Enhancing Knowledge of Contraception and Safe Sex among Hispanic Teens

The aim of this DNP project was to increase knowledge regarding safe sex practices, and contraception among Hispanic adolescents in order to improve their ability to prevent unintended pregnancies. Teen pregnancy rates are notably higher among Hispanic individuals in underserved areas with limited access to contraceptive education and family planning services. This is problematic because pregnancy at an early age often leads to increased financial burden as well as poor health, negative outcomes, and decreased life expectancy for mother and child. The objectives for this project were to 1) Identify barriers that prevent Hispanic teens from using birth control to avoid unintended pregnancies, 2) Implement an educational program to enhance participants' knowledge regarding safe sex practices and birth control options and availability, 3) Share DNP project results with clinicians and staff at the site of implementation, and 4) Present project outcomes at the American College of Nurse-Midwives regional meeting. Teenage pregnancy rates in the United States have been declining steadily over the last 6 years. However, current evidence indicates that there are significant racial disparities in the incidence of pregnancy among adolescents. In 2014, incidence of teen pregnancy was highest among Hispanic teens with rates that were more than double the national average. Women who become pregnant during adolescence are more likely to develop conditions such as heart disease and cervical cancer which are among the top ten causes of death in the United States. Poor health and low socioeconomic status significantly increase mortality rates and decrease life expectancy among this population. Children who are born to teenage mothers are more likely to have poor health, live in poverty, and use illegal substances. They are also more likely to engage in unhealthy sexual practices and become teen parents themselves. The implementation of this project involved clinicians at a local community health clinic who assessed teenage patients for birth control use and asked them to complete a short, anonymous questionnaire to identify barriers to their use of contraception. Those who were interested in learning more about birth control methods were invited to participate in a contraceptive workshop where they had the opportunity to learn about their proper use and availability. Participants learning was evaluated using a pre- and post-test format of key concepts. Results were presented to clinicians and staff at the clinical site to promote awareness of barriers and increase uptake of contraception among Hispanic teens. The results of this project indicated that over one third of the adolescents who completed the questionnaire were already using contraception. This suggests appropriate availability of resources and information in this particular setting. However, a large portion of the teens who were not using contraception reported feeling too embarrassed to request information about this topic and obtain contraception from their primary care providers. The contraceptive workshop implemented with this scholarly project demonstrated a significant improvement in participants' knowledge of birth control options. This suggests that a contraceptive workshop could be an effective intervention in a variety of primary care settings. There is a clear need for contraceptive education among Hispanic adolescents. By identifying barriers to contraceptive use and providing the appropriate information and resources, clinicians can play a role in decreasing rates of unintended pregnancy in these high risk populations.

Running head: KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Enhancing Knowledge of Contraception and Safe Sex among Hispanic Teens Stanley Garzón, BSN, RN University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 2 Executive Summary The aim of this DNP project was to increase knowledge regarding safe sex practices, and contraception among Hispanic adolescents in order to improve their ability to prevent unintended pregnancies. Teen pregnancy rates are notably higher among Hispanic individuals in underserved areas with limited access to contraceptive education and family planning services. This is problematic because pregnancy at an early age often leads to increased financial burden as well as poor health, negative outcomes, and decreased life expectancy for mother and child. The objectives for this project were to 1) Identify barriers that prevent Hispanic teens from using birth control to avoid unintended pregnancies, 2) Implement an educational program to enhance participants' knowledge regarding safe sex practices and birth control options and availability, 3) Share DNP project results with clinicians and staff at the site of implementation, and 4) Present project outcomes at the American College of Nurse-Midwives regional meeting. Teenage pregnancy rates in the United States have been declining steadily over the last 6 years. However, current evidence indicates that there are significant racial disparities in the incidence of pregnancy among adolescents. In 2014, incidence of teen pregnancy was highest among Hispanic teens with rates that were more than double the national average. Women who become pregnant during adolescence are more likely to develop conditions such as heart disease and cervical cancer which are among the top ten causes of death in the United States. Poor health and low socioeconomic status significantly increase mortality rates and decrease life expectancy among this