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

ORGINAL PAPER

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

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

Abstract Objective: Identify ways to increase the impacta well-known home-based intervention—the Nurse FamilyPartnership (NFP)—has on conception rates among teenagemothers. Methods: Secondary analysis of data collected on111, 13-to-19 years old, primiparas who were visited in theirhomes by nurses during, and for 2 years after pregnancy.Data bearing on assistance with family and career planningwere culled from the nurses’ records. These were graded ona 3-point scale. Higher scores reflected more active, thera-peutic interventions. The primary outcome was repeat preg-nancy. Results: The pregnancy rate at 6, 12, and 24 monthswas 8.3%, 18.4%, and 28.1%. Teenagers who conceivedwere less likely to have used contraceptives during the pre-vious six months than those who did not. Almost everyonereceived the recommended number of visits. However, dis-cussions and active interventions related to lapses in con-traceptive use were only documented during 30% of visits.Those who conceived had as many visits and discussionsof this type as those who did not. Nurses rarely involvedboyfriends and family. Other differences between teens thatdid and did not conceive support the NFP theoretical frame-work. Conclusions: Contrary to the stated aims of the inter-vention, the nurses rarely documented therapeutic interven-tions that could make repeated childbearing fit less harmo-niously into the teenagers’ lives. The best way to strengthenthe impact of this program on teen pregnancy rates is todeepen the nurses’ training so that they are able to intervene

S. Gray · J. Sheeder (�) · R. O’Brien · C. Stevens-SimonDepartment of Pediatrics & School of Nursing, University ofColorado Health Sciences Center Denver,Coloradoe-mail: jeanelle.sheeder@uchsc.edu

actively enough to bring about behavioral change in familyplanning.

Keywords Teen pregnancy . Home visiting . Youthdevelopment

Introduction

The prevention of closely spaced teen pregnancies is animportant, easy-to-define but enigmatically elusive publichealth goal in the United States (US). Statistics indicate thatAmerican teenage mothers are considerably less likely togive birth now than a decade ago (Klerman, 2004). Despitethis progress, approximately 1-in-4 parous teens has at leastone additional child before age 20 (Klerman, 2004). It isdifficult to distinguish between the causes and consequencesof these pregnancies (Geronimus, 1991; Stevens-Simon &Lowry, 1995). However, with each additional teen-birth therisk of prematurity, developmental delays and accidental andnon-accidental trauma increases among offspring. The likeli-hood of finishing high school and being self-supporting alsodecreases 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 least2 years is a national priority for teenagers (US Departmentof Health and Human Services, 2000).

This should be an easy goal to achieve. Most youngwomen who become pregnant during adolescence insist thatthey and their boyfriends do not want more children “any-time soon” (Kelly, Sheeder, Scott, & Stevens-Simon, 2005;Stevens-Simon, Kelly, & Kulick, 2001). Most also have rea-sons to postpone further childbearing and know how to do so.They have aspirations for their futures and their children’s

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futures that are as incompatible with early childbearing asthose of their never-pregnant peers. Moreover, almost ev-eryone receives contraceptive counseling and supplies onrepeated occasions and the majority use birth control afterdelivery (Kershaw et al., 2003). However, the heightenedcontraceptive vigilance that can result from a pregnancyoften wanes rapidly in daily living environments that areconducive to first teen pregnancies. Thus, even teens thathave just given birth and are not consciously planning an-other baby quickly become inconsistent contraceptive usersat best (Kelly, Sheeder, Scott, & Stevens-Simon, 2005).

