District Health Department #10 Lake County

1. District Health Department #10Lake County

2. Lake County Teen Pregnancy Group Project Tonya Allendorf, Karley Daniel, Michael Dugan, Gena Furgeson, Tracy Giraud, and Kathy LaPonise Ferris State University

3. Lake County Lake county is a rural community with a population of 11,498 (United States Census Bureau [USCB], 2013) located in the northwestern part of Michigan’s Lower Peninsula, 80 miles north of Grand Rapids. “Home to 200,000 acres of public-owned land, Lake County is intersected by two major highways, US-10 and M-37” (Lake County Chamber of Commerce [LCCC], 2013). Lake County is a seasonal town that uses tourism as an industry (LCCC, 2013). The lakes offer wildlife and fishing opportunities, there are trails for motorsports, and several annual events throughout the summer months (LCCC, 2013). While Lake County has annual summer events, the overall health of the community depends upon the year-round industry of the area.

4. Community Strengths Community Assets Beautiful natural resources Safe community Collaboration between agencies and resources available Existing services Lake County Chamber of Commerce Satellite Health Clinic Lake County Health Department. Baldwin Family Health Center Baldwin Teen Health Clinic

5. Community Weaknesses Areas of Concern Teen pregnancy rate of 68.5 per 1,o00 or 6.85 percent Teen (ages 15-19) repeat pregnancy rate of 28.6 % (Hill et al, 2011, p. 43) High rate of child abuse/ neglect High poverty rates High unemployment rates Low rates of high school graduation Low percentage of continuing education and completion of advanced degrees Lack of Resources No hospital in Lake County High ratio of patients to available primary care providers. Lack of health coverage High percentage of the population on Medicare and Medicaid. No public transportation

6. Community Weakness Focus Area Our focus area Teen pregnancy and repeat teen pregnancy Why is this a concern? “There is a strong association between teenage pregnancy and child well-being. Morbidity associated with children of teenage pregnancy includes pre-term birth, low birth weight, child abuse, neglect, poverty and premature death” (DiNapoli, 2012, p. 441).

7. Theories related to pregnancy Three broad categories • Social-cognitive-ecological theories • Self-efficacy • Support • Developmental theories • Search for identity • Potential for role confusion • Resilience Theory • “Ego development and the elasticity of individuals to rebound in life” (Polk, 1997). • The Resilience-Recoil-Rebound Theory of Teen Pregnancy Prevention (RRRTTPP) (Porter & Holness, 2011).

8. Community Risks Potential risks • Lake County teens are at a risk for higher pregnancy rates due to it being a rural community. “The teen birth rate in rural counties was one-third higher compared to the rest of the country”, 43% in rural settings compared to 33% in urban ones (The National Campaign to Prevent Teen Pregnancy [TNCTPTP], 2010). • Teen pregnancy leads to high costs to taxpayers. Increased health care, increased foster care, increased incarceration rates, and lost revenue due to lower education and job status all add to taxpayer burden. In 2008, it was estimated that it cost $11 billion dollars in U. S. tax dollars due to teen pregnancy (Centers for Disease Control and Prevention (CDC, 2012). • Pregnant teenagers and their children have lower school performance, higher drop out rates, more health problems, higher incarceration rates, and unemployment (CDC, 2012). This can strain and be a drain on community resources. • “Poverty is a cause as well as a consequence of early childbearing . . . approximately one quarter of teen mothers goes on well-fare within 3 years of the child’s birth” (TNCTPTP, 2013)

9. Existing Resources- Teen Pregnancy Focus Baldwin Health Department Family planning, WIC, Maternal Child Health Programs Baldwin Teen Health Center Two providers and two behavior health therapists. Health Educator-Quran Griffin • Safer Choices-comprehensive sex education program-22 lessons to 9th and 12th graders. • Sex Can Wait taught mostly 7-8 graders abstinence based program. • Puberty education 4-6 grade-healthy relationships and goal setting.

10. Disciplines Addressing this Problem • Teachers • Social workers • Behavioral Therapists • Physicians • Faith community

11. Adequacy of Existing Resources They are making changes, but due to the scope of the problem and societal risk factors additional resources are necessary. Biggest need is financial support.

12. Community Nursing Diagnosis Risk of pregnancy among teenagers in Lake County. Related to poverty, lower levels of educational attainment, high rates of confirmed child abuse and neglect, and a large percentage of children living in single parent households. As demonstrated by teen pregnancy rate at 68.5 per 1,000 and repeat teen births at 28.6%.