population. Children who are born to teenage mothers are more likely to have poor health, live in poverty, and use illegal substances. They are also more likely to engage in unhealthy sexual practices and become teen parents themselves. The implementation of this project involved clinicians at a local community health clinic who assessed teenage patients for birth control use and asked them to complete a short, anonymous questionnaire to identify barriers to their use of contraception. Those who were interested in learning more about birth control methods were invited to participate in a contraceptive workshop where they had the opportunity to learn about their proper use and availability. Participants learning was evaluated using a pre- and post-test format of key concepts. Results were presented to clinicians and staff at the clinical site to promote awareness of barriers and increase uptake of contraception among Hispanic teens. The results of this project indicated that over one third of the adolescents who completed the questionnaire were already using contraception. This suggests appropriate availability of resources and information in this particular setting. However, a large portion of the teens who were not using contraception reported feeling too embarrassed to request information about this topic and obtain contraception from their primary care providers. The contraceptive workshop implemented with this scholarly project demonstrated a significant improvement in participants' knowledge of birth control options. This suggests that a contraceptive workshop could be an effective intervention in a variety of primary care settings. There is a clear need for contraceptive education among Hispanic adolescents. By identifying barriers to contraceptive use and providing the appropriate information and resources, clinicians can play a role in decreasing rates of unintended pregnancy in these high risk populations. This project has been guided by faculty Chair Pamela Phares, PhD, APRN; FNP Specialty Track Director Julie Balk, DNP, APRN, FNP-BC, CNE; Assistant Dean of MS & DNP Programs Pamela Hardin, PhD, RN; and Content Expert Annabel Sheinberg, MM, Education Director for Planned Parenthood of Utah. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 3 Table of Contents Executive Summary 2 Acknowledgements 4 Problem Statement 5 Clinical Significance and Policy Implications 5 Purpose and Objectives 6 Literature Review 7 Theoretical Framework 9 Implementation 10 Evaluation 12 Implementation and Evaluation Table 13 Results 15 Recommendations for the Future 16 Doctor of Nursing Practice Essentials 18 Conclusions 19 References 20 Appendices 21 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 4 Acknowledgements First and foremost, I would like to thank my family for providing guidance and support as I have made my way through this long journey of becoming a Family Nurse Practitioner. I would also like to thank Dr. Gillian Tufts who has been my mentor from day one and has taught me what it really means to be a primary care provider. To Dr. Amanda Al-Khudairi and Dr. Sara Hake who introduced me to the field of nursing and were my inspiration to become an advanced practice clinician. And finally, to Dr. Phil Taylor and Patience Nelson for being exceptional preceptors and sharing their knowledge and experience with me to allow me to be the best practitioner I can be. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 5 Problem Statement Teenage pregnancy rates in the United States have been steadily decreasing over the last six years. Rates dropped from 34.2 per 1,000 in 2010 to 24.2 per 1,000 in 2014 (Public Health Indicator Based Information System, 2016a). However, these rates remain significantly higher than those of other developed nations around the world. According to Dogan-Ates and CarrisonBasham (2007), pregnancy rates in the United States are approximately two times higher than those of Canada and ten times higher than those of Switzerland. Analysis of teen pregnancy rates shows significant disparity in the incidence of pregnancy among adolescents based on race and ethnicity. Hispanic teens have the highest incidence of unintended pregnancies in the U.S. with rates that are more than double the national average (Public Health Indicator Based Information System, 2016b). This is a serious problem not only in terms of financial burden for individuals, families, and communities, but also in terms of health status and well-being. According to Danawi (2016), teenage mothers and their children are at increased risk for experiencing negative health outcomes during pregnancy and later in life. These negative outcomes are more prevalent among Hispanic teens due to their vulnerable status and limited access to resources and education to improve their living conditions and quality of life. Clinical Significance and Policy Implications Because unintended pregnancies have a significant impact the lives of Hispanic teens and their families, it is important to create awareness and develop interventions that can effectively address and prevent pregnancy. Faced with unintended pregnancy, teens experience physical, emotional, social, and financial burdens that ultimately limit their opportunities to get an KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 6 education, secure better paying jobs, and provide a better life for their loved ones (Dogan-Ates & Carrion-Basham, 2007). Identifying and understanding effective educational approaches to address safe sex, birth control, and family planning services allows health care providers to effect real reduction in