Accordingly, efforts to prevent teenage mothers fromputting themselves at risk for rapid successive pregnan-cies have been directed toward increasing the perceived op-portunity 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 oftenencouraged to pursue educational and career goals that areincompatible with early childbearing in the US (Philliber,Kaye, Herrling, & West, 2002; Resnick et al., 1997; Roth& Brooks-Gunn, 1998). This approach is teleologically ap-pealing. Yet, evidence supporting its efficacy for preventingteen pregnancy is scant, generally circumstantial, and of ex-tremely variable quality (Klerman, 2004). Little data is avail-able from clinical trials. For example, integrating teenagemothers back into the educational system has never had thesame positive impact on their contraceptive use as the sponta-neous pursuit of higher educational goals (DiCenso, Guyatt,& Griffith, 2002; Klerman, 2004; Quint, Bos, & Polit, 1997;Stevens-Simon & Lowry, 1995). Indeed such efforts can havea paradoxically negative impact on reproductive behavior(Quint, Bos, & Polit, 1997). Similarly, the magnitude of thebenefit attributed to many programs is so disproportionateto their intensity that the reports are hard to take seriously.For example, attending four peer-group meetings over two-years is not apt to convince 90% of teen mothers to postponechildbearing for 3 years (Key, Barbosa, & Owens, 2001).It is also unlikely that attending a school for teen mothersfor as little as 7 weeks postpartum would convince 70% ofenrollees to take the steps needed to remain non-pregnant for5 years (Seitz & Apfel, 1993). Yet, the concept that postpar-tum school return and future-oriented goal setting preventrepeat conception during adolescence is still very popular inthe US (Klerman, 2004).

Globally, fertility data support this view (Darroch, Singh,& Frost 2001). However, there is nothing about these ac-tivities that necessarily makes teenagers want to avoid con-ception. Poor, inner-city American teenagers, their parents,and community leaders have the same educational, career,and life-style goals as their less sociodemographically de-prived counterparts (Blum, 1998; Chervin, 2005; Gallup-Black & Weitzman 2004; Ginsberg et al., 2002; Jumping-

Eagle, Sheeder, & Stevens-Simon, 2005). However, sincethey do not believe that adolescent childbearing is an imped-iment to achieving these goals, pregnancy prevention is givena low priority rating (Blum, 1998; Chervin, 2005; Gallup-Black & Weitzman 2004; Ginsberg et al., 2002). Changingthis normative belief is a difficult task.

The clearest evidence that it is possible to do so comesfrom a series of randomized trials in which Olds and col-leagues demonstrated that exposure to an intensive pre-and postnatal home-based intervention significantly reducedsubsequent conception rates among low-income, first-timemothers (American Academy of Pediatrics, 1998; Klerman,2004, National Commission to Prevent Infant Mortality,1989; Olds, 2002). Teenage mothers who were visited bynurses were approximately one third less likely than thosewho were not to give birth within 2 years (Olds, 2002). How-ever, 1-in-4 of the teens who were visited at least monthlyin their homes gave birth during the first 2 postpartum years(Klerman, 2004; Olds, 2002). We reviewed the nurse homevisitors’ clinical records to determine how the family plan-ning component of this theoretically sound program couldbe strengthened.

Methods

Study population

We conducted a secondary analysis of data collected on agroup of 735 medically indigent, primiparous women whowere recruited from prenatal clinics in Denver, Colorado be-tween March of 1994 and June of 1995 (Olds, 2002; Oldset al., 2002). These women were enrolled in a 3-armed,randomized trial of a program of prenatal and infancy homevisiting known today as the Nurse Family Partnership (NFP).Two groups received home visits. One group was visited byBachelor prepared, registered nurses with training and ex-perience in public health or maternal and child health. Theother group was visited by lay, paraprofessionals who wererequired to have a high school education and no collegepreparation in the “helping professions.” Members of thethird group received no home visits. Our interest was in un-derstanding how the in-home intervention prevented rapidsecond pregnancies among teenage mothers. Hence, all par-ticipants who were over 19 years of age at conception andthose who were not randomized to receive home visits wereexcluded. Next, because the nurses delivered the in-homeintervention in a more effective manner than the paraprofes-sionals (Olds et al., 2002; Olds et al., 2004), teenagers whowere randomized to the paraprofessional group were alsoexcluded. Finally, we excluded 10 of the 121 nurse visitedteens; 4 did not give birth to living babies, 2 received nohome 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 Ameri-can) group of 111 mostly unmarried (90.1%), 13-to-19 yearsolds (mean ± sd: 17.4 ± 1.6 years at conception), 39%of whom were less that 17 years of age at conception. Atenrollment almost everyone (97.2%) was attending schooland/or working. Subsequently, most also received an ad-equate amount of prenatal care and gave birth at term tohealthy, well-developed infants. The original study was ap-proved by the Institutional Review Board for the Universityof Colorado Health Sciences Center and all participants pro-vided informed consent at enrollment (Olds et al., 2002; Oldset al., 2004).

