Prev Sci (2006) 7:389–395 DOI 10.1007/s11121-006-0045-2

ORGINAL PAPER

Having the Best Intentions is Necessary but not Sufficient: What would Increase the Efficacy of Home Visiting for Preventing Second Teen Pregnancies? Sarah Gray · Jeanelle Sheeder · Ruth O’Brien · Catherine Stevens-Simon

Published online: 15 August 2006 C Society for Prevention Research 2006


Abstract Objective: Identify ways to increase the impact a well-known home-based intervention—the Nurse Family Partnership (NFP)—has on conception rates among teenage mothers. Methods: Secondary analysis of data collected on 111, 13-to-19 years old, primiparas who were visited in their homes by nurses during, and for 2 years after pregnancy. Data bearing on assistance with family and career planning were culled from the nurses’ records. These were graded on a 3-point scale. Higher scores reflected more active, therapeutic interventions. The primary outcome was repeat pregnancy. Results: The pregnancy rate at 6, 12, and 24 months was 8.3%, 18.4%, and 28.1%. Teenagers who conceived were less likely to have used contraceptives during the previous six months than those who did not. Almost everyone received the recommended number of visits. However, discussions and active interventions related to lapses in contraceptive use were only documented during 30% of visits. Those who conceived had as many visits and discussions of this type as those who did not. Nurses rarely involved boyfriends and family. Other differences between teens that did and did not conceive support the NFP theoretical framework. Conclusions: Contrary to the stated aims of the intervention, the nurses rarely documented therapeutic interventions that could make repeated childbearing fit less harmoniously into the teenagers’ lives. The best way to strengthen the impact of this program on teen pregnancy rates is to deepen the nurses’ training so that they are able to intervene S. Gray · J. Sheeder (
) · R. O’Brien · C. Stevens-Simon Department of Pediatrics & School of Nursing, University of Colorado Health Sciences Center Denver, Colorado e-mail: [email protected]

actively enough to bring about behavioral change in family planning. Keywords Teen pregnancy . Home visiting . Youth development

Introduction The prevention of closely spaced teen pregnancies is an important, easy-to-define but enigmatically elusive public health goal in the United States (US). Statistics indicate that American teenage mothers are considerably less likely to give birth now than a decade ago (Klerman, 2004). Despite this progress, approximately 1-in-4 parous teens has at least one additional child before age 20 (Klerman, 2004). It is difficult to distinguish between the causes and consequences of these pregnancies (Geronimus, 1991; Stevens-Simon & Lowry, 1995). However, with each additional teen-birth the risk of prematurity, developmental delays and accidental and non-accidental trauma increases among offspring. The likelihood of finishing high school and being self-supporting also decreases among parents (Blankson et al., 1990; Geronimus, 1991; Rigsby, Macones & Driscoll, 1998; Stevens-Simon & Lowry, 1995; Stevens-Simon, Roghmann, & McAnarney, 1990). Thus, in the US, an inter-pregnancy interval of at least 2 years is a national priority for teenagers (US Department of Health and Human Services, 2000). This should be an easy goal to achieve. Most young women who become pregnant during adolescence insist that they and their boyfriends do not want more children “anytime soon” (Kelly, Sheeder, Scott, & Stevens-Simon, 2005; Stevens-Simon, Kelly, & Kulick, 2001). Most also have reasons to postpone further childbearing and know how to do so. They have aspirations for their futures and their children’s Springer

