include:  (1) case managed clients will maintain or improve key measures of health and economic stability when compared to clients in the 2000 program, and over the course of this AFLP program; (2) case managed teenage mothers will report reduced social isolation after participation in an AFLP support group and related social activities; and (3) case managed young fathers will report reduced social isolation after participation in an AFLP support group and related social activities. 

The following intervention strategies have been established: (1) home-based visitation for case management, mental health screening and counseling; (2) parenting education and support groups; (3) social activities to bring families together; and (4) referrals to community resources.

The evaluation is designed to assess the degree to which the program is meeting its objectives of improving outcomes for its clients by adding a mental health component to its existing services of home visits by case managers. The evaluation also reports on general program effectiveness and progress made in program implementation.

Methods

The Research Evaluation Pathway uses a randomized experimental approach to look at access to mental health counseling services, comparing a treatment group of clients that receive access to teen-focused, home-visiting Marriage and Family Therapists (MFTs) and a control group that does not have access to services provided by teen-focused, home-visiting MFTs, but receives all other program services and referrals to community mental health services. Clients are randomly assigned to treatment and control groups after program staff have obtained parental consent for the clients to participate in the study (clients 18 or older can consent for themselves).  The program obtained approval from a federally-registered Institutional Review Board in June 2008.

The Program Evaluation Pathway employs a quasi-experimental approach, using three types of comparisons. First, evaluators compare outcomes of clients served in Care 2005 with those served in Care 2000 (the program implemented locally from 2000-2005). In the second method, evaluators look for maintenance and improvement over time in Care 2005, comparing outcomes for the most recent year to outcomes for the baseline year (2005-2006).  The third method is within-group over time, using measures from pre- and post-intervention. 

The goal of the Research Evaluation Pathway is to understand the extent to which the added mental health services program components result in improved outcomes. Clients in the treatment group who are screened for signs and symptoms of depression with the Beck Depression Inventory II (BDI-II) and score above a defined cut-off, or show other concerning signs, will be referred to a teen-focused, home-visiting MFT while clients in the control group who meet these criteria will be referred to community mental health services.  Differences between the two groups in the level of change in mental health, education/economic and social isolation outcomes are then analyzed. 

Various data collection instruments are used in this evaluation of AFLP. These include mental health assessments (such as the BDI-II), surveys, forms to record demographic information, and the Lodestar database (a state-mandated tool used in California’s AFL programs). 

Four types of analysis will be performed for this program.  The first will make use of data collected using an experimental research design.  This data analysis will include independent sample T-tests to look for statistically (and substantively) significant differences between the treatment and control groups.  The second analysis will look at observational data collected on successive cohorts, with evaluators conducting multiple logistic regressions.  The last two analyses will use descriptive statistics on 1) data measuring long-term outcomes and 2) data collected over time, within-group.

Results

Results are not available for program outcomes in this evaluation for two major reasons. First, the lack of a control group in the original research design was unacceptable under OAPP evaluation guidelines and required a complete change in methodology.  The second was the necessity to obtain approval from a federally-registered IRB for the research evaluation (our initial IRB was not federally approved).  With OAPP’s authorization of the new research design, the program was able to receive approval from a federally-registered IRB in June 2008.  Outcome evaluation data collection began in mid-July 2008 – none are available to report as yet.  However, staff were trained to administer the BDI-II resulting in increased screening for depression, and leading to an improvement to the mental health referral process.  And over the course of the reporting year, staff became increasingly comfortable at discussing mental health with teens and referring those in need of counseling. Staff also reports a decrease in stigma around mental health among the teen moms because AFLP’s mental health services have become more teen friendly. Support groups for teen moms grew stronger this year as participants took on more leadership roles in the community, developed relationships with their peers, and built stronger support systems.  

Discussion

The program saw full implementation of its proposed home visitation-based case management, mental health counseling services, and support group coordination. Referrals from schools, community clinics, hospitals, and other public health agencies and community-based organizations continue to be robust in numbers. With two MFTs and other highly qualified staff in the program, SMCHD was able to better serve young parents and their children.  With a new evaluation research design completed and IRB approval obtained, new evaluation systems are in place to address program outcomes.

Implications

Implementing the research portion of our program required acquiring IRB approval.  Providing and measuring a mental health component necessitated steps to protect the program’s subjects.  This process was quite entailed and lengthy; and therefore, data was unable to be collected for much of the year.  The program is now enrolling new AFL cases into the research pathway and collecting data. 

Contact Information

Danell Weese
Phone: (650) 573-3467
Email: dweese@co.sanmateo.ca.us