Running head: ADDRESSING ADOLESCENT PREGNANCY 1

Addressing Adolescent Pregnancy in Manatee County: A Health Policy Study

Ramsey Valdes

University of South Florida

 ADDRESSING ADOLESCENT PREGNANCY 2

Addressing Adolescent Pregnancy in Manatee County: A Health Policy Study

Named after the state animal, Manatee County (MC) in sunny Florida (FL) ranks 17 out

of 67 counties in terms of its health outcomes (County Health Rankings & Roadmaps [CHR&R],

2018). In Manatee County (MC), Florida (FL) per 1000 females between the ages of 15-19, 34

are becoming pregnant, while the United States top performer rate is 15 per 1000, and the FL

rate 25 per 1000 (CHR&R, 2018). Teen pregnancy and births can lead to significant mental and

physical health problems for both mother and child making this a health priority for the county.

This paper seeks to identify and explore the county’s strengths and weakness, investigate

interventions that can decrease the teen birth rate, and develop a health policy that can positively

impact MC youth.

Overview of Manatee County, FL

MC is located on the west coast of FL between Hillsborough, Sarasota, and Pinellas

counties. It is approximately 742 square miles in size and has a population of 385,571 people

(US census Bureau, 2017). The population follows a bell curve with most residents being

between that ages of 18-65, most live with at least 2 other people in a household, and 77% have

internet access in the home (US Census Bureau, 2017). The county is made up of mostly urban

areas with only 5.8% of the area being considered rural (CHR&R, 2018). MC’s top employers

are Bealls Inc with 1,786 employees, Manatee Memorial Hospital with 1,280 employees, and

Publix grocery with 989 employees (Bradenton area economic development cooperation [EDC],

2019). The major health system of the county is the manatee health system that includes 2 major

hospitals: Manatee Memorial and Lakewood Ranch (Manatee Healthcare System, 2019). MC is

considered quintessential FL with its mix of outdoor and urban activities; however, there are
 ADDRESSING ADOLESCENT PREGNANCY 3

stark differences between county, state, and United States (US) access to and indicators of

health.

Comparison of Local vs. State Populations

Socioeconomic and population factors heavily influence the health and healthcare system

of an area. When comparing MC and FL, MC has both positive and negative factors that affect

the overall health of its citizens. Poverty is a huge factor in health as it determines the resources

available. In MC, 10.8% of families are considered at poverty level which is less than the state

percentage of 14% (US Census Bureau). MC also has a higher percentage (88.9%) of population

older than 25 with a high school diploma than the state (87.6%) (US Census Bureau, 2017). The

population in MC is made of 16% Hispanics, but only 3% of the population older than five is not

proficient in English compared to 6% of the FL’s population (CHR&R, 2018). However, when

it comes to healthcare MC has less access than the state. In MC there is 1,760 patients to one

provider but across FL 1,380:1 is averaged (CHR&R, 2018). Health is so complicated that all of

these factors play a significant role, and none can singularly be taken to determine health

outcomes.

Analysis and Interpretation of Data

Public health outcomes can quantitatively describe the overall health of a

particular group of people. When compared to other FL counties and other states, MC has both

strengths and weaknesses. It is important to recognize both the good and the bad to identify

areas of improvement.

Identified Strengths

A health indicator is a population factor that, along with others, can give an indication of

what the health of the community looks like. MC has 3 health indicators that are strengths of the
 ADDRESSING ADOLESCENT PREGNANCY 4

county when compared to the US and the state of FL. The first is that MC has a mammography

screening percentage of 70% while FL has a 68% (CHR&R, 2018). Breast cancer is a common

type of cancer that is costly to treat. The likelihood of catching the illness before advanced

stages is increased in MC since higher numbers of women with Medicare are screened.

The second strength is that unemployment in MC is 4.6% which is less than FL’s 4.9%

(CHR&R, 2018). This strength is particularly important as finances and living conditions play a

large role in quality and access of health care. According to Vancea and Utzet (2017), young

people are particularly at risk for health issues when in vulnerable situations such as

unemployment. Therefore, a lower rate of unemployment in the county means that people are

more able to afford and access the resources that they need to reach good health outcomes

The third strength lies with their smallest residents. MC’s low birthweight is 7%, while

the overall FL percent is 9%. This statistic means less babies in MC are born weighing less than

would be deemed fit (CHR&R, 2018). Birthweight of an infant can be an indicator of future

health related risks (CHR&R, 2018).