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futures that are as incompatible with early childbearing as those of their never-pregnant peers. Moreover, almost everyone receives contraceptive counseling and supplies on repeated occasions and the majority use birth control after delivery (Kershaw et al., 2003). However, the heightened contraceptive vigilance that can result from a pregnancy often wanes rapidly in daily living environments that are conducive to first teen pregnancies. Thus, even teens that have just given birth and are not consciously planning another baby quickly become inconsistent contraceptive users at best (Kelly, Sheeder, Scott, & Stevens-Simon, 2005). Accordingly, efforts to prevent teenage mothers from putting themselves at risk for rapid successive pregnancies have been directed toward increasing the perceived opportunity costs of inconsistent contraceptive use (DiCenso, Guyatt, & Griffith, 2002; Klerman, 2004; Resnick et al., 1997; Rigsby, Macones & Driscoll, 1998; Stevens-Simon, Beach, & Klerman, 2001). These young women are often encouraged to pursue educational and career goals that are incompatible with early childbearing in the US (Philliber, Kaye, Herrling, & West, 2002; Resnick et al., 1997; Roth & Brooks-Gunn, 1998). This approach is teleologically appealing. Yet, evidence supporting its efficacy for preventing teen pregnancy is scant, generally circumstantial, and of extremely variable quality (Klerman, 2004). Little data is available from clinical trials. For example, integrating teenage mothers back into the educational system has never had the same positive impact on their contraceptive use as the spontaneous pursuit of higher educational goals (DiCenso, Guyatt, & Griffith, 2002; Klerman, 2004; Quint, Bos, & Polit, 1997; Stevens-Simon & Lowry, 1995). Indeed such efforts can have a paradoxically negative impact on reproductive behavior (Quint, Bos, & Polit, 1997). Similarly, the magnitude of the benefit attributed to many programs is so disproportionate to their intensity that the reports are hard to take seriously. For example, attending four peer-group meetings over twoyears is not apt to convince 90% of teen mothers to postpone childbearing for 3 years (Key, Barbosa, & Owens, 2001). It is also unlikely that attending a school for teen mothers for as little as 7 weeks postpartum would convince 70% of enrollees to take the steps needed to remain non-pregnant for 5 years (Seitz & Apfel, 1993). Yet, the concept that postpartum school return and future-oriented goal setting prevent repeat conception during adolescence is still very popular in the US (Klerman, 2004). Globally, fertility data support this view (Darroch, Singh, & Frost 2001). However, there is nothing about these activities that necessarily makes teenagers want to avoid conception. Poor, inner-city American teenagers, their parents, and community leaders have the same educational, career, and life-style goals as their less sociodemographically deprived counterparts (Blum, 1998; Chervin, 2005; GallupBlack & Weitzman 2004; Ginsberg et al., 2002; JumpingSpringer

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Eagle, Sheeder, & Stevens-Simon, 2005). However, since they do not believe that adolescent childbearing is an impediment to achieving these goals, pregnancy prevention is given a low priority rating (Blum, 1998; Chervin, 2005; GallupBlack & Weitzman 2004; Ginsberg et al., 2002). Changing this normative belief is a difficult task. The clearest evidence that it is possible to do so comes from a series of randomized trials in which Olds and colleagues demonstrated that exposure to an intensive preand postnatal home-based intervention significantly reduced subsequent conception rates among low-income, first-time mothers (American Academy of Pediatrics, 1998; Klerman, 2004, National Commission to Prevent Infant Mortality, 1989; Olds, 2002). Teenage mothers who were visited by nurses were approximately one third less likely than those who were not to give birth within 2 years (Olds, 2002). However, 1-in-4 of the teens who were visited at least monthly in their homes gave birth during the first 2 postpartum years (Klerman, 2004; Olds, 2002). We reviewed the nurse home visitors’ clinical records to determine how the family planning component of this theoretically sound program could be strengthened.

Methods Study population We conducted a secondary analysis of data collected on a group of 735 medically indigent, primiparous women who were recruited from prenatal clinics in Denver, Colorado between March of 1994 and June of 1995 (Olds, 2002; Olds et al., 2002). These women were enrolled in a 3-armed, randomized trial of a program of prenatal and infancy home visiting known today as the Nurse Family Partnership (NFP). Two groups received home visits. One group was visited by Bachelor prepared, registered nurses with training and experience in public health or maternal and child health. The other group was visited by lay, paraprofessionals who were required to have a high school education and no college preparation in the “helping professions.” Members of the third group received no home visits. Our interest was in understanding how the in-home intervention prevented rapid second pregnancies among teenage mothers. Hence, all participants who were over 19 years of age at conception and those who were not randomized to receive home visits were excluded. Next, because the nurses delivered the in-home intervention in a more effective manner than the paraprofessionals (Olds et al., 2002; Olds et al., 2004), teenagers who were randomized to the paraprofessional group were also excluded. Finally, we excluded 10 of the 121 nurse visited teens; 4 did not give birth to living babies, 2 received no home visits, and 4 were missing data.