13. Factors and Measures Causative Factors • Social: poverty, being a child of a teen parent, low education level, rural teen, lack of health services. • Personal: peer influence, lack of parental involvement, lack of sexual knowledge, desire to have a baby, desire to please partner. Direct and Indirect Measures • Direct measures: Rates of teen pregnancy, repeat teen pregnancy, and sexual knowledge. • Indirect measures: Poverty levels, levels of education attainment, parental involvement, unemployment rates, and marriage rates

14. Project Overview Issue of concern: Teen pregnancy and repeat pregnancy. Scope of problem: The above rates are higher than Michigan and US averages Target group: Lake County teenagers Unmet needs vs existing services: Lack of funding for Baldwin Teen Health Center beyond 2013. Repeat studies are needed to evaluate program effectiveness and procure future funding. Evidence based practice: A literature review was performed to identify areas existing programs can be strengthened. Evaluate and target risk factors that increase likelihood of repeat pregnancies. Planning and Implementation: Data gathered can be used by Lake County Health Department, Baldwin Teen Health Center, Spectrum Reed City Hospital, and other key stakeholders to increase awareness for continued sex education programs and teen pregnancy resources in Lake County. Presentations to local businesses and the health department, along with grant proposals to the state and federal government will secure funds to maintain successful programs.

15. SMART Goal The number of pregnant girls aged 19 and younger in Lake County will be reduced by 53% from 68.5 per 1000 births in 2010 to 36.2 per 1000 or fewer births in 2020 (District Health Department #10, 2011). The repeat pregnancy rates will be decreased by 50% from 28.5% to 13% by 2020 (Hill et al., 2011).

16. Planning Who – Pregnant teens and teens in general in Lake County is the targeted population. What – Reduce teen pregnancy for girls under age 19 in Lake County from 68.5 % to the Healthy People 2020 target of 36.2% and decrease repeat pregnancies by 50% to 13%. Establish a taskforce to write grants for funding to petition the state and federal governments, approach local businesses, collaborate with the local health department, and school systems to bring about the most cost effective and sustainable partnership for the future funding of this excellent program. When – Achieve target goal of 36.2% in 7 years by 2020. Where – Lake County, District Health Department #10 Why – Reduce the number of teen pregnancy. Reducing the number of teen pregnancies will benefit the community and individuals by reducing strain on resources, improving educational results, better economical opportunities, and improved health benefits. How – Assessment surveys and interviews to gather data. Educational seminars and events to provide information and health promotion to teens, parents, and the community. Creating a multidisciplinary team to research and implement policy and interventions regarding teen sexual behaviors, availability of health providers and centers, safe teen center “hangouts”, and education about the risks and pitfalls of teen pregnancy.

17. The Ecological Model “According to this model, behavior is a result of the knowledge, values, and beliefs of people, as well as numerous social influence. These social influences include relationships, social support networks, and community structure” (DeMarco & Segraves, 2012, p. 79).

18. Theoretical Support • A PAUSE (Adding Power and Understanding in Sex Education) is a program based on a Social Influences Theoretical Model where Social Learning Theory is a central component . A PAUSE is based on three influences on behavior, personal factors, improved knowledge and communication, and social influences (Mellanby, Newcombe, Reese, & Tripp, 2011). • A PAUSE uses a on a pre and post test evaluation. • The students answer an anonymous questionnaire regarding knowledge, attitudes, and beliefs about sex, during the first session and the last session of class. • A teacher and a nurse educate the teens on anatomy, physiology, and health promotion in the middle and high school settings. • The teen mothers serve as mentors. • This ‘joined up thinking’ team approach works well. • The teens receive the factual information better from adult leaders. • The peer leaders are more effective in changing attitudes This is just a model of the research that has been done in the past to test effectiveness of a program intervention similar to those at the Baldwin Teen Health Center. Due to the newness of this program in the area there is no research with which to compare any prior interventions. The geopolitical climate is supportive of efforts to reduce teen pregnancies and repeat teen pregnancies to support a stronger economic environment.

19. Intervention The intervention will be based on the five external spheres of influence cited by Porter & Holness (2011) as family, peer group, school, church, and community. • Education within these spheres about the prevalence and risk factors associated with teen pregnancies. • Partner with these spheres to bring about collaborative partnerships to create greater change and influence in the community.

