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Brindis, C.D. (2009). Journal of Adolescent Health,, 32S:79–90

Brindis, C.D. (2009). Journal of Adolescent Health,, 32S:79–90

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Meeting the Reproductive Health Care Needs ofAdolescents: California’s Family Planning Access,Care, and Treatment Program
To examine the effect of the California Officeof Family Planning’s Family Access, Care, and TreatmentProgram (Family PACT), which was established in 1997to provide comprehensive, reproductive health servicesfor low-income adolescents and adults. Program evalua-tion was used to measure access to services, develop aprofile of users, identify service utilization patterns, andassess the sensitivity of the health care system to theneeds of adolescents.
Data sources include baseline data on Cali-fornia’s previously established family planning services,enrollment, and claims data for the first 4 years of FamilyPACT, client exit interviews, and on-site observations.
Adolescents represented 21% of all clientsserved by Family PACT in fiscal year 2000–2001 (FY2000–2001). Adolescent clients served increased from100,000 in FY 1995–1996 to more than 260,000 in FY2000–2001(161% increase). The proportion of males hasincreased from 1% to 11%. In FY 2000–2001, Hispanicscomprised 50% of adolescent clients, followed by 32%white, 9% African-American, and 6% Asian, Filipino, orPacific Islander. Over one-half were aged 18 or 19 years,42% were aged 15 to 17 years, and 5% were aged youngerthan 15 years. Contraceptive methods most often dis-pensed were barrier methods (55% for females, 72% formales), oral contraceptives (44%), contraceptive injec-tions (16%), and emergency contraceptives (7%); 57%received sexually transmitted infection screening.
By linking eligibility determination tothe delivery of services, removing cost barriers, increas-ing the numbers and types of providers offering publiclyfunded services, and ensuring confidentiality, greaternumbers of adolescents obtained needed reproductivehealth care, thus ensuring an opportunity to reduceunintended pregnancies and sexually transmittedinfections. ©
Society for Adolescent Medicine, 2003
Adolescent reproductive health servicesConfidentialityPublicly funded family planning services
Over the past decade, the United States has experi-enced rapid declines in adolescent pregnancy, reach-ing its lowest rates since initially recorded in 1975.This decline was from 117 in 1985 to 94 pregnanciesper 1000 females aged 15 to 19 years in 1997, repre-senting a 19% reduction[1].A parallel trend has beendocumented for the U.S. teen birth rate, which in-creased from 51.0 births per 1000 teens in 1985 to 62.1in 1991[2].However, throughout the 1990s, the teenbirth rate declined steadily, falling to a record low of45.9 births (preliminary data) per 1000 teens in 2001[3].Although the United States continues to have oneof the highest adolescent pregnancy rates comparedwith those of other industrialized countries, severalsignificant factors appear to have contributed to thedecline in teenage pregnancy and births: delayedsexual activity, more conservative attitudes among
From the Center for Reproductive Health Research and PolicyStudies, University of California, San Francisco, CaliforniaAddress correspondence to: Claire D. Brindis, Dr.P.H., University of California San Francisco, 3333 California Street, Suite 265, San Fran-cisco, CA 94143-0936.Manuscript accepted February 19, 2003.
© Society for Adolescent Medicine, 2003 1054-139X/03/$see front matterPublished by Elsevier Inc., 360 Park Avenue South, New York, NY 10010 doi:10.1016/S1054-139X(03)00065-X
adolescents about casual sex and out-of-wedlockchildbearing; fear of sexually transmitted infections(STIs), especially acquired immunodeficiency syn-drome (AIDS); increased condom use especially atfirst intercourse; increased use of more effectivelong-acting hormonal birth control methods, espe-cially contraceptive injections; an emphasis on childsupport enforcement; and a stronger economy, withbetter job prospects for young people[4,5].Contin-ued reduction in adolescent pregnancy rates willrequire federal and state policies that promote ado-lescent pregnancy prevention messages, supportingresponsible sexual behaviors, along with access toconfidential reproductive health care.Over the past 30 years, states have expandedminors
authority to consent to health care, includingcare related to sexual activity[6].This policy recog-nizes that, although parental involvement is desir-able, many minors will remain sexually active butwill not seek services if parental consent is required[7].Thus, adolescents need to have the ability toreadily access available reproductive health servicesthrough a variety of channels[8].A recent studydocuments that most sexually active adolescent girlswould stop using all reproductive health services, ordelay testing and treatment for STIs and humanimmunodeficiency virus (HIV), if their parents wereinformed that they were seeking prescribed contra-ceptives[9].Furthermore, almost all the girls (99%), regardlessof all races and ages studied, reported that theywould remain sexually active, even if they stoppedusing the reproductive sexual health care servicesbecause of mandatory parental notification. Thelikely outcome of mandatory parental notification forprescribed contraceptives would be an increase inteen pregnancies and the spread of STIs[9].Thus,key to the continuation of promising trends in thereduction of too-early childbearing is the availabilityof federal- and state-subsidized confidential andcomprehensive reproductive health services to ado-lescents. Family planning providers are in a uniqueposition to offer education, counseling, and clinicalservices to help adolescents develop healthy relation-ships and make responsible decisions about theirhealth and well-being that will have a lasting effecton their lives.The State of California has a long and distin-guished history of providing comprehensive andconfidential family planning services to low-income,uninsured adolescents, women, and men of repro-ductive health age who are in need of care. From1974 to 1997, the Office of Family Planning (OFP) inthe California Department of Health Services (DHS)contracted annually with public and private, non-profit family planning agencies throughout the state.Under this Clinical Services Contract Program(CSCP), which was funded through a limited budgetfrom California
s General Fund, these agencies de-livered family planning services to low-incomewomen and men. By fiscal year (FY) 1995
1996, 142agencies with 450 sites participated in the CSCP, andfunding was capped at $47 million from the state