pregnancy rates and improve the health of this population. When individuals are able to make informed decisions regarding their reproductive life, they will be empowered to prevent unintended pregnancy which will have far-reaching future implications to their health and socioeconomic prospects. Teen pregnancy also creates significant financial burden on the health care system as a whole. According to the National Campaign to Prevent Teen and Unplanned Pregnancy (2017), teen childbearing costs taxpayers at least $9.4 billion each year in the United States and approximately $71 million in the state of Utah alone. The implementation of policies to decrease the rates of unintended pregnancies will therefore help reduce financial burden and, in turn, help improve other social problems such as poverty, child neglect, school failure, and poor preparation for the workforce (National Campaign to Prevent Teen and Unplanned Pregnancy, 2017). Purpose and Objectives The purpose of this scholarly project is to improve knowledge regarding safe sex practices, birth control, and family planning among Hispanic teens in order to improve their ability to prevent unintended pregnancies. The objectives for this project are as follows: • Identify barriers that prevent Hispanic teens from using birth control to avoid unintended pregnancies KNOWLEDGE OF CONTRACEPTION AND SAFE SEX • 7 Implement an evidence-based educational program to enhance participants' knowledge regarding safe sex practices and birth control options and availability • Share DNP project results with clinicians and staff • Present project outcomes in a peer-reviewed forum Literature Review Search Strategy The literature review for this project was performed utilizing the research databases CINAHL and PubMed. The search terms used include teen pregnancy, Hispanic teens, sexual education, pregnancy rates, unintended pregnancy, contraception, barriers, culture, and accessibility. Additional sources were located by review of article reference lists. Only articles published between 2007 and 2017 were included in the review of literature. Prevalence According to the Public Health Indicator Based Information System (2016a), teenage pregnancy rates in the United States have decreased from 34.2 per 1,000 in 2010 to 24.2 per 1,000 in 2014. During this time, the state of Utah has seen a similar trend in rates decreasing from 27.9 per 1,000 to 19.5 per 1,000 (Public Health Indicator Based Information System, 2016a). Similar to national rates, rates of teen pregnancy in Utah show disparity in the incidence of teen pregnancy rates based on race and ethnicity. As of 2014, Hispanic teens held the highest teen pregnancy rates in the state with an average of 43.4 per 1,000 which is more than double the state average during that year (Public Health Indicator Based Information System, 2016b). According to Aparicio, Pecukonis, and Zhou (2014), teenage pregnancy rates in Latino communities are approximately twice as high as those of other teenagers, not only in Utah, but in most areas of the United States. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 8 Health Status and Life Expectancy Current evidence suggests that women who become pregnant during adolescence are more likely to develop conditions such as heart disease and cervical cancer which are among the top ten causes of death in the United States (Danawi, 2016). Furthermore, it has been shown that a combination of poor health and socioeconomic factors such as poverty and limited access to health care, play a major role in increasing mortality rates and decreasing life expectancy among this population (Danawi, 2016). Research also indicates that teenage mothers are more likely to be diagnosed with mental health conditions such as depression and anxiety which can ultimately hinder their ability to care for themselves and their families. (Patel & Sen, 2012). According to Dogan-Ates and Carrison-Basham (2007), children who are born to teenage mothers are more likely to have poor health, live in poverty, and use illegal substances. They are also more likely to engage in unhealthy sexual practices and become teen parents themselves. Financial Implications Dogan-Ates and Carrion-Basham (2007) foud that lack of education, low socioeconomic status, and limited support systems are predictors of higher unintended pregnancy rates. These factors commonly prevent individuals from obtaining higher education and improving their quality of life. Consequently, those who live in poor communities, tend to experience higher pregnancy rates due to limited education and resources. Utah cities such as West Valley City, South Salt Lake, and Rose Park have some of the highest rates of poverty and teen pregnancies in the state supporting the contention that low income and lack of education are strongly correlated with increased rates of unintended pregnancies among adolescents (Public Health Indicator Based Information System, 2016a). KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 9 Sexual Education and Birth Control Availability A prospective cohort study conducted by Birgisson, Zhao, Secura, Madden, and Peipert (2015), demonstrated that the rates of teen pregnancy and abortions can be greatly reduced by improving access to family planning information and services. Their study was performed in St. Louis, Missouri and included more than 9000 female participants. These women were counseled on all contraceptive options available and given the birth control method of their choice at no cost for three years. At the end of this study in 2008, the rates of teen pregnancy and abortion in