20. Community Interventions • Assess teens on their attitudes and behaviors regarding sex. • Use assessment tools such as Pregnancy Risk Assessment Monitoring System (PRAMS) and Youth Risk Behavior Survey (YRBS). • Assess teen programs and centers for effectiveness providing information and activities to which teens can relate. • Work with existing sexual education programs provided by the Teen Health Center in Lake County. • Provide meaningful activities and opportunities for the teens to engage in. • Initiate new programs and offer changes where needed. • Collaborate with Teen Health Center educator to continue and expand parent workshops on how to talk to their teens and support groups. • Provide community health fairs at local venues that includes information, statistics, costs, and health problems associated with teen pregnancy. • Assess health care availability for teens who are pregnant. Assess teens access to these facilities. Provide transportation and funds as needed. • Create interdisciplinary team to analyze current methods and funding for teen pregnancy programs and services. Team will provide resources to continue, expand, and fund programs in existence and in the future. • Evaluate on a yearly basis progress at the end of the school year on the effectiveness of the interventions. • Interventions should show yearly decreases of 5% of teenage pregnancy for 7 years to meet 2020 goal of 36.2%.

21. Primary Prevention • Recognizing teens at risk and bringing attention to the subject. • Providing support and resources to assist teen’s with pregnancy process. • Going into county schools, middle schools and high schools and providing resources, education, and providing support. • Pushing for more sex education in schools, allowing more support and communication for teenage girls with school nurses, teachers, and other staff members. • Encouraging parents to talk to their teens about risks for teen pregnancy. • Showing Lake County teen’s statistics and how it can change their lives. • Allowing teen mothers to speak about their experiences, their ups and downs. • Teaching about condoms and other contraceptives, demonstrating the proper use and how they are used. • Speaking and educating on abstinence and peer pressure. Where and when would you turn to for help as a pregnant teenager.

22. Secondary Prevention • Providing support and resources to assist teens with pregnancy process. • Educate and refer pregnant teens to Baldwin Health Department programs: Health Futures and Maternal Infant Health Program. These programs have a home visitation component and offer follow up with the pregnant teens during the critical time period of having a repeat pregnancy. • Provide contraception for teen mothers • Provide support groups and parenting classes of teen mothers and fathers. • Provide educational opportunities and child care • Encourage continuing education goals

23. Evaluation • Our goal is to decrease the percentage of teenage pregnancies by at least five percent each year. • Program evaluation will be based on the DHD#10 annual reports over the next ten years. • Personal interviews with teens & families who are part of the program about improvements and successful interventions will be evaluated. • Interviews with teens choosing not to become involved will be conducted to determine their resistance or barriers to participation and would focus on areas the current program could improve to meet their needs. • Funding for Baldwin Teen Health Center and other community partners will be obtained to continue providing sex education programs to Lake county in 2014. • A task force will be establish for 2014 to provide continuing funds of this program.

24. References Brown, G., Brady, G., & Bayley, J. (2010). Teenagers uncovered: Geraldine Brown and colleagues argue that understanding young people’s thinking on sex is key to reducing teenage pregnancies. Nursing Standard, 24(52). Retrieved from http://0-go.galegroup.com.libcat.ferris.edu/ps/retrieve.do?sgHitCountType=None&sort=DASORT&inPS=true& prodId=AONE&userGroupName=lom_ferrissu&tabID=T002&searchId=R1&resultListType=RESULT_LIST&contentSegment=&searchType=AdvancedSearchForm&currentPosition=1&contentSet=GALE|A237733282&&docId=GALE|A237 733282&docType=GALE&role= Centers for Disease Control and Prevention. (2012). The importance of prevention section. Retrieved from http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm Conroy, K., Engelhart, T., Arandia, P., Forbes, P., & Cox, J. (2013). Relationship between rapid repeat pregnancy and depression in low-income, minority teen mothers. Journal Of Adolescent Health, 52(s1), S109. doi: 10.1016/j.jadohealth.2012.10.247. DeMarco, R.F. & Segraves, M.M. (2012). Frameworks for health promotion, disease prevention, and risk reduction. In Harkness, G.A., & DeMarco, R.F. Community and public health nursing: Evidence for practice (pp. 65-87). Philadelphia, PA: Wolters Kluwer Health |Lippincott Williams & Wilkins. District Health Department #10. (2011). Health profile chartbook: Lake county. Retrieved from http://www.spectrumhealth.org/documents/Osceola_and_Lake_Counties_CHNA.pdf District Health Department #10. (2013). Personal Health Division. Retrieved from http://dhd10.org/personal-health El-Kamary, S. S., Higman, S. M., Fuddy, L., McFarlene, E. Sia, C., & Duggan, A. K. (2004). Hawaii start home visiting program: Determinants and impact of rapid repeat births. Pediatrics, 114(3), e317-e326. doi:10.1542/peds.2004-0618 DiNapoli, P. (2012). School health. In Harkness, G.A., & DeMarco, R.F. Community and public health nursing: Evidence for practice (pp. 433-450). Philadelphia, PA: Wolters Kluwer Health |Lippincott Williams & Wilkins.