Identified Weaknesses

While there are positive health aspects in MC, there are also items that should be

addressed. The percent of children in single parent household is 39% in MC, 38% in FL, and the

US top performers average 20% (CHR&R, 2018). Children of single parents are more likely to

have a negative health issue (CHR&R, 2018) and report lower psychosocial scores on child

health questionnaires’ (Herten, Bai, Hafkamp, Landgraf, & Raat, 2015). This statistic shows the

importance of home life in the health and development of children.

MC also has a high percentage of children in poverty. The percent of children in poverty

is 21% in MC which matched the state of FL but and far from the top performers at 12%
 ADDRESSING ADOLESCENT PREGNANCY 5

(CHR&R, 2018). Children in poverty, often lack the necessary resources to maintain good

mental and physical health outcomes. Wickham, Whitehead, Taylor-Robinson, and Barr (2017)

found that a transition into poverty in early childhood is associated with mental health issues for

both parent and child.

Finally, teen birth rate in MC is 34 with a severe difference in race, while the US top

performers rate is 15, and the FL rate is 25 (CHR&R, 2018). This statistic means in MC per

1000 females between the ages of 15-19, 34 are becoming pregnant (CHR&R, 2018). Teen

pregnancy can lead to significant health problems for both mother and child such as anemia and

low birth weights making this a potential issue facing MC (American Pregnancy Association,

2017).

Identification of a Priority Health Issue

The rate of teens giving birth in MC is almost two times that of the top performers in the

country and 10 births higher than the state average making this a serve public health obstacle.

Adolescents are vulnerable to negative health outcomes due to the transitional nature of these

years; and, because pregnancy has a significant social, mental, and physical impact it can be

discerned that pregnant teens are at even higher risk for negative outcomes. There are both

maternal and fetal complications that result from early pregnancy such as eclampsia,

developmental delays, infant mortality, and infections (CHR&R, 2018). Adolescent parents

have also been found to have a greater possibility of experiencing depressive symptoms

exemplifying the complexity of this issue (Siegel & Brandon, 2014). The danger of teen

pregnancy ultimately falls to the lack of resources and support. These mothers and fathers often

do not have the financial ability or worldly know how to take care of a child leaving the whole

family to poor health outcomes. While the trend is not reported for the county, an increasing
 ADDRESSING ADOLESCENT PREGNANCY 6

trend could cause an increase cost to the county in education and healthcare and a decrease in the

quality of life for citizens.

Discussion and Application of Community Health Models

Community health models are tools used to examine the contributing factors that

influence the overall health of a group. They are particularly important in the development of

interventions that can improve the health of a community. For example, the Social Determinants

of Health Model is a place-based standard used to develop interventions/objectives that promote

equal opportunity health through the environment (U.S. Department of Health and Human

Services [HHS], 2019). To develop health interventions using the model, one must analyze the

five social determinants (economic stability, education, social and community context, health

care, and neighborhood environment) (HHS, 2019). This model allows a person to identify

environmental areas of weakness and find solutions. The social factors that contribute to the teen

birth rate in MC fall under four of the five determinants. Teens who lack economic stability are

extremely vulnerable; 4.6% of the county aged 16 and over are unemployed, 21% of children are

in poverty, and 14% of the population lacks adequate food access (CHR&R, 2018). Education

and afterschool activities play a large role in teen pregnancy; only 78% of ninth graders graduate

high school and 16% of 16 to 24-year-olds are not working or in high school and are considered

disconnected youth (CHR&R, 2018). Health access is strained in MC with primary care

physicians outnumbered 1,760:1 (CHR&R, 2018). Finally, the neighborhood and environment

see teens being subjected to 581 violent crimes per 100,000 population (CHR&R, 2018). While

not all factors can be addressed with one priority health intervention, it is important to keep all

social determinants in mind while developing solutions to address the teen pregnancy rate.

Population Diagnosis
 ADDRESSING ADOLESCENT PREGNANCY 7

MC adolescents, aged 15 to 19, are at increased risk of becoming pregnant related to

increased child poverty, lack of appropriate education, and increased rates of disconnected youth.