Intervention

Details of the training and supervision the nurses receivedand the NFP intervention has been published (Olds, 2002;Olds et al., 2002; Olds et al., 2004). Briefly, while nurse-directed, the NFP is designed to be client-centered, thera-peutic, and supportive. The primary goals are to optimize:1) pregnancy outcomes by helping women improve health-related behaviors; 2) child health and development by help-ing parents provide competent care; and 3) maternal lifecourse development by helping women develop a visionfor their futures consistent with their aspirations. To assistwomen in accomplishing these goals, the nurses encouragedthem to set small achievable objectives, the accomplishmentof which would give them the self-confidence to tackle otherproblems in their lives. The nurses also guided them to-ward the appropriate use of health and human services andhelped them develop strong supportive relationships withfamily members and friends. Of particular relevance to thisinvestigation, both pre- and post-natally women were to becounseled about contraception and the importance of spac-ing subsequent children within the context of achieving theirgoals. The caseload was approximately 25 families. Visitswere to occur weekly for four weeks after enrollment, everytwo weeks until delivery, weekly for the first six postpartumweeks, then every two weeks through the 21st postpartummonth, 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 clinicalrecords the nurses maintained for each teen mother. Entriesbearing on contraceptive use and life-course developmentwere abstracted. These were coded first as either nurse orteen initiated and then graded on a 3-point scale such thatlow scores reflected passive, supportive interventions andhigh scores reflected progressively more active, therapeuticinterventions. Specifically, 1 point was assigned to entriesbearing on problem identification, 2 points to goal setting,

and 3 points to activities related to obtaining or using contra-ception or achieving a goal. We were interested in both thefrequency and the consistency with which these topics wereaddressed. Hence, the analysis considered the absolute num-ber of such record entries as well as the proportion of visitsfor which they were made. All data extraction and coding ofrecord entries was done by the primary author, with reviewby other members of the research team. Since the nurseswere not given a standardized record form to complete therewas no way to know if failure to record was synonymouswith failure to discuss. To minimize the impact of incom-plete documentation we also analyzed the proportion of therecommended visits each teen received. The primary purposewas to compare the home visit experiences of teen motherswho had and had not conceived again by the 6th, 12th, and24th postpartum month. Time to second pregnancy was basedon maternal report of last menstrual period. In addition, weexamined two shorter-term indices of intervention success:contraceptive use and work on goals. Finally, four of themost salient and widely implicated risk factors for rapid re-peat teen conception, age at conception, race/ethnicity, andmarital 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 popu-lation. The documented nurse-teen discussions about con-traception and/or life course development were tallied andgrouped so that they antedated the conceptions that had oc-curred by the 6th, 12th, and 24th postpartum month. Prena-tal interactions were analyzed separately and in combinationwith those that occurred following delivery. Student’s T-testsand Chi-square analyses were used to compare the charac-teristics and home visit histories of teens that had and hadnot conceived again at 6, 12, and 24 months postpartum. Fi-nally, Chi-square analyses were used to compare the homevisit histories of teenagers who had and had not used con-traception and had and had not worked on their goals at 6,12, and 24 months postpartum. All analyses were performedwith SPSS/PC; (version 12; 2004).

Results

The data presented in Table 1 show that the attrition rate wasvery low. It rose from 2.7% at 6, to 11.7% at 12, and 18.8%at 24 months postpartum. Moreover, record entries revealedthat almost all (94.6%) of the teenagers formulated short-term goals, such as returning to school and exploring jobopportunities, and took steps toward accomplishing one or

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Table 1 Conception Rate (N = 111)

Months postpartum

Outcome variable 6 months 12 months 24 monthsReceiving home visits (%) 108 (97.3) 98 (88.3) 89 (81.2)Pregnant (%) 9 (8.3) 18 (18.4) 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 movetoward accomplishing a long-term goal, such as developinga 4-to-5 year contraceptive and work-study plan that wouldenable her to pursue a career that she might find as rewardingas motherhood. Of equal concern, only 20% of the recordsdocumented a prenatal plan for postpartum contraception.Nonetheless, 45.6% of the teens used contraception duringthe puerperium and 83.5% had done so by the end of thesixth post-partum month. Indeed almost everyone (88.4%)used contraception at some point during the 2-year studyperiod. 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 asso-ciations between the explanatory variables and repeat con-ception (Table 2). At each assessment teenagers who con-ceived were less likely to report contraceptive use during theprevious 6-to-12 months than those who did not. However,the majority of those who became pregnant also reported thatthey used contraception within 6 months of conception. Noneof the implicit transitions from protected to unprotected inter-course and reasons for them were documented in the nurses’records. The nurses may have been unaware of these lapsesor not considered it important to record them. Assistancewith contraception or short-term goals was documented dur-ing 30% of the visits. However, help with long-term goalswas only recorded during 10% of the visits.