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This left us with a racially and ethnically diverse (25.2% White, 18% Black, 54.1% Hispanic, and 2.7% Native American) group of 111 mostly unmarried (90.1%), 13-to-19 years olds (mean ± sd: 17.4 ± 1.6 years at conception), 39% of whom were less that 17 years of age at conception. At enrollment almost everyone (97.2%) was attending school and/or working. Subsequently, most also received an adequate amount of prenatal care and gave birth at term to healthy, well-developed infants. The original study was approved by the Institutional Review Board for the University of Colorado Health Sciences Center and all participants provided informed consent at enrollment (Olds et al., 2002; Olds et al., 2004). Intervention Details of the training and supervision the nurses received and the NFP intervention has been published (Olds, 2002; Olds et al., 2002; Olds et al., 2004). Briefly, while nursedirected, the NFP is designed to be client-centered, therapeutic, and supportive. The primary goals are to optimize: 1) pregnancy outcomes by helping women improve healthrelated behaviors; 2) child health and development by helping parents provide competent care; and 3) maternal life course development by helping women develop a vision for their futures consistent with their aspirations. To assist women in accomplishing these goals, the nurses encouraged them to set small achievable objectives, the accomplishment of which would give them the self-confidence to tackle other problems in their lives. The nurses also guided them toward the appropriate use of health and human services and helped them develop strong supportive relationships with family members and friends. Of particular relevance to this investigation, both pre- and post-natally women were to be counseled about contraception and the importance of spacing subsequent children within the context of achieving their goals. The caseload was approximately 25 families. Visits were to occur weekly for four weeks after enrollment, every two weeks until delivery, weekly for the first six postpartum weeks, then every two weeks through the 21st postpartum month, and finally monthly until the child’s second birthday. Data collection and definition of variables The primary source of data for this analysis was the clinical records the nurses maintained for each teen mother. Entries bearing on contraceptive use and life-course development were abstracted. These were coded first as either nurse or teen initiated and then graded on a 3-point scale such that low scores reflected passive, supportive interventions and high scores reflected progressively more active, therapeutic interventions. Specifically, 1 point was assigned to entries bearing on problem identification, 2 points to goal setting,

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and 3 points to activities related to obtaining or using contraception or achieving a goal. We were interested in both the frequency and the consistency with which these topics were addressed. Hence, the analysis considered the absolute number of such record entries as well as the proportion of visits for which they were made. All data extraction and coding of record entries was done by the primary author, with review by other members of the research team. Since the nurses were not given a standardized record form to complete there was no way to know if failure to record was synonymous with failure to discuss. To minimize the impact of incomplete documentation we also analyzed the proportion of the recommended visits each teen received. The primary purpose was to compare the home visit experiences of teen mothers who had and had not conceived again by the 6th, 12th, and 24th postpartum month. Time to second pregnancy was based on maternal report of last menstrual period. In addition, we examined two shorter-term indices of intervention success: contraceptive use and work on goals. Finally, four of the most salient and widely implicated risk factors for rapid repeat teen conception, age at conception, race/ethnicity, and marital and educational status were abstracted (Klerman, 2004; Rigsby, Macones & Driscoll, 1998; Stevens-Simon, Beach, & Klerman, 2001; Stevens-Simon, Kelly, & Kulick, 2001). Data analysis Summary statistics were used to describe the study population. The documented nurse-teen discussions about contraception and/or life course development were tallied and grouped so that they antedated the conceptions that had occurred by the 6th, 12th, and 24th postpartum month. Prenatal interactions were analyzed separately and in combination with those that occurred following delivery. Student’s T-tests and Chi-square analyses were used to compare the characteristics and home visit histories of teens that had and had not conceived again at 6, 12, and 24 months postpartum. Finally, Chi-square analyses were used to compare the home visit histories of teenagers who had and had not used contraception and had and had not worked on their goals at 6, 12, and 24 months postpartum. All analyses were performed with SPSS/PC; (version 12; 2004).

Results The data presented in Table 1 show that the attrition rate was very low. It rose from 2.7% at 6, to 11.7% at 12, and 18.8% at 24 months postpartum. Moreover, record entries revealed that almost all (94.6%) of the teenagers formulated shortterm goals, such as returning to school and exploring job opportunities, and took steps toward accomplishing one or Springer

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Prev Sci (2006) 7:389–395 Conception Rate (N = 111) Months postpartum

Outcome variable Receiving home visits (%) Pregnant (%)

6 months 108 (97.3) 9 (8.3)

12 months 98 (88.3) 18 (18.4)

