Rationale
Rapid Repeat Pregnancy Prevention
According to the National Center for Health Statistics, one out of every six births in 2019 for teenage mothers was a result of a repeat pregnancy (Martin, et al., 2021). Maslowsky and colleagues (2019) reviewed 30 years of scientific literature regarding repeat teen pregnancy, and noted that repeat teen mothers were at heightened risk for unemployment and high school discontinuation relative to first-time teen mothers. If a repeat pregnancy occurs within 18 months of the previous birth, the subsequent child has an elevated likelihood of being born preterm and experiencing low birth weight (Conde-Agudelo, et al, 2006).
This disconcerting association between a brief interpregnancy interval and adverse birth outcomes holds even after controlling for various confounds. Long-acting reversible contraception—IUDs and implants—appears to be a promising approach for reducing rapid repeat pregnancies. Multiple studies have found a significant decrease in rapid repeat pregnancies for adolescent patients after receiving long-acting reversible contraception (LARC) within a few weeks of giving birth (Damle, et al., 2015; Tocce, et al. 2012).
Empirically supported interventions to prevent rapid repeat teen pregnancy often last 18 to 30 months (Stevens, et al., 2017; Olds, et al., 2007). The long duration of such existing interventions may deter many adolescents from initiating and completing such programs. Furthermore, such interventions may not encourage mothers to consider immediate postpartum placement of long-acting reversible contraception. Placement of such devices during the labor and delivery stay ensures timely contraceptive coverage while not requiring adolescents to attend a separate postpartum visit to obtain the most effective forms of birth control.
HPV Vaccination
The HAT program addresses HPV vaccination due to the high prevalence and severity of these infections as well as low vaccination uptake among adolescents. The Centers for Disease Control and Prevention (CDC) estimates about 14 million Americans become infected with the human papillomavirus (HPV) every year (CDC, 2021). HPV infections can cause cervical, vaginal, vulvar, penile, oropharyngeal and anal cancer (CDC, 2020). However, HPV vaccines can greatly reduce the likelihood of cancer. Lei and colleagues (2020) followed 1.6 million Swedish girls and women for ten years to compare outcomes for vaccinated versus unvaccinated patients. After adjusting for various confounds, the incident rate of cervical cancer for vaccinated women was just one-eighth the rate for unvaccinated women if the shots were received before 17 years of age. The incidence rate of cervical cancer for vaccinated women was one-half the rate for unvaccinated women if the shots were received from 17 to 30 years of age.
Despite the high efficacy and widespread availability of these HPV vaccines, only 54.2% of American adolescents have received all the recommended shots (CDC, 2020). A recent systematic review indicated that reminder-only and multicomponent strategies (e.g., education, school-based interventions) generally increase HPV vaccination coverage in high-income countries (Acampora, et al. 2020). However, these empirically supported interventions may only reach those adolescents who are in regular contact with schools or other organizations.
Furthermore, while pregnant adolescents typically receive prenatal services, these patients may be at particular risk of being unvaccinated. HPV shots cannot be administered during pregnancy; the shots are only medically acceptable after delivery occurs. Therefore, novel approaches are needed to assist vulnerable populations such as low-income pregnant adolescents in obtaining these vaccinations.
Medical Home
The HAT intervention encourages adolescents to establish a medical home due to the highly beneficial services often found in primary care settings. Although various definitions of a medical home exist, this term generally refers to a patient having an ongoing relationship with a primary care clinician who provides comprehensive and coordinated services. According to the 2018 National Survey of Children’s Health, only 48.2% of all youth had an established medical home (Health Resources and Services Administration, 2020). Regarding low-income adolescents, nearly 1 in 5 had not completed even a single well-visit within the past 12 months (Black, et al., 2016).
Previous research has found that primary care screening and intervention services are worthwhile to address diverse adolescent concerns, including tobacco use (Hollis, et al., 2005; Pbert, 2008), alcohol use (D’Amico, et al., 2018), obesity (U.S. Preventive Services, 2017), and sexually transmitted infections (U.S. Preventive Services, 2020). While text messages and financial incentives have increased attendance for primary care appointments (Robotham, et al., 2016; Greene, 2011), these interventions have typically assisted patients who already have a primary care provider. Greater work is needed to implement and evaluate interventions to help patients initiate primary care services, including locating clinicians who are accepting new patients with public insurance and attending first appointments.