Of equal concern, the nurses’ notes almost never men-tioned the views of the father of the baby and/or otherboyfriends on contraception and conception. Documentedefforts to involve boyfriends, baby-fathers, or other familymembers in discussions about family and career planningwere also extremely rare. Teenagers who conceived againdid not differ significantly from those who did not with re-gard to the frequency, consistency, or intensity with whichthey and their nurse visitor discussed these topics. Nonethe-less, the other differences between teenagers who did anddid not conceive support the NFP’s theoretical framework(Table 2). Teenagers who became pregnant within 6 monthswere less likely than those who did not to be in school or highschool graduates (66.7% compared to 97.8%; p < 0.0001)and to have taken steps to accomplish their goals. Those whoconceived within 7-to-12 months were less likely than thosewho did not to be in school or high school graduates (88.9%

compared to 100%; p < 0.001) and to have taken steps to ac-complish their long-term goals. They were also more likelyto be married (44.4% compared to 7%; p < 0.001). Finally,none of those who conceived during the second postpartumyear had formulated a prenatal contraceptive plan, whereas18.6% of those who were not pregnant had done so.

One plausible explanation for our unanticipated findingsis that the nurses neglected to document everything they did.Hence, we moved next to an analysis of the relationshipbetween repeat conception and visit frequency. We found asignificant correlation (r = 0.48; p < 0.001) between the fre-quency of prenatal and postpartum home visits. On averagethe teenagers received more than the recommended numberof prenatal home visits (mean ± sd: 6.5 ± 3.7; range: 0-to-16) and nearly three-quarters of the recommended number ofpostpartum visits (Table 2). Bivariate analyses revealed thatthe teenagers who conceived again did not differ significantlyfrom those who did not with regard to the proportion of therecommended prenatal or postpartum home visits they re-ceived. However, teenagers who remained non-pregnant in-variably received a smaller proportion of the recommendedpostpartum visits than those who conceived. This was nottrue of prenatal home visits. Hence, the nurses may have de-tected the need for additional help and responded by inten-sifying the postpartum intervention. If more frequent visitswere a consequence of sexual risk taking, reverse causationcould be partially to blame for our failure to demonstrate anassociation between visit frequency and repeat conception.However, since almost everyone received close to the rec-ommended number of visits, it is likely that visit content wasalso a factor. Finally, none of the short-term indices of in-tervention success we examined (i.e., use of conception andwork on goals), were related to the number of completed vis-its (data available by request). Teenagers who had not usedcontraception or worked on their personal goals received asmany or more visits as those who had. Once again, almosteveryone received the recommended number of home vis-its and the comparisons produced a picture that was mostconsistent with no or reverse causation.

Discussion

The purpose of this study was to identify ways to enhancethe theoretically sound NFP intervention. Reviewing thenurses’ home visit records provided a unique perspectiveon the changes needed to attain a greater reduction in therate of unplanned teen conceptions during the first 2 post-partum years. Contrary to theory and the stated aims of theintervention, the nurses rarely documented that they explic-itly tried to help the teens postpone a second pregnancy.Assistance with obtaining contraception or achieve short-term goals that might motivate the teen to keep using birth

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Table 2 Differences among teen mothers who did and did not conceive (N = 111)

Months Postpartum 0–6 Months Postpartum 7–12 Months Postpartum 13–24Conceived Yes No Yes No Yes No

Outcome variableAge at conception (mean ± sd years) 17.4 ± 1.5 17.4 ± 1.6 17.7 ± 1.1 17.4 ± 1.7 16.6 ± 2.1 17.5 ± 1.7Minority race/ethnicity(%) 77.8 73.3∗∗∗∗∗ 55.6 73.2∗∗∗∗∗ 28.6 76.3∗∗

