Teen Options to Prevent Pregnancy (TOPP)

Length | Elements | Staffing

Length of Program

Teen Options to Prevent Pregnancy was originally a 18-month program with an intended dose of monthly telephone-based, one-on-one motivational interviewing sessions with a trained nurse educator. During this time, participants also had access to contraception via transportation to clinics or hospitals, in-person visits from a TOPP nurse educator or appointments to receive services at a TOPP clinic.

 

Program Elements

There are three main components to the TOPP program:

• Telephone-based, one-on-one motivational interviewing sessions with a trained nurse educator. Commonly covered topics included importance of birth spacing and preventing rapid repeat pregnancy; birth control methods (ranging from abstinence to long-acting reversible methods); misconceptions that inhibit contraceptive use; future planning for achieving birth control; and birth spacing goals. Registered nurses use MI to elicit information about past experiences with and beliefs about contraception and pregnancy; provide individualized education about birth control options (including abstinence) based on a participant’s preferences; and guide a participant toward effective contraception if they are interested in using it. Given their high efficacy, satisfaction, and continuation rates, implants and intrauterine devices (long-acting reversible contraception [LARC]) are particularly emphasized.
• Access to contraception via transportation to clinics/hospitals, in-person visits from a TOPP nurse educator, or services at a TOPP clinic. Condoms shoudl be routinely distributed through this contraceptive clinic to highlight that long-acting reversible contraception, the form of birth control particularly emphasized in the TOPP intervention, does not protect against sexually transmitted infections.
• Access to a TOPP social worker to screen for risk factors (e.g., domestic violence or depression) and provide service and resource referrals as needed.

 

Staffing Requirements

The core component of TOPP—motivational interviewing—is delivered by trained nurse educators. Registered nurses with previous clinical experience in women’s health should be rigorously trained and receive coaching in Motivational Interviewing from a certified Motivational Interviewing Network Trainer. The maximum caseload for a full-time TOPP nurse is 40 to 60 participants.

Two afternoons per week, a board-certified obstetrician-gynecologist should be available to provide contraceptive services solely to intervention group participants. The TOPP clinic is available to participants who are not already affiliated with another physician or who are struggling to receive timely or effective contraceptive care from their existing provider. Staff can provide transportation to clinics, and social workers can make referrals to additional services as needed.

Theory | Logic Model | Evidence Summary | References

Theory

The intervention draws on Anderson's Behavioral Model of Health Service Use which suggests that contraceptive behavior will be changed by altering a woman’s perspective of her need for birth control and providing her easy access to it. The Behavioral Health Use Model incorporates both individual and contextual determinants of health. There are three main components which determine health services use:

• Predisposing Factors: In this case, the predisposing factors are teen mothers who are from underserved areas whose attitudes and beliefs are influenced by their access to care, as well as their perceived need for care.
• Enabling Factors: In this case, the behavior change will occur due to Medicaid coverage of birth control, transportation services, and the nurses’ use of motivational interviewing to provide education in regard to birth spacing. This enabling factor will heighten the awareness of the teen mother’s understanding of her need for available forms of birth control. Referrals to social support services are delivered by nurse educators and a social worker to program participants over an 18-month period.
• Need Factors: In this case, population health indices regarding birth spacing and its relationship to prematurity and low birth weight infants. Additionally, prematurity and low birth rate infants are the leading cause of infant mortality in our nation.

 

Logic Model

The program logic model can be found here:

Logic Model (pdf)

 

Evidence Summary

Research Design

From October 2011 to January 2014, 598 adolescent females were enrolled from seven obstetrics-gynecology clinics and five postpartum units of a large hospital system in a Midwestern city. Eligibility criteria at baseline were as follows: (1) English speaking; (2) 10 to 19 years of age;(3) at least 28 weeks pregnant or less than 9 weeks postpartum; (4) regular telephone service; and (5) enrollment in Medicaid. Low-income adolescents were selected because they were expected to particularly benefit from the TOPP transportation assistance in contrast to higher-income adolescents. Individuals were eligible regardless of interest in utilizing contraception, changing birth control methods, or desire to delay subsequent pregnancies.

After learning about the study, interested adolescents aged 18 years and older provided written consent. Younger ado-lescents provided written assent while a parent or guardian provided written consent for the youth to participate. A computerized program randomly assigned participants to either the intervention condition (TOPP; n ¼ 297) or the control condi-tion (UC; n ¼ 301).Study procedures were approved by two separate hospital systems’ institutional review boards: one for the organization that delivered the TOPP program and one for the organization that served as the local independent evaluator.

The duration of the TOPP intervention was 18 months for two reasons. First, this time frame afforded multiple opportunities to build rapport with participants as well as to assist them in establishing and refining a birth control regimen. Second, this time frame underscored the health benefits of avoiding a rapid repeat pregnancy. When deemed appropriate, a TOPP nurse reminded a participant that an interpregnancy interval of less than 18 months has been associated with a heightened risk of adverse birth outcomes (e.g., prematurity). The intervention had four components:(1) MI-based telephone calls and home/community visits between a registered nurse and an adolescent; (2) access to a part-time contraceptive clinic; (3) transportation assistance; and (4) social worker assistance.

Data Gathering

Each adolescent in both groups was contacted at 6 months after enrollment (midintervention) and 18 months after enrollment (postintervention) for a survey administered by research staff unaware of that participant’s study condition. These independent evaluators did not serve as study interventionists and had separate office space from the TOPP clinicians. The surveys featured multiple-choice questions assessing demographic characteristics, contraceptive use, pregnancy status, and future pregnancy intentions.