St. Louis were 34.0 and 9.7 per 1,000 respectively; these were significantly lower than the national average of 158.5 and 41.5 per 1,000 during that same year (Birgisson et al., 2015). Hispanics, Pregnancy, and Family Planning Hispanic teens are also at increased risk for repeat pregnancies when compared to teens in all other ethnic groups (Bouris et al., 2012). According to Aparicio, Pecukonis, and Zhou (2014), Hispanic patients may be less likely to use contraception due to cultural values and religious beliefs. Evidence suggests that parental views of contraception and sexual intercourse also play a significant role in the sexual behavior of Hispanic adolescents. This is supported by the results of a telephone survey of 1008 Hispanic adolescents where 55% identified their parents as the primary influence on sexual decision making (Bouris et al., 2012). While these influences can make it challenging for health care professionals to promote birth control use, they can also create an opportunity for the implementation of family oriented interventions. Teaching adolescents and their parents about healthy sexual practices may result in increased support and acceptance of contraceptive use among this population. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 10 Theoretical Framework To effectively educate Hispanic teens about the use of contraceptive use for the prevention of unintended pregnancy, it is necessary to take into account the cultural differences that affect their sexual behaviors and practices. For that reason, this scholarly project and its related interventions will be guided by the theoretical framework known as the Transcultural Nursing Theory. According to Sagar (2012), this theory focuses on understanding how cultural differences in beliefs and values affect the way in which individuals behave and interact with others in their environment. In order to properly address the issue of pregnancies among Hispanic teens, it is necessary to understand how their culture affects age of sexual debut, education received from parents or family, and barriers to receiving information regarding contraception. Incorporating cultural norms of the group into teaching content and methods may improve relevance and eventual uptake of the information. Implementation Following the proposal presentation (see appendix A) and approval by College of Nursing faculty to carry out this project, the implementation phase was begun. This scholarly project was implemented at local community health center located in the city of Rose Park in the state of Utah. This clinic provides health care services to individuals of low socioeconomic status who have limited or no health insurance coverage. Over 50% of patients at this clinical site are Hispanic or of Hispanic descent. During the past two years, clinicians at this health care center have provided services to 522 Hispanic adolescents between the ages 15-17 which was the targeted age group being studied in this project. The medical team at this facility is made up of KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 11 three physicians, two family nurse practitioners, and three physician assistants, all of whom are fluent in English and Spanish. This implementation began with clinicians at the community health center identifying Hispanic adolescents, ages 15-17, and requesting for them complete a short, anonymous questionnaire. These questionnaires were given during routine, health maintenance visits and included the following three questions: 1) Are you or your partner (s) currently using birth control?, 2) If your answer to the previous questions was "No" please indicate why, and 3) Would you like to learn more about birth control and pregnancy prevention? (See Appendix F). This initial screening helped identify areas for targeted education and interventions to increase knowledge and access to contraceptive services. The second step of this implementation consisted of extending an invitation to attend a one hour contraceptive workshop for participants who expressed their interest in learning more about birth control and pregnancy prevention. This workshop focused on the proper use, efficacy, and availability of each method as well as community resources through which to access contraceptives. The lesson utilized in this workshop was obtained through the Planned Parenthood Association of Utah Education Department and was one of five modules in their Healthy Sexuality series. It consisted of 30 minutes of lecture followed by 15 minutes case studies and role play, and finally 15 minutes for questions and comments (See Appendix A). These group classes were offered three times during a two month period. Patients were contacted via phone and scheduled to attend one of the class offerings. Participants' information was kept in a secured cabinet at the site of implementation to protect patient privacy and ensure compliance with HIPAA and the University of Utah IRB. The intent of this intervention was to KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 12 increase patients' knowledge and prepare them to make informed decisions regarding contraceptive choices. The final step included a presentation of the project outcomes at a community health center provider meeting as well as at the American College of Nurse-Midwives regional meeting. The purpose of this dissemination was to create awareness of barriers to contraception faced by Hispanic teens in underserved areas of the state of Utah and promote the implementation of contraceptive classes on a larger scale in similar clinical settings. Evaluation The evaluation