In school/high school graduate(%) 66.7 97.8∗∗∗∗∗ 88.9 100.0∗∗∗∗ 100.0 100.0Married (%) 11.1 11.1∗∗∗∗∗ 44.4 7.0∗∗∗∗ 0.0 8.5Prenatal contraceptive plan (%) 33.3 18.9 22.2 18.3 0.0 18.6∗∗∗

Formulated educational/career goals (%)Short-term 77.8 95.6∗∗∗∗∗ 88.9 95.8∗ 100.0 94.9Long-term 0.00 23.3∗∗∗∗∗ 11.1 23.9∗ 14.3 27.1Used contraception (%)0-6 months postpartum 55.6 92.1∗∗∗∗ 55.6 95.7∗∗∗∗ 85.7 96.6∗∗

7-12 months postpartum 66.7 97.1∗∗∗∗ 71.4 79.313-24 months postpartum 85.7 98.3Home visits (% of ideal number+)Prenatal 97 116 105 119∗∗ 110 122Postnatal 96 69 82 67++ 77 67Total 97 92 98 92∗∗ 94 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 weeklyagain for the first six postpartum weeks, then every two weeks through the 21st postpartum month, and finally monthly until the child’s secondbirthday.++p = 0.07.

control were only recorded during 30% of the visits. Helpwith achieving longer-term life-course goals was reportedeven less often. Olds repeatedly emphasizes the importanceof framing child spacing as a mean to an end, rather than anend in itself (Olds, 2002). Yet, we found no evidence that thenurses tried to help the teens understand that the goal of fam-ily planning was not to postpone the birth of the next childfor 2 years, but to optimize the chance of obtaining what theymost wanted for themselves in life. Olds has also written ex-tensively about ecological models of behavior (Olds, 2002).Given the tremendous influence the father of the baby andother boyfriends have on the contraceptive decisions teenmothers make (Ford, Sohn, & Lepkowski, 2001; Zavodny,2001), it is surprising that the nurses rarely mentioned malepartners’ views on contraception and conception or involvedthem in decision making.

These new insights are noteworthy because the uniquesuccess of the NFP for preventing rapid second pregnanciesis usually attributed to the attention the home visitors give tohelping young, socio-economically disadvantaged mothersand their families equate contraceptive use with obtainingthe life-style they want (Klerman, 2004). The teens whosehistories we reviewed clearly received more support duringthe first 2 postpartum years then they would have obtained ifthey had not been visited by a nurse. Moreover, like others(Olds, 2002) we found that the NFP remains popular enoughwith the target population to have a significant impact on re-productive health attitudes and behavior. As many as a third

of enrollees drop-out of most teen pregnancy prevention pro-grams during the first, and half do so during the second postpartum year (Klerman, 2004). The fact that the nurses main-tained in-home contact with 80% of the teens for 2 years anddelivered 75% of the planned visits to most of them is a sig-nificant accomplishment. Thus, we believe that the simplestand easiest way to strengthen the impact this program hason repeat teen pregnancy is to train the nurses to interveneactively enough to bring about long-term attitudinal and be-havioral change in family planning. However we realize thatfinding that implementation of the family planning portionof the intervention was not optimal does not allow us to con-clude that efficacy would be improved by greater adherenceto the theoretical model (Stevens-Simon, 2003).

Like any study, ours has some inherent, unavoidable limi-tations that must be considered in interpreting the data. Thiswas a secondary data analysis. Thus we cannot tell if homevisit frequency and repeat conception were unrelated be-cause the intervention was ineffective or because nurse visitswere a marker of risk. If more frequent visits are a conse-quence of, rather than a cure for, sexual risk taking reversecausation may be to blame. Similarly, since the nurses rarelydocumented efforts to involve family members, we do notknow if the in-home intervention failed to cultivate kinshipsupport that could have helped the teenagers postpone con-ception (Duggan et al., 2004; El-Kamay et al., 2004; Gomby,Culross, & Behrman, 1999). Despite these methodologicallimitations, it is important that almost all (88.4%) the teens

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began to use contraception after delivery and that the mostconsistent difference between those who did and did notconceive was the proportion who used contraception dur-ing the retrospective 6-to-12 months. This is consistent withthe results of prior studies (Kelly, Sheeder, Scott, & Stevens-Simon, 2005; Stevens-Simon & Kelly, 1999; Stevens-Simon,Kelly, & Kulick, 2001). It demonstrates that the problem isnot convincing teenagers to use contraception after delivery.Rather, since most teens conceive again during adolescenceby default and not design, it indicates that a more expliciteffort to help them understand that it is worth their while tokeep using contraception is needed.