25. References continued Hill, M., Mullins, M., Warner, L., & VanArk, L. (2011). Health and healthcare landscape of Osceola and Lake counties: Research results from the 2011 community-wide health needs assessment (CHNA Report 11_28_11). Hope College, The Carl Frost Center for Social Science Research, A research project for Spectrum Health Reed City Hospital. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved= 0CDkQFjAB&url=http%3A%2F%2Fwww.spectrumhealth.org%2Fdocuments%2FOsceola_and_Lake_Counties_ CHNA.pdf&ei=19w0UchF8aFywGWjICAAQ&usg=AFQjCNFWbpGAwo5ecnIYTNGUhKypWnR9YQ&bvm=bv.4 3148975,d.aWc. Lake County Chamber of Commerce. (2013). History. Retrieved from http://www.lakecountymichigan.com/history.html Lake County Chamber of Commerce. (2013). Michigan’s outdoor recreation paradise. Retrieved from http://www.lakecountymichigan.com Mellanby, A., Newcombe, R., Rees, J., & Tripp, J. (2001). A comparative study of peer led and adult led school sex education.Health Education Research Theory & Practice, 16(4), 481-492. doi: 10.1093/her/16.4.481 Minnick, D. J., & Shandler, L. (2011). Changing adolescent perceptions on teenage pregnancy. Children & Schools, 33(4), pp. 241-248. Retrieved from http://0-web.ebscohost.com.libcat.ferris.edu/ehost/detail?sid=73b9bbb1- b005-4606-b886-266945a87f57%40sessionmgr115&vid=5&hid=118 Olszewski, J. & Wisdom, K. (2004). Michigan surgeon general’s health status report: Healthy Michigan 2010. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source= web&cd=1&ved= 0CDIQFjAA&url=http%3A%2F%2Fwww.michigan.gov%2Fdocuments%2FHealthyMichigan_2010_1_88117_7.pdf &ei=19w0UcmhF8aFywGWjICAAQ&usg=AFQjCNEkBBBTP_OsfdRkctyRnHfaBsH2Mg&bvm=bv.43148975,d.a Wc

26. References continued Pender, N., Murdaugh, C., & Parsons, M.A. (2011). Health promotion in nursing practice (6thed.). Upper Saddle River, NJ: Pearson. Polk, L. V. (1997). Toward a middle range theory of resilience. Advances in Nursing Science, 19(3), 1-13. Retrieved from http://0-ovidsp.tx.ovid.com.libcat.ferris.edu/sp-3.8.1a/ovidweb.cgi?QS2= 434f4e1a73d37e8c676ec2d6238753f215e7f75416b12f681ac10b179f25951ceda015f24de8c266290587f7 79adb7ffbcc6e780338b0206d1c40f34e8306c6eaa9ef1bb2538f5d37460a4f11bc77a8e1d98c05f9b2ea e383bf006f9884c1b3272467f1cab273eb34a293ad61780558f52e18ae39b8200116b283653bd128f52ce5 ae76dccd388872979e289a7267f757f726e2fc4f39ebb471f6a9e6ecc4787101e484be71ede487fff272ee db4c4527d1a37aba903f0fe1a72a90e488ca91b858620b7753331e2aedf897aafa2ef42dc981aae2002142 9621b41bff2c7ed08195785625e171c245ca0b217b8ea2e6fb38a4163b4a56a54f0f062683fe350b31a4efe 7d0feabc69cb200270ef66120010ae21f0ade6f28876d7b5285800db14ed1c00e9cc76c86b98534fd73d 6335185e485be3c1c4a92ce8dd1aac8e74b1afc1215f514bfa8e3c641bbb143d46b3e9d06091ee9877f283 6a05d6a255a3d1a13521fde4554a7a4af0097c8d5051ac556ce393cf88d44279901ed3b5fa9000a0bb49c b3135e47529f57d6a4789d1d277f94af7a486e0ee164f32a5070be40e93e148d4d98cf1efd79bfe4e65c3 76c20e0150a855e607c7dc4e7615f08840eda9 Porter, L. S. & Holness, N. A. (2011). Breaking the repeat teen pregnancy cycle. Nursing for Women’s Health. 15(5), 368-381. doi: 10.111/j.1751-486x.2011.01661.x. Stanger-Hall, K., & Hall, D. (2011). Abstinence-only education and teen pregnancy rates: Why we need comprehensive sex education in the U.S. PLoS ONE 6(10): e24658. doi: 10.1371/journal. pone.0024658