process began by obtaining IRB approval for the implementation of this scholarly project at the selected clinical site. This was followed by analysis of anonymous surveys and identification of the most common barriers to contraceptive use among adolescent Hispanic patients. Individuals who chose take part in this project and participate in the workshop were given a pre- and post-test in order to assess learning as a consequence of their attendance. Effectiveness of the educational content and format of the workshop was evaluated by comparing participants' pre- and post-test scores. Approval to attend a provider meeting was requested once these interventions were successfully implemented and the data had been analyzed. The results of this project were presented to and discussed with clinicians and other staff. It is hoped that awareness of the most common barriers to contraceptive use among adolescent Hispanic patients was improved among clinicians in the clinic and that promotion of the workshop will be considered for other clinical sites. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 13 Lastly, evaluation for the dissemination of this project in a peer reviewed forum was done by obtaining approval to participate at the American College of Nurse Midwives regional meeting in April of 2017. A podium presentation at this event was evidence of successful completion of this goal. Implementation and Evaluation Table Objective Implementation Identify barriers that prevent Submitted application to Hispanic teens from using Institutional Review Board birth control to avoid (IRB) for approval of project unintended pregnancies implementation Evaluation IRB approval granted Clinicians at the community Common barriers to health center were asked to contraceptive use were identify Hispanic adolescents, identified and documented ages 15-17, and request for them complete a short, anonymous questionnaire. These questionnaires were given during routine, health maintenance visits and assessed for birth control use, barriers to initiation of contraception, and interest in KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 14 learning more about birth control options and pregnancy prevention Implement an evidence-based Participants who expressed Participants were given a pre- educational program to their interest in learning more and post-test in order to enhance participants' about birth control and evaluate their knowledge of knowledge regarding safe sex pregnancy prevention were contraceptive methods before practices and birth control invited to attend a one hour and after attending the options and availability contraceptive workshop. This workshop workshop focused on the proper use, efficacy, and availability of each method as well as community resources through which to access contraceptives. Share DNP project results Requested approval to attend Approval for presentation was with clinicians and staff to a clinic meeting and present granted increase understanding of information regarding common barriers preventing barriers to birth control use Presented information at a their patients from using and results from provider meeting during the contraception contraception workshop month of April, 2017 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 15 Present project outcomes in a Submitted an abstract in Acceptance was granted to peer-reviewed forum consideration to disseminate participate in this event and project outcomes at the project outcomes were American College of Nurse- successfully disseminated by Midwives regional meeting means of a podium presentation Results A total of 32 participants completed the anonymous questionnaire (25 females and 7 males). Results indicated that 13 of these adolescents were already using contraception while the remaining 19 were not. The most common barriers to contraceptive use identified by these questionnaires were "being too embarrassed to request and discuss information regarding birth control methods" and "not being sexually active". Other, less common barriers identified included "being unsure where to obtain contraception", "concerns regarding side effects", and "cultural or religious beliefs". None of the participants reported "affordability" or "lack of partner support" as reasons for not using contraception at the time (see appendix D). From the 32 participants who completed the anonymous questionnaire, 11 demonstrated interest in learning more about contraception and nine chose to participate in the contraceptive workshop. All of the adolescents who participated in the class were female. None of the males who filled out the questionnaire attended the workshop. There were a total of 3 classes offered throughout the implementation of this project. A pre- and post-test were offered at the beginning and at the end of each class. The average pre-test score was 63% while the average post-test score was 91% (See appendix D). KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 16 Over one third of the adolescents who completed the anonymous questionnaire were already using contraception. This suggests that there is appropriate availability of resources and information in this particular setting. However, since a large portion of the teens reported feeling too embarrassed to discuss contraception with others, availability of information and resources alone may not be enough to promote the use of birth control. These data support the notion that clinicians should initiate the discussion during office visits in order to allow patients to ask questions and obtain clinically accurate information that they can