Long-acting contraceptives which ensure the “do nothing”position is non-pregnant (rather than pregnant), are an at-tractive short-term solution (Stevens-Simon & Kelly, 1999).They provide a unique window of opportunity during whichusers can be helped to set goals that make repeated childbear-ing fit less harmoniously into their lives. However, simplypreventing closely spaced teen pregnancies with long-activecontraceptives should not be the goal. To reduce morbid-ity, teen mothers must also be helped to acquire the skillsand gain the self-confidence they need to become produc-tive, self-sufficiency members of society (Stevens-Simon &Kelly, 1999). Based on our review of their records we believethat the nurses failed to discuss the use of contraception andthe importance of child spacing frequently enough in thiscontext to prevent contraceptive vigilance from waning intandem with the strength of the teens’ otherwise fickle desireto remain non-pregnant. Their weekly record entries seldomindicated they were aware of the lapses in contraceptive usethat must have occurred. Thus, their failure to prevent repeatconception can also be traced to their failure to target fertilityexplicitly enough to impact the participants’ willingness torisk an unplanned conception (Klerman, 2004).

As a result, even when provided with education about andaccess to contraception many of the teens quickly found theprospects of having another child less onerous than thoseof daily contraceptive use. Most continued to endorse goalsthat are incompatible with closely spaced adolescent child-bearing in western industrial societies. Yet, 8.3% conceivedwithin six months and the one- and two-year pregnancy rateswere 18.4% and 28.1%, respectively. The intervention mightprevent more pregnancies if the nurses intervened more vig-orously and in ways that could impact the pervasive misper-ception that childbearing has little to do with the obstaclesthat prevent teen parents from leading the safe, economi-cally self-sufficient lives most say they want (Blum, 1998;Chervin, 2005; Gallup-Black & Weitzman 2004; Ginsberget al., 2002).

Further study is needed to determine why the nurses con-sistently neglected to implement this crucial portion of theNFP. The available data raise concerns about the adequacy oftheir preparation. Apart from the program specific training

and supervision they received, the only requirement was thatnurses have a bachelor’s degree and some experience in pub-lic or maternal and child health (Olds et al., 2002; Olds et al.,2004). None of this assures competency in helping teenagersplan their lives. Research demonstrates that home visitors’actions are consistent with their self-ratings of competence inaddressing risk (Duggan et al., 2004). Obtaining competencyevaluations from the nurses would be one way to determineif their failure to discuss pregnancy prevention within thecontext of life course development and to include boyfriendsin family planning discussions reflected their lack of train-ing and confidence in these strategies. Evidence that recordformat influences the process of care (Duggan, Starfield, &Deangelis, 1990; Duggan et al., 2004), suggests that the pro-gram implementation system may have also been a factor.For example, home visitors in another program attributedtheir impact on the proportion of children who had primaryhealth care providers and their lack of impact on the propor-tion of mothers who had rapid second pregnancies to the factthat the forms they completed required documentation of thechild’s medical home base but not the mother’s contracep-tive method (Duggan, Starfield, & Deangelis, 1990; Dugganet al. 2004). Corroborative findings from other studies (Shea,DuMouchel, & Bahamonde, 1996) suggest that incorporat-ing the protocols Olds developed for addressing family plan-ning in an ecological context into an electronic home visitrecord might correct the implementation problems we iden-tified. By guiding the intervention and reminding the nursesabout critical nuances in the practice guidelines, this de-vise could simultaneously structure and record the care theyprovide. This would improve the fidelity of the interventionand fill training gaps by teaching home visitors who lacktraining in adolescent medicine how to address the problemsteen-headed families encounter (Sheeder, Scott, & Stevens-Simon, 2004). These on-line, theory-based protocols wouldalso ensure that the information needed to implement, mon-itor, and evaluate complex interventions like the NFP is col-lected consistently and uniformly enough to evaluate efficacyat the national-level.

Acknowledgements The investigators thank Dr David Olds for hishelpful comments in preparing this manuscript.

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