27. References continued The National Campaign to Prevent Teen and Unplanned Pregnancy. (2010). Teen pregnancy, poverty, and income disparity. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source= web&cd=1&ved=0CDIQFjAA&url=http%3A%2F%2Fwww.thenationalcampaign.org%2Fwhy-it- matters%2Fpdf%2Fpoverty.pdf&ei=5YlsUcqIGpCJ2AX5zYDwAg&usg=AFQjCNF_J0YV5HPdJMvfra_m mW1x6_J5-Q&bvm=bv.45175338,d.b2I The National Campaign to Prevent Teen and Unplanned Pregnancy. (2013). Science says 47: Teen childbearing in rural America. Retrieved from http://www.thenationalcampaign.org/resources /pdf/ss/ss47_teenchildbear inginruralamerica.pdf The National Campaign to Prevent Teen and Unplanned Pregnancy. (2013). Grants from the office of adolescent health. Retrieved from http://www.thenationalcampaign.org/federalfunding/ funding_announcements.aspx United States Census Bureau, American fact finder. (2007). All sectors: Geographic area series: Economic-wide key statistics: 2007. 2007 economic census. Retrieved from http://factfinder2. census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ECN_2007_US_00A1 United States Census Bureau, American fact finder. (2010). Profile of general population and housing characteristics: 2010. 2010 demographic profile data. Retrieved from http://factfinder2. census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_DP_DPDP1 United States Census Bureau, American fact finder. (2011). Selected economic characteristics 2007- 2011 American community survey 5-year estimates. Retrieved from http://factfinder2.census. gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_11_5YR_DP03

28. References continued United States Census Bureau. (2013). State and county quick facts: Lake county, Michgian. Retrieved from http://quickfacts.census.gov/qfd/states/26/26085.html United Way of Jackson County. (2007). Pursuing hope for our youth: Summary of teen pregnancy prevention strategic planning 2006-2007: Jackson county, Michigan. Retrieved fromhttp:// www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=0CEgQFjAE&url=htt p%3A%2F%2Fjacksondata.org%2Fsites%2Fjacksondata.org%2Ffiles%2FJCHDpregnancypreventi on.pdf&ei=19w0UcmhF8aFywGWjICAAQ&usg=AFQjCNGU6leJPVQoP1WFDW5bvsM1f6ESWA &bvm=bv.43148975,d.aWc  Wikipedia: The Free Encyclopedia (2006). File:Map of Michigan highlighting Lake County.svg. Retrieved from http://en.wikipedia.org/wiki/FileMap_of_Michigan_highlighting_Lake_ County.svg. Wikipedia. (2013, March 19). Poverty in the United Sates. Retrieved from http://en.wikipedia.org/wiki/Poverty_ line_in_the_United_States Zehnder-Merrell, J. (2012). Right start in Michigan and its counties-2012, Right start in Michigan 2012: A closer look at maternal and infant well-being. Lansing, MI: Michigan League for Human Services. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s& source=web&cd=6&ved=0CE0QFjAF&url= http%3A%2F%2Fwww.milhs.org%2Fwpcontent%2Fuploads%2F2012%2F04%2FRSwithAppendix.pdf&ei=19w0 UcmhF8aFywGWjICAAQ&usg=AFQjCNGbGI97MPM92lu5we77tji1SPIq9g&bvm=bv.43148975,d.aWc