then use to prevent unintended pregnancies for themselves. The most common reported reason for not using contraception was "sexual inactivity". This would suggest that a large number of teens in this setting are delaying sexual debut until late adolescents or early adulthood. While these individuals may not be faced imminent risk for unintended pregnancy, they may still benefit from learning more about contraception and pregnancy prevention. Doing so will allow them to make informed decisions and avoid unintended pregnancies later in life. It is also important to point out that none of the male participants who completed the questionnaire demonstrated interest in attending the contraceptive workshop. Whether it be due to personal views or cultural beliefs, these results suggest that contraceptive use continues to be perceived as a woman's responsibility and, therefore, men do not feel as motivated to learn more about birth control options and their proper use. Clinicians should provide information regarding contraceptive methods to all of their adolescent patients, male and female, even if they report not being sexually active. At the same time, health care providers should ensure that these patients understand that pregnancy prevention is a shared responsibility and that basic knowledge of birth control options is of vital KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 17 importance for decreasing the risk of unintended pregnancies. Furthermore, patients should be educated regarding information and resource availability and reassured that the clinical setting is a "no-judgment" zone where sexuality and other similar topics can be discussed openly and safely. The contraceptive workshop implemented with this scholarly project demonstrated a significant improvement in participants' knowledge of birth control options. This suggests that similar contraceptive workshops could prove to be effective educational interventions in other primary care settings. However, due to the small sample size recruited for this project, these results cannot be generalized to other populations. Recommendations for the Future Due to the constraints of a semester and unforeseen delay in IRB approval to begin this project, the time for recruitment and implementation was limited. A larger study, with more participants studied over a longer period of time may have yielded different results. At the same time, it could have been beneficial to include a wider age range for participants as 15-17 year olds may not accurately represent all adolescents. While group classes demonstrated improvement in contraceptive knowledge, individualized interventions may prove to be just as effective and significantly easier to arrange and schedule. Clinicians should consider offering structured and scheduled contraceptive visits wherein adolescents would learn about and discuss contraceptive methods as well as obtain the method of their choice before leaving the clinic. This would avoid delay in initiating contraception and reduce the period of vulnerability during which unintended pregnancy might occur. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 18 Essentials of Doctoral Education for Advanced Nursing Practice This scholarly project addressed three of the eight DNP essentials set forth by the American Association of Colleges of Nursing (AACN) for doctoral education of advanced practice nurses (AACN, 2006). The purpose of these essentials is to promote leadership, scholarships, and expertise in clinical practice, professional collaboration, and policy making (AACN, 2006). Essential II: Organizational and Systems Leadership for Quality Improvement of Systems Thinking An important element of the advanced practice nurse role involves being a leader as well as identifying and addressing areas that must be improved in order to promote population wellness. This scholarly project addresses this DNP essential by identifying a need or gap in evidence, which in the case of this project addressed barriers to contraceptive use among Hispanic adolescents through the implementation of an intervention that aimed at improving the health outcomes for this population. Essential VI: Inter-professional Collaboration for Improving Patient and Population Outcomes. Another important part of being a doctoral-prepared APRN includes collaboration with other members of the medical team to provide holistic care to all patients. In order to address this essential, this project will promote collaboration among health care providers at a local community health center in order to identify patients that could benefit from participating in a contraceptive workshop. At the same time, clinicians will gain knowledge that may improve contraceptive care and teen pregnancy prevention in sexually active teens who are seen as patients in the clinic. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 19 Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health Doctor of Nursing Practice essential VII will support this project as it focuses on prevention and health promotion as a way to improve health among populations. This is accomplished by improving teens' self-agency through risk identification and provision of an educational intervention regarding contraceptive methods in an effort to increase their access to and use of family planning methods. Prevention of pregnancy in high risk Hispanic teens will improve long term health outcomes in this population. Conclusions It is important for clinicians to assess for barriers to contraceptive use among Hispanic adolescents as they are at increased risk for unintended pregnancies, not only locally but nationally. Once these barriers have been identified, protocols should be put into place to provide appropriate education and resources in an effort to promote contraceptive use, improve access to contraception, and initiate these methods in a timely manner, thus reducing teen pregnancies in this high risk population. A contraceptive workshop can be a simple and effective intervention to carry out this goal. However, clinicians should not limit themselves to workshops or group classes but should also consider individual contraceptive health encounters focused on identifying contraceptive knowledge and needs, improving access to contraception, and providing follow up to ensure its consistent use. KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 20 References American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf Aparicio, E., Pecukonis, E. V., & Zhou, K. (2014). Sociocultural factors of teenage pregnancy in Latino communities: Preparing social workers for culturally responsive practice. Health & Social Work, 39(4), 238-243 6p. doi:hsw/hlu032 Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. (2015). Preventing unintended pregnancy: The contraceptive CHOICE project in review. Journal of Women's Health (15409996), 24(5), 349-353 5p. doi:10.1089/jwh.2015.5191 Bouris, A., Guilamo-Ramos, V., Cherry, K., Dittus, P., Michael, S., & Gloppen, K. (2012). Preventing rapid repeat births among Latina adolescents: The role of parents. American Journal of Public Health, 102(10), 1842-1847 6p. doi:10.2105/AJPH.2011.300578 Danawi, H., Bryant, Z., & Hasbini, T. (2016). Targeting unintended teen pregnancy in the U.S. International Journal of Childbirth Education, 31(1), 28-31 4p. Dogan-Ates, A., & Carrion-Basham, C. (2007). Teenage pregnancy among Latinas. Examining risk and protective factors. Hispanic Journal of Behavioral Sciences, 29(4), 554-569 16p. Kirven, J. (2014). Maintaining their future after teen pregnancy: Strategies for staying physically and mentally fit. International Journal of Childbirth Education, 29(1), 57-61 5p. National Campaign to Prevent Teen and Unplanned Pregnancy (2017). Counting it up: The public costs of teen childbearing. Retrieved from https://thenationalcampaign.org/why-itmatters/public-cost KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 21 Patel, P., & Sen, B. (2012). Teen motherhood and long-term health consequences. Maternal & child health journal, 16(5), 1063-1071 9p. doi:10.1007/s10995-011-0829-2 Public Health Indicator Based Information System (2016a). Health indicator report of adolescent births. Retrieved from https://ibis.health.utah.gov/indicator/view/AdoBrth.Race.html Public Health Indicator Based Information System (2016b). Health indicator report of Utah population characteristics: Poverty, all persons. Retrieved from https://ibis.health.utah.gov/indicator/view/Pov.SA.html Sagar, P. (2012). Transcultural nursing theory and models. New York City, New York: Springer Publishing Company KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix A 22 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Background  The United States has seen a reduction in teen pregnancy rates over the past 6 years  34.2 per 1,000 in 2010 vs. 24.2 per 1,000 in 2014  This trend has also been seen in the state of Utah  27.9 per 1,000 in 2010 vs. 19.5 per 1,000 in 2014  U.S. teen pregnancy rates are two times higher than Canada's  U.S. teen pregnancy rates are ten times higher than Switzerland's (Public Health Indicator Based Information System, 2016a; Dogan-ates & CarrisonBasham, 2007) 23 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Significance & Policy Implications  Increasing knowledge regarding contraception will help prevent teen pregnancy and the physical, emotional, social, and financial implications associated with it  By identifying barriers to utilizing birth control, health care providers will be better able to educate their patients and improve access to family planning services and resources  Reducing teen pregnancy rates will decrease Medicaid/government funds utilization and overall burden on the health care system (Dogan-Ates & Carrison-Basham, 2007) 24 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Theoretical Framework  Transcultural Nursing Theory  Understanding how cultural differences in beliefs and values affect the way in which individuals behave and interact with others in their environment  Hispanic culture and initiation of sexual activity, education received from parents/family, and barriers to receiving information and contraception  This information will help guide interventions that are appropriate and specific for this population (Sagar, 2012) 25 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 26 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 27 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 28 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 29 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix B 30 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 31 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 32 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 33 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix C 34 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 35 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 36 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 37 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX 38 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix D 39 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix E 40 KNOWLEDGE OF CONTRACEPTION AND SAFE SEX Appendix F 41