24 months 89 (81.2) 25 (28.1)

more of them during the first 2 postpartum years. By contrast, only a minority (20%) of the teenagers set and made a move toward accomplishing a long-term goal, such as developing a 4-to-5 year contraceptive and work-study plan that would enable her to pursue a career that she might find as rewarding as motherhood. Of equal concern, only 20% of the records documented a prenatal plan for postpartum contraception. Nonetheless, 45.6% of the teens used contraception during the puerperium and 83.5% had done so by the end of the sixth post-partum month. Indeed almost everyone (88.4%) used contraception at some point during the 2-year study period. However, the repeat pregnancy rate rose from 8.3% at 6, to 18.4% at 12, and 28.1% at 24 months postpartum (Table 1). Examination of bivariate relationships revealed few associations between the explanatory variables and repeat conception (Table 2). At each assessment teenagers who conceived were less likely to report contraceptive use during the previous 6-to-12 months than those who did not. However, the majority of those who became pregnant also reported that they used contraception within 6 months of conception. None of the implicit transitions from protected to unprotected intercourse and reasons for them were documented in the nurses’ records. The nurses may have been unaware of these lapses or not considered it important to record them. Assistance with contraception or short-term goals was documented during 30% of the visits. However, help with long-term goals was only recorded during 10% of the visits. Of equal concern, the nurses’ notes almost never mentioned the views of the father of the baby and/or other boyfriends on contraception and conception. Documented efforts to involve boyfriends, baby-fathers, or other family members in discussions about family and career planning were also extremely rare. Teenagers who conceived again did not differ significantly from those who did not with regard to the frequency, consistency, or intensity with which they and their nurse visitor discussed these topics. Nonetheless, the other differences between teenagers who did and did not conceive support the NFP’s theoretical framework (Table 2). Teenagers who became pregnant within 6 months were less likely than those who did not to be in school or high school graduates (66.7% compared to 97.8%; p < 0.0001) and to have taken steps to accomplish their goals. Those who conceived within 7-to-12 months were less likely than those who did not to be in school or high school graduates (88.9% Springer

compared to 100%; p < 0.001) and to have taken steps to accomplish their long-term goals. They were also more likely to be married (44.4% compared to 7%; p < 0.001). Finally, none of those who conceived during the second postpartum year had formulated a prenatal contraceptive plan, whereas 18.6% of those who were not pregnant had done so. One plausible explanation for our unanticipated findings is that the nurses neglected to document everything they did. Hence, we moved next to an analysis of the relationship between repeat conception and visit frequency. We found a significant correlation (r = 0.48; p < 0.001) between the frequency of prenatal and postpartum home visits. On average the teenagers received more than the recommended number of prenatal home visits (mean ± sd: 6.5 ± 3.7; range: 0-to16) and nearly three-quarters of the recommended number of postpartum visits (Table 2). Bivariate analyses revealed that the teenagers who conceived again did not differ significantly from those who did not with regard to the proportion of the recommended prenatal or postpartum home visits they received. However, teenagers who remained non-pregnant invariably received a smaller proportion of the recommended postpartum visits than those who conceived. This was not true of prenatal home visits. Hence, the nurses may have detected the need for additional help and responded by intensifying the postpartum intervention. If more frequent visits were a consequence of sexual risk taking, reverse causation could be partially to blame for our failure to demonstrate an association between visit frequency and repeat conception. However, since almost everyone received close to the recommended number of visits, it is likely that visit content was also a factor. Finally, none of the short-term indices of intervention success we examined (i.e., use of conception and work on goals), were related to the number of completed visits (data available by request). Teenagers who had not used contraception or worked on their personal goals received as many or more visits as those who had. Once again, almost everyone received the recommended number of home visits and the comparisons produced a picture that was most consistent with no or reverse causation.

Discussion The purpose of this study was to identify ways to enhance the theoretically sound NFP intervention. Reviewing the nurses’ home visit records provided a unique perspective on the changes needed to attain a greater reduction in the rate of unplanned teen conceptions during the first 2 postpartum years. Contrary to theory and the stated aims of the intervention, the nurses rarely documented that they explicitly tried to help the teens postpone a second pregnancy. Assistance with obtaining contraception or achieve shortterm goals that might motivate the teen to keep using birth

Prev Sci (2006) 7:389–395 Table 2

Differences among teen mothers who did and did not conceive (N = 111)