Community/Population-based Interventions

Teen birth rate is a particularly troubling priority health outcome as it has an impact on

physical, mental, and social health for an extended period of time. The implementation of

interventions to address teen pregnancy in MC can be divided by 3 prevention levels and two

population levels. These interventions are targeted toward increasing education, reaching

disconnected youth, and addressing lack of resources.

Primary Level of Prevention

MC has a variety of programs for adolescents that aim to prevent teen pregnancy;

therefore, reducing the teen birth rate. One of those programs is called It’s yoUR Choice. Run

by the MC school district, this program uses the Draw the Line and Safer Choices curriculums

which have been found by HHS and CDC to be effective in reducing teen pregnancy (CDC,

2019). The primary intervention in this program is to teach health, making it an individual

approach. MC school district (2018) reports that the overall goal is reduction of high-risk

behaviors through health promotion education. MC promotes good health, since teen pregnancy

can lead to health complications such as eclampsia, developmental delays, infant mortality, and

infections (CHR&R, 2018). Stakeholders in this program include the school board, as they risk

their jobs on choosing effective curriculum, taxpayers, as they fund the project, parents, because

they care for their children, and students, as they are directly impacted by the program and its

effectiveness. Funding for this program must be in the school board budget which currently is

set at $889.4 million which is above the needed expense of $831 million due to a tax increase

(Sabella, 2018). The role of a nurse in this level of prevention is to advocate for its existence and
 ADDRESSING ADOLESCENT PREGNANCY 8

be willing and ready to advise on the curriculum when needed. The strengths of this program are

that it is evidence backed and provided to all teens in MC (MC School District, 2018). The

weaknesses are that it does not provide increased resources for those in poverty and does not

reach disconnected youth.

Secondary Level of Prevention

The encouragement of contraception by primary health care providers (PCP) to sexually

active adolescents in MC is a secondary level of prevention. This method is highly controversial

and there are little resources in this area. However, there is evidence that shows that the teen

birth rate was decreased when adolescents were educated on and given long acting reversible

contraception (Secura, Allsworth, Madden, Mullersman, & Peipert, 2010). This prevention

method would be individual if screening is conducted by the PCP; however, there is potential for

this topic to be systems or community wide. Screening of adolescents’ sexual health can be used

to identify at risk individuals and allow the PCP to take appropriate action to ensure the health of

vulnerable individuals. This prevention method also has the ability to reach disconnected youth

as it is not performed at school. Stakeholders in this prevention include the PCP and patients as

they are directly involved in contraception discussions and parents as they are in charge of their

children. Funding for contraception would come from insurance companies and parents, which

is a weakness of this intervention. The role of the nurse is to aid in developing screening tools,

take non-judgmental assessments, and to ensure that there is an understanding of all

contraceptive options (Ott & Sucato, 2014).

Tertiary Level of Prevention

Resources and support are the hallmarks of appropriate tertiary prevention. The teen

parent program enables teen parents to earn a high school diploma and should be suggested to
 ADDRESSING ADOLESCENT PREGNANCY 9

every teen parent at a PCP visit (School District of MC, 2014). According to Kane, Morgan,

Harris, and Guikey (2014), childbearing teens have 0.7-1.9 fewer years of schooling. Education

has long been the key to earning better jobs and financial stability; therefore, lack thereof is a

contributor to the current MC teen birth rate. This intervention would be on an individual level

and would attempt to deal with the financial and social consequences of being a teen parent and

attempt to prevent further negative impacts. Providing for a newborn can be financially difficult;

therefore, a program to ensure an education would have a positive effect on the usual

consequences and can prevent negative impact such as lack of food, poverty, and having a

disconnected child (American Pregnancy Association, 2017). Stakeholders in this program

include legislators as they create such programs, community tax payers that fund the program,

parents directly benefit. Funding for this program would be government based and school board

allocated, which for MC is currently not an issue due to tax increase but may be an issue as cost

of living increases. The role of the community nurse is to recognize at risk youth prior to the

need for a tertiary intervention, distribute information on the teen parent program, and follow up

on the registration process of their clients.