sgeneral fund[10].Client demand for services far outstripped thelimited funding available under CSCP. In an effort toincrease access to care, the California State Legisla-ture approved an expanded DHS family planninginitiative, the Family PACT (Planning Access, Care,and Treatment) Program, with phased-in implemen-tation beginning in January 1997[11].This innova-tive program represents the first effort in the countryto establish a legal entitlement to state-funded ser-vices and supplies for both female and male low-income residents[11].The new program was devel-oped in collaboration with a number of stakeholdergroups, including the American College of Obstetricsand Gynecology, the California Academy of FamilyPhysicians, the California Family Health Council, theCalifornia Medical Association, the California Pri-mary Care Association, the California Women
s andChildren
s Health Coalition, the Planned ParenthoodAffiliates of California, and a number of CSCP con-tractors[10].Family PACT is administered by DHS/OFP, re-sponsible for program policy (including determina-tion of the scope of services), program monitoring,quality improvement, and evaluation. Program mon-itoring and evaluation of the Family PACT programare currently conducted by the Center for Reproduc-tive Health Research and Policy in the Department ofObstetrics, Gynecology, and Reproductive HealthSciences and the Institute for Health Policy Studies,University of California, San Francisco, under aninteragency agreement with DHS/OFP.Family PACT is designed to improve access tocomprehensive family planning reproductive healthservices by removing cost barriers, increasing thetypes and numbers of providers, and ensuring con-fidentiality. Confidential, comprehensive servicesare provided to adolescents at no cost and withoutparental consent. Eligibility for adolescents is basedon personal income and health insurance, not par-ents
income or insurance coverage. Furthermore,clinics can also apply for separate funding for theTeenSmart program that operates in more than 50
family planning agencies throughout California, en-abling them to provide more in-depth counselingservices to adolescent clients.In addition, direct marketing to adolescents incounties with high pregnancy rates, notably the
sUp to Me
multimedia campaign (which includes atoll-free telephone number to facilitate setting upgeographically convenient appointments), increasesawareness about teen pregnancy prevention for bothteenagers and their families. Incorporating thesetypes of strategies is especially important becauseadolescents have unique characteristics that placethem at heightened risk of unintended pregnancyand STIs. In addition to confidentiality concerns,adolescents often have difficulty accessing servicesowing to costs, lack of transportation, and a lack ofknowledge about where to obtain services[8,12].Compared with adults, adolescents often need addi-tional time for counseling and education; may bemore fearful of pelvic examinations, blood tests, andthe side effects of birth control; and may be less likelyto follow up on referrals[8,12].In the followingsection, we present background information on theFamily PACT program.
Ensuring that high-quality family planning servicesare available to meet the needs of California
s low-income citizens is a public health priority, as well asan important contribution to meeting personal healthneeds. Over the next three decades, California
spopulation is expected to grow by 55% (from 33million to more than 51 million), a rate of growthhigher than that of any other state[13].Fueling thisincrease is a 34% increase in the number of adoles-cents aged 10 to 19 years between the years 1995 and2005[14].Although some of this population increasewill result from immigration, most of it will be owingto births to California residents. Many of the ex-pected births will occur among the state
s poorestwomen: teenagers and women with family incomesat or below 200% of the federal poverty level. Thisgroup makes up 38% of California
s women ofreproductive age but accounts for nearly two-thirdsof California
s births[15].Although some low-income women can receivefamily planning services through Medi-Cal (thestate
s Medicaid program), many other low-incomewomen cannot access or do not qualify for thiscoverage and, thus, face significant financial barrierswhen they attempt to obtain such services. Adoles-cents face an even greater array of barriers to suchservices. In addition to unintended pregnancies, mil-lions more experience STIs. In California, STIs con-stitute two-thirds of the communicable disease re-ported, and the state
s adolescent population isparticularly affected, because approximately 35% ofchlamydial infections occur among adolescents[16].In response to this epidemic, Family PACT hasredesigned its benefits package to include a newarray of STI-related services.In an effort to increase access to family planningreproductive health services beyond the limitationsof the CSCP, the Family PACT program was devel-oped and implemented in 1997. Eligible clients in-clude all persons residing in California who have anincome at or below 200% of the federal poverty level,are at risk of pregnancy or causing pregnancy, andhave no other source of health care coverage forconfidential family planning services. Adolescentsare considered a family of one and have the legalright to consent to their own reproductive healthservices.Family PACT differs from its predecessor in sev-eral key respects. First, the provider base has beensignificantly expanded to include private providers,pharmacies, and laboratories. Before 1997, Califor-nia
s family planning program included publiclyfunded providers, such as county health depart-ments, and private, nonprofit providers, such ascommunity clinics and Planned Parenthood clinics.In 1997, Family PACT also invited private, for-profitproviders, that were already Medi-Cal providers, toparticipate in the Family PACT program. Pharma-cies, as well as clinics, are distribution sites forover-the-counter and prescription drugs and contra-ceptive supplies. As a result of these changes, thenumber of providers participating in the state familyplanning program expanded from approximately450 clinic sites under CSCP in FY 1995
1996 to 1432in Family PACT in FY 1997
1998 and 1929 in FY2000
2001. A 5-year Medicaid 1115b Waiver Dem-onstration Project allocating matching funds for fam-ily planning services was approved in December1999 by the federal Health Care Financing Adminis-tration, now known as the Center for Medicare andMedicaid Services. As part of the demonstrationproject, OFP has the opportunity to demonstrate theeffect of this California model on three hard to reachpopulations: adolescent women, low-income men,and low-income women living in areas of highunmet need.Second, client eligibility determination and enroll-ment occur at point of service, designed to reduce

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