JSI @ APHA 2013: Addressing social determinants of health in teen pregnancy prevention

This year’s APHA conference has provided me and my colleagues with an exciting opportunity to share our work in examining and addressing social determinants of health as they relate to teen pregnancy here in the United States.

Recently released federal data reports that birth rates among teenagers are at a record low, with rates declining across all racial and ethnic groups. However, even with strong prevention messages and access to contraception, disparities in teen pregnancy persist with absolute numbers in the US remaining high compared to other industrialized nations. Looking at teen pregnancy through the social determinants of health lens can help to pinpoint the root causes of broader health inequities.

A root cause analysis (RCA) process brings community stakeholders together to identify contributing factors and underlying causes of a health issue with the goal of reducing its impact. Applied to teen pregnancy prevention, an RCA followed by a community wide action planning process can be used to forge a shared understanding of teen pregnancy and its influences within a particular community, spurring innovative ideas and strategies for addressing the underlying causes that impact teen pregnancy.

As part of the CDC/OAH Teen Pregnancy Prevention Initiative, JSI provides technical assistance and training to 9 grantees throughout the country in raising awareness and capacity to integrate a “social determinants of health” framework in teen pregnancy prevention. In so doing, JSI worked with several grantees to conduct a “root cause analysis” (RCA). The findings were presented at the American Public Health Association Meeting held in Boston.

Grantees in North Carolina, Connecticut, and Alabama convened community stakeholders representing social service agencies, faith based organizations, and school administrations to participate in the process. Representation differed depending on grantee site. Guided by the RCA tool developed by JSI, participants were asked to identify protective and risk factors related to teen pregnancy in their community. These factors were written on sticky notes and placed on a “socio-ecological model” to differentiate individual, interpersonal, community and society-level factors. This process allowed participants to identify the proximal versus more distal factors and begin prioritizing which factors or “root causes” were more amenable to be addressed given the available resources. Participants were also asked to reflect on the process beyond the identification of root causes to the benefits and unanticipated outcomes of the process.

At the individual level, factors related to teen pregnancy were lack of school engagement, lack of hope and aspirations for the future, and low self-esteem. Interpersonal factors included lack of parent-child communication around sex and contraception, lack of mentoring and significant adults or “life coaches.” Homelessness, high youth unemployment, the lack of job training, poverty and violence were among the factors at the community/societal level.

Grantees reported that the RCA process provided the language to engage a diverse set of community stakeholders to focus on teen pregnancy prevention efforts. It created a sense of camaraderie among leadership teams and facilitated a collective effort to identify determinants to be prioritized and addressed.

However, the task of addressing these determinants can be overwhelming. As one grantee recently commented, “we are the department of health; we are not the department of poverty eradication!”  Another grantee surmised that they do not have the capacity or resources to address racism and inequities. The RCA process shows us that while distal factors such as poverty and racism exist, there are more immediate factors that can be addressed that may go on to influence policies and change community norms. Bringing a diverse group of stakeholders together and identifying root causes is the first step among many in a long process of closing the gaps in teen birth disparities, community by community.

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