In addition to survey data, information on future births was gathered through the state’s vital statistics files for the subset of study participants 18 years old or older at baseline. After receiving a few key pieces of identifying information on each adolescent (e.g., name, date of birth), the local health department queried the statewide birth certificate data files to see whether the individual had a birth 6 to 30 months after enrollment in the study. This time frame fully covers the less-than-18 month interpregnancy interval the TOPP intervention was designed to prevent.

Findings

Overall 493 adolescents of the total 598 study participants completed at least part of the 6-month survey (82.4%). There were no significant differences in survey completion rates between the TOPP and UC groups (83.8% vs 81.1%, P = .385). Usage of LARC within the past 3 months was more common in the TOPP vs UC groups (35.9% vs 21.9%, P = .002). Similarly, having unprotected vaginal intercourse within the past 3 months was less common in the TOPP vs UC groups (13.2% vs 22.8%, P = .009).

Overall, 472 participants of the total 598 study participants completed at least part of the 18-month survey (78.9%). There were no significant differences in survey completion rates between the intervention and control groups (79.8% vs 78.1%, P = .610). Usage of LARC within the past 3 months was more common in the TOPP vs UC groups (40.2% vs 26.5%, P = .002). Furthermore, reports of repeat pregnancies (20.5% vs 38.6%, P less than .001), unintended repeat pregnancies (17.2% vs 34.7%, P less than .001), and repeat births (10.3% vs 20.6%, P = .009) over the last 18 months were lower in the TOPP vs UC groups. Seven UC participants reported having an abortion within the past 18 months, while no TOPP participants did. There were no group differences in pregnancy in-tentions over the next year or educa-tional attainment. Birth certificate data were obtained for the subset of participants aged 18 or 19 years old at baseline (n = 433, 72.4% of the total sample) to assess future births. The percentage of participants with a live birth 6 to 30 months after enrollment was lower in the TOPP vs UC groups (23.9% vs 35.5%, difference, -.6%, 95% confidence interval [CI], [-20.5 to -2.7], P = .011).

The principal finding was the 18.1% absolute reduction in self-reported repeat pregnancy in the TOPP intervention group relative to the UC control group (20.5% vs 38.6%) at 18 months. Similarly, TOPP led to an 11.6% absolute reduction in repeat births according to birth certificate files (23.9% vs 35.5%) at 30 months. The consistency of the significant differences across two diverse data sources increases confidence in the conclusion that TOPP produced reductions in rapid repeat pregnancy rates. Furthermore, the beneficial outcomes were achieved through an intervention that lasted on average 4.5 hours, which is substantially briefer than alternative approaches. No evidence of harmful effects of the TOPP program on sexual risk behaviors, such as having sexual intercourse without a condom or greater number of partners, was found.

 

References

Stevens, J., Lutz, R., Osuagwu, N., Rotz, D., Goesling, B. 2017. A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. American Journal of Obstetrics and Gynecology 217 (4) :423.e1–423.e9.

General Adaptation Guidance | Policy

Adaptation Guidance

ETR is a leader in developing adaptation guidelines to enable professionals to adapt evidence-based intervention programs for implementation in underserved communities, while maintaining fidelity to the intervention's core components. ETR works with program developers to ensure that these tools are of the highest quality and meet the different needs of the field and end users, e.g., teachers, trainers, program mangers/staff, research teams, and funders.

See ETR’s General Adaptation Guidance

For answers to Frequently Asked Questions about program adaptations, please visit our Program Support Help Desk.

Read ETR's Adaptations Policy.

Training & TA

For over 30 years, ETR has been building the capacity of community-based organizations, schools, school districts, and state, county and local agencies in all 50 states and 7 U.S. territories to implement and replicate evidenced-based programs (EBPs) to prevent teen pregnancy, STD/STI and HIV. Our nationally recognized training and research teams work in partnership with clients to customize training and technical assistance (TA) to address the needs of their agencies and funding requirements.

Training

Training and ongoing coaching in Motivational Interviewing with a MINT trainer is strongly recommended before implementing the TOPP program. Training for TOPP and ongoing MI coaching is available from Gary Stofle, LISW-S, LICDC-CS, BCD, who worked with the original TOPP study. Visit mitrainingfortopp.info/ for more information.

Technical assistance (TA), coaching and ongoing support

ETR provides in-person and web- or phone-based TA before, during and/or after program implementation. TA is tailored to the needs of the site and is designed to support quality assurance, trouble-shoot adaptation issues, and boost implementation.

Enrichment Training

To support a holistic approach to teen pregnancy and HIV prevention programs, ETR offers a number of additional training and technical assistance opportunities, including content-specific workshops, skill-based trainings, organizational development consultation and much more. To learn more about these opportunities, visit our Training & TA pages >>

Adaptation

Adaptation support materials, training and/or TA are available to assist educators/clinic staff in meeting the needs of individual communities by implementing EBPs effectively and consistently with core components. All adaptation support is based on ETR's groundbreaking, widely disseminated adaptation guidelines and kits for effective adaptations.

Evaluation

ETR also provides evaluation support for EBP implementation. ETR uses well-established tools for measuring fidelity and outcomes. ETR's evaluation support blends participatory approaches with cutting-edge evaluation science. Services address process and outcome evaluation and include assistance with evaluation planning, instrument design and development, implementation fidelity, data management and analysis, performance measurement, continuous quality improvement (CQI) protocols, and effective tools and strategies for reporting results.

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