Nutrition and Healthy Eating
Proper eating during pregnancy is essential to the development of the fetus and the health of the mother. Unfortunately, pregnant adolescents often consume fast food, unhealthy snacks, and soda (Wise and Arcamone, 2011). Barriers to proper nutrition for pregnant adolescents include lack of knowledge about healthy options and the ease of obtaining unhealthy alternatives. Previous interventions seeking to increase the nutritional knowledge of low-income adolescent mothers have not demonstrated improvements in dietary intake (Vander Wyst, et al, 2019; Davis, et al., 2013). Therefore, novel approaches to increasing healthy eating in this vulnerable population deserve attention.
Educational and Career Attainment
The HAT intervention addresses educational and career attainment because adolescent mothers often have difficulties in these domains over both the short and long run. A Child Trends survey found that 66% of adolescents who had a child before turning 20 obtained a high school diploma or GED by age 22 compared to 94% of adolescents who did not experience a teen pregnancy (Child Trends, 2010). Taylor and colleagues (2009) followed a large cohort of adolescents for several years. They found that adolescent mothers were less likely to complete post-secondary education and reported having less prestigious occupations relative to participants who first gave birth during their adult years.
Previous interventions often feature multiple components such as case management, school restructuring, skills training, and counseling (Steinka-Fry, et al., 2013). However, many communities may not have the resources to adopt such comprehensive interventions. Further work is needed to determine if less resource-intensive interventions can significantly increase educational and career attainment for adolescent mothers.
Financial Literacy
The HAT intervention addresses financial literacy because better financial well-being is associated with higher academic performance, psychological health, and life satisfaction. Data from the National Endowment for Financial Education suggest that 22% of American teens lack basic financial literacy (NEFE, 2017). Previous studies indicated that teens often make suboptimal financial decisions, including high-interest loans, inadequate budgeting, and insufficient savings (Sinha, et al., 2018).
Past interventions to promote financial literacy among adolescents have generated positive outcomes, such as increased financial knowledge and better credit scores (Brown, et al., 2014; Asarta, et al., 2014; Carlin and Robinson, 2012). Unfortunately, these interventions often last dozens of hours and are often based in schools. The long duration and limited venues for such programs may preclude many adolescents from participating. Therefore, briefer and home-based strategies may be needed to reach many adolescents. In particular, pregnant teens may be an especially important subpopulation because soon they will become parents who are financially responsible for their newborns.
Nicotine Cessation
The HAT intervention addresses nicotine use within the context of financial literacy due to its high prevalence and serious consequences for both mother and child. Nearly 10% of mothers 15 to 19 years of age had smoked cigarettes during pregnancy according to a 2018 National Center for Health Statistics brief (Drake, et al., 2018). Approximately 11% of all high school students used e-cigarettes according to the 2021 National Tobacco Youth Survey (Gentzke, et al., 2022). Nicotine usage during adolescence often develops into adulthood dependence and can serve as a gateway to other forms of substance abuse (Ren and Lotfipour, 2019).
Furthermore, smoking during adolescence can cause significant future health problems such as suboptimal brain development (Yuan et al., 2015), adult lung cancer (Jayes, et al., 2016), and chronic obstructive pulmonary disease (COPD) (CDC, 2021). In addition, many women who smoke during pregnancy are at high risk for developing pregnancy complications. Women who smoke while pregnant have elevated risks for a preterm delivery, a low-birthweight child, and even infant death (APA, 2019). Nicotine use during pregnancy can also damage the baby’s developing lungs and brain, lead to birth defects, and may decrease the necessary nutrients available to the baby while in the womb (CDC, 2020).
Pharmacological interventions (e.g., nicotine replacement therapy) have been shown to decrease smoking during late pregnancy but not alter birth outcomes (Claire, et al., 2020). In contrast, behavioral interventions (e.g., counseling) not only decrease smoking during late pregnancy but also reduce the proportion of infants born low birthweight (Chamberlain, et al., 2017). However, both types of interventions have significant limitations. Medications have sometimes been found to be ineffective to reduce adolescent smoking in the long run (Scherphof, et al., 2014). Psychosocial interventions may be unfeasible when clinicians lack the time and/or training to deliver such services and when adolescents lack the time and/or motivation to receive such services. Therefore, innovative strategies are needed to encourage nicotine cessation among pregnant adolescents.