Development of Health Policy

The health policy developed for MC is to decrease the number of teen girls, aged 15-19,

who become pregnant through screening processes so that the number of teen pregnancies

matches the FL average of 25 (CHR&R, 2018). Use of the secondary level of prevention will be

the focus of the health policy. The policy will direct adolescent PCPs screen and provide

education to adolescents and parents using a standardized questionnaire that can be adaptive and

given on a tablet/computer. The discussion of sexual health in the PCP office can often be

difficult for adolescents and providers; answers are likely to be false without good rapport, and
ADDRESSING ADOLESCENT PREGNANCY 10

parents being in the room may skew truthful responses. Goyal et. al (2016) developed a program

that is understandable and given online to access for STI in pediatric emergency departments.

Using this technology, the questionnaire, and the study as a guide, MC public health can create

an easy to use, computerized questionnaire that takes the awkwardness out of the conversation

and tailors interventions based on the adolescent’s answers.

The policy has the possibility of being a positive impact on the county as it could

identify teens at risk so that interventions can be enacted, therefore, decreasing pregnancies and

resource use. However, some limitations include that MC already has a high provider to patient

rate and that the PCP will need to have the resources to administer the questionnaire. The policy

will address the needs of the at-risk population. It will be administered during PCP visits and,

therefore, have the possibility of reaching disconnected youth, will be given regardless of

poverty state, and be individualized. PCPs are likely to have knowledge of each adolescents’

environmental influences on pregnancy such as their education, economic status, and family life.

This fact means that interventions, like prescribing contraception, to prevent pregnancy can be

taken based on the screening and background knowledge. The proposed policy can enhance the

general health within MC. Teen pregnancy impacts the parents for the rest of their lives in all

areas including health care. An adolescent parent is more likely to be financially unstable and

have to make decisions on whether to buy food or go see a doctor for their cough. Consequently,

the overall health of the community may see an increase if teen pregnancy is decreased through

this policy. It also should be noted that questions can be used to identify possible risk for

sexually transmitted infections – which will overall positively impact health in MC.

The overarching goal of this policy is to decrease the number of teens that become

pregnant and increase the overall health of MC youth. Seeing MC teen pregnancy numbers go
ADDRESSING ADOLESCENT PREGNANCY 11

from 34 per 1000 births to the FL average of 25 per 1000 births would be a good starting place

(CHR&R, 2018). The steps in enacting this plan would have to start with the development and

testing of a standardized online questionnaire and the development of a system to have answers

go solely to the PCP. The PCP would then administer the questionnaire during annual visits to

screen for at risk behaviors. To do this, MC public health would need to gather data of what is

being asked currently and develop questions. Once this is completed, PCP and their teams

would need to be approached and taught how to use the new system. To get this started the

public health department would need to be approached as well as a PCP that shows interest in

this policy. Stakeholders affected by the health policy include patients, parents of patients,

public officials (health department), and health care providers. Funding for this project would

need to be allocated by the county. To administer the questions providers would also need to

find funds from their practice to have the technology. Supporters of this project have a large role

in moving it forward and advocating for its use; these people would include the public health

department, some parents, and some providers. The opposition are those that would not want the

policy put into effect and may include parents who do not want their child subjected to this line

of questioning and community members that believe this is not good use of taxpayer dollars.

Conclusion

In MC, FL out of 1000 females between the ages of 15-19, 34 are becoming pregnant. An

increase in the number of teen births is particularly important in public health as the event can

affect the lives of all involved causing increased costs, lower quality of life for citizens, and an

overall negative impact on health. There are interventions that can influence the social

determinants contributing to increased birth rate such as It’s yoUR choice, encouragement of

contraception, and the teen parent program. The development of a health policy related to an
ADDRESSING ADOLESCENT PREGNANCY 12

electronic screening tool for risky behavior has the possibility of decreasing the number of

adolescent births in MC. The goal is to reduce the number of pregnancies to 25 of 1000 teens

from 34 in 1000 teens. Identifying risk and applying early intervention such as contraception is

the key to meeting this goal. While there may be opposition and funding concern, the overall

health of MC youth should be on the forefront of our minds.