Conceived Outcome variable Age at conception (mean ± sd years) Minority race/ethnicity(%) In school/high school graduate(%) Married (%) Prenatal contraceptive plan (%) Formulated educational/career goals (%) Short-term Long-term Used contraception (%) 0-6 months postpartum 7-12 months postpartum 13-24 months postpartum Home visits (% of ideal number+ ) Prenatal Postnatal Total ∗

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Months Postpartum 0–6 Yes No

Months Postpartum 7–12 Yes No

17.4 ± 1.5 77.8 66.7 11.1 33.3

17.4 ± 1.6 73.3∗∗∗∗∗ 97.8∗∗∗∗∗ 11.1∗∗∗∗∗ 18.9

17.7 ± 1.1 17.4 ± 1.7 55.6 73.2∗∗∗∗∗ 88.9 100.0∗∗∗∗ 44.4 7.0∗∗∗∗ 22.2 18.3

77.8 0.00

95.6∗∗∗∗∗ 23.3∗∗∗∗∗

88.9 11.1

95.8∗ 23.9∗

55.6

92.1∗∗∗∗

55.6 66.7

95.7∗∗∗∗ 97.1∗∗∗∗

97 96 97

116 69 92

105 82 98

119∗∗ 67++ 92∗∗

Months Postpartum 13–24 Yes No 16.6 ± 2.1 17.5 ± 1.7 28.6 76.3∗∗ 100.0 100.0 0.0 8.5 0.0 18.6∗∗∗ 100.0 14.3 85.7 71.4 85.7 110 77 94

94.9 27.1 96.6∗∗ 79.3 98.3 122 67 93

p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.005, ∗∗∗∗ p< 0.001,∗∗∗∗∗ p < 0.0001.

+

Ideally, the nurses visited the teenagers weekly for the first four weeks following enrollment, then every two weeks until delivery, then weekly again for the first six postpartum weeks, then every two weeks through the 21st postpartum month, and finally monthly until the child’s second birthday.

++

p = 0.07.

control were only recorded during 30% of the visits. Help with achieving longer-term life-course goals was reported even less often. Olds repeatedly emphasizes the importance of framing child spacing as a mean to an end, rather than an end in itself (Olds, 2002). Yet, we found no evidence that the nurses tried to help the teens understand that the goal of family planning was not to postpone the birth of the next child for 2 years, but to optimize the chance of obtaining what they most wanted for themselves in life. Olds has also written extensively about ecological models of behavior (Olds, 2002). Given the tremendous influence the father of the baby and other boyfriends have on the contraceptive decisions teen mothers make (Ford, Sohn, & Lepkowski, 2001; Zavodny, 2001), it is surprising that the nurses rarely mentioned male partners’ views on contraception and conception or involved them in decision making. These new insights are noteworthy because the unique success of the NFP for preventing rapid second pregnancies is usually attributed to the attention the home visitors give to helping young, socio-economically disadvantaged mothers and their families equate contraceptive use with obtaining the life-style they want (Klerman, 2004). The teens whose histories we reviewed clearly received more support during the first 2 postpartum years then they would have obtained if they had not been visited by a nurse. Moreover, like others (Olds, 2002) we found that the NFP remains popular enough with the target population to have a significant impact on reproductive health attitudes and behavior. As many as a third

of enrollees drop-out of most teen pregnancy prevention programs during the first, and half do so during the second post partum year (Klerman, 2004). The fact that the nurses maintained in-home contact with 80% of the teens for 2 years and delivered 75% of the planned visits to most of them is a significant accomplishment. Thus, we believe that the simplest and easiest way to strengthen the impact this program has on repeat teen pregnancy is to train the nurses to intervene actively enough to bring about long-term attitudinal and behavioral change in family planning. However we realize that finding that implementation of the family planning portion of the intervention was not optimal does not allow us to conclude that efficacy would be improved by greater adherence to the theoretical model (Stevens-Simon, 2003). Like any study, ours has some inherent, unavoidable limitations that must be considered in interpreting the data. This was a secondary data analysis. Thus we cannot tell if home visit frequency and repeat conception were unrelated because the intervention was ineffective or because nurse visits were a marker of risk. If more frequent visits are a consequence of, rather than a cure for, sexual risk taking reverse causation may be to blame. Similarly, since the nurses rarely documented efforts to involve family members, we do not know if the in-home intervention failed to cultivate kinship support that could have helped the teenagers postpone conception (Duggan et al., 2004; El-Kamay et al., 2004; Gomby, Culross, & Behrman, 1999). Despite these methodological limitations, it is important that almost all (88.4%) the teens Springer