Addressing the health concern of MC teen pregnancies was relevant to my preceptorship

in mother/baby. Often, I would see young mothers who did not have the support and resources

they needed. It would break my heart to know that I was sending this new baby home to what

may not be an ideal situation. The health indicator may be a way to access the overall health of a

community but there is a person behind that number. This study has made me realize that as a

nurse, I have the ability to identify a problem in practice, research the impacts, and come up with

a possible evidenced backed solution. I will use the information I have gathered as motivation

to be aware of the resources that I can give my patients. As a nurse, it is my duty to be conscious

of the problems that face the community I serve and cognizant of how I can change health on an

individual and community basis.

ADDRESSING ADOLESCENT PREGNANCY 13

References

American Pregnancy Association. (2017). Teen pregnancy issues and challenges. Retrieved from

http://americanpregnancy.org/unplanned-pregnancy/teen-pregnancy-issues-challenges/

Bradenton area economic development cooperation. (2019). Largest employers · Bradenton area

edc. Retrieved January 22, 2019, from https://bradentonareaedc.com/doing-business-

here/largest-employers/

Centers for Disease Control and Prevention. (2019). About teen pregnancy. Retrieved from

https://www.cdc.gov/teenpregnancy/about/index.htm

County Health Rankings & Roadmaps. (2018). Manatee County Demographics. Retrieved from

http://www.countyhealthrankings.org/app/florida/2018/rankings/manatee/county/outcome

s/overall/snapshot

Goyal, M.K., Shea, J.A., Hayes, K.L., Badolato, G., Chamberlin, J.M., Zaoutis, T., & Fein, J.

(2016). Development of a sexual health screening tool for adolescent emergency

department patients. Academy of Emergency Medicine, 23(7), 809-815. doi:

10.1111/acem.12994

Kane, J., Morgan, S., Harris, K., & Guikey, D. (2014). The educational consequences of teen

childbearing. Demography,50(6), 2129-2150. doi:10.1007/s13524-013-0238-9.

Herten, M. H., Bai, G., Hafkamp, E., Landgraf, J. M., & Raat, H. (2015). Determinants of health-

related quality of life in school-aged children: A general population study in the

Netherlands. Plos One, 10(7). doi: 10.1371/journal.pone.0134650

Manatee Healthcare System. (2019). Excellence in care for Bradenton, Lakewood Ranch,

Sarasota and the surrounding region. Retrieved January 22, 2019, from

https://www.manateehealthcaresystem.com/about
ADDRESSING ADOLESCENT PREGNANCY 14

Ott, M., & Sucato, G. (2014). Contraception for adolescents. American Academy of

Pediatrics, 134(4). Retrieved from

https://pediatrics.aappublications.org/content/134/4/e1257.

Sabella, G. (2018, September 4). Manatee school board OKs $889.4 million budget. Bradenton

Herald. Retrieved from

https://www.bradenton.com/news/local/education/article217784225.html

School District of Manatee County. (2014). School board of Manatee county teen parent

program [Brochure]. FL: Author.

School District of Manatee County. (2018). It’s your choice. Retrieved from

https://www.manateeschools.net/Page/5900

Secura, G., Allsworth, J., Madden, T., Mullersman, J., & Peipert, J. (2010). The contraceptive

choice project: Reducing barriers to long-acting reversible contraception. American

Journal of Obstetrics and Gynecology. doi: 10.1016/j.ajog.2010.04.017

Siegel, R., & Brandon, A. (2014). Adolescents, pregnancy, and mental health. Journal of

Pediatric and Adolescent Gynecology 27(3), 138-150. doi: 10.1016/j.jpag.2013.09.008

U.S. Census Bureau. (2017). Census.gov. Retrieved January 30, 2019, from

https://www.census.gov/

U.S. Department of Health and Human Services. (2019). Social determinants of health.

Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-

determinants-of-health

Vancea, M., & Utzet, M. (2017). How unemployment and precarious employment affect the

health of young people: A scoping study on social determinants. Scandinavian Journal of

Public Health,45(1), 73-84. doi:10.1177/1403494816679555

ADDRESSING ADOLESCENT PREGNANCY 15

Wickham, S., Whitehead, M., Taylor-Robinson, D., & Barr, B. (2017). The effect of a transition

into poverty on child and maternal mental health: A longitudinal analysis of the UK

Millennium Cohort Study. The Lancet Public Health, 2(3). doi:10.1016/s2468-

2667(17)30011-7