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began to use contraception after delivery and that the most consistent difference between those who did and did not conceive was the proportion who used contraception during the retrospective 6-to-12 months. This is consistent with the results of prior studies (Kelly, Sheeder, Scott, & StevensSimon, 2005; Stevens-Simon & Kelly, 1999; Stevens-Simon, Kelly, & Kulick, 2001). It demonstrates that the problem is not convincing teenagers to use contraception after delivery. Rather, since most teens conceive again during adolescence by default and not design, it indicates that a more explicit effort to help them understand that it is worth their while to keep using contraception is needed. Long-acting contraceptives which ensure the “do nothing” position is non-pregnant (rather than pregnant), are an attractive short-term solution (Stevens-Simon & Kelly, 1999). They provide a unique window of opportunity during which users can be helped to set goals that make repeated childbearing fit less harmoniously into their lives. However, simply preventing closely spaced teen pregnancies with long-active contraceptives should not be the goal. To reduce morbidity, teen mothers must also be helped to acquire the skills and gain the self-confidence they need to become productive, self-sufficiency members of society (Stevens-Simon & Kelly, 1999). Based on our review of their records we believe that the nurses failed to discuss the use of contraception and the importance of child spacing frequently enough in this context to prevent contraceptive vigilance from waning in tandem with the strength of the teens’ otherwise fickle desire to remain non-pregnant. Their weekly record entries seldom indicated they were aware of the lapses in contraceptive use that must have occurred. Thus, their failure to prevent repeat conception can also be traced to their failure to target fertility explicitly enough to impact the participants’ willingness to risk an unplanned conception (Klerman, 2004). As a result, even when provided with education about and access to contraception many of the teens quickly found the prospects of having another child less onerous than those of daily contraceptive use. Most continued to endorse goals that are incompatible with closely spaced adolescent childbearing in western industrial societies. Yet, 8.3% conceived within six months and the one- and two-year pregnancy rates were 18.4% and 28.1%, respectively. The intervention might prevent more pregnancies if the nurses intervened more vigorously and in ways that could impact the pervasive misperception that childbearing has little to do with the obstacles that prevent teen parents from leading the safe, economically self-sufficient lives most say they want (Blum, 1998; Chervin, 2005; Gallup-Black & Weitzman 2004; Ginsberg et al., 2002). Further study is needed to determine why the nurses consistently neglected to implement this crucial portion of the NFP. The available data raise concerns about the adequacy of their preparation. Apart from the program specific training Springer

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and supervision they received, the only requirement was that nurses have a bachelor’s degree and some experience in public or maternal and child health (Olds et al., 2002; Olds et al., 2004). None of this assures competency in helping teenagers plan their lives. Research demonstrates that home visitors’ actions are consistent with their self-ratings of competence in addressing risk (Duggan et al., 2004). Obtaining competency evaluations from the nurses would be one way to determine if their failure to discuss pregnancy prevention within the context of life course development and to include boyfriends in family planning discussions reflected their lack of training and confidence in these strategies. Evidence that record format influences the process of care (Duggan, Starfield, & Deangelis, 1990; Duggan et al., 2004), suggests that the program implementation system may have also been a factor. For example, home visitors in another program attributed their impact on the proportion of children who had primary health care providers and their lack of impact on the proportion of mothers who had rapid second pregnancies to the fact that the forms they completed required documentation of the child’s medical home base but not the mother’s contraceptive method (Duggan, Starfield, & Deangelis, 1990; Duggan et al. 2004). Corroborative findings from other studies (Shea, DuMouchel, & Bahamonde, 1996) suggest that incorporating the protocols Olds developed for addressing family planning in an ecological context into an electronic home visit record might correct the implementation problems we identified. By guiding the intervention and reminding the nurses about critical nuances in the practice guidelines, this devise could simultaneously structure and record the care they provide. This would improve the fidelity of the intervention and fill training gaps by teaching home visitors who lack training in adolescent medicine how to address the problems teen-headed families encounter (Sheeder, Scott, & StevensSimon, 2004). These on-line, theory-based protocols would also ensure that the information needed to implement, monitor, and evaluate complex interventions like the NFP is collected consistently and uniformly enough to evaluate efficacy at the national-level. Acknowledgements The investigators thank Dr David Olds for his helpful comments in preparing this manuscript.

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