Section 2- Literature Review and Problem Statement *Synthesis of Peer-Reviewed Scholarly Resources In the United States, teen pregnancy rates declined nine percent from 2013 to 2013 but adolescent teen pregnancy is still a pressing public health issue. A synthesis of the literature reflects the differences in state policies and the effect of funding on reproduction and sexual education and the availability of family planning and abortion services (Beltz, Sacks, Moore & Terzian, 2015). An overview of recent research and theory concerning adolescent sexual and reproductive health suggests that public health leaders implement evidence-based teen pregnancy prevention initiatives that expand access to low-cost or free contraception and family planning services and educational and media campaigns that promote safe sexual activity (Thomas, 2012). Thomas (2012) indicates that new research has shown that efforts made by public health leadership to expand rather than limit teen pregnancy prevention policies, on a state and federal level, could produce economic savings to taxpayers. A review of the literature also suggest a need for extensive social research to examine the deficiencies in state-level policies that may restrict access to abortion services, public assistance benefits and contraceptive and reproductive care for sexually active adolescents and use the data gathered to support policy-level changes (Thomas, 2012). Santelli, Lindbergh, Fine & Singh (2007) examined the effect of the overall effectiveness of contraceptive use among sexually active adolescents as the primary determinant of declining teen pregnancy rates. The authors note that the call for abstinence-only education programs supported by leaders from the federal government has increased since 1998, even though there is a deficient lack of evidence-based research support for abstinence –based programs for reproductive and sexual health for adolescents (Santelli et al., 2007). Based on their study, using an overall pregnancy risk index and the combined impact of changes in adolescent sexual activity and effective contraception use, the author’s findings showed a large decline in pregnancy risk among 15 to 17 year olds, from 9.7 to 4.4 from 1995 to 2002 (Santelli et al., 2007). The authors also suggested that public health leadership in the United States that promotes abstinence-based education as the primary strategy to delay initiation of sexual activity, prevent teen pregnancy, and sexually transmitted illness (STIs) as a failure and ineffective (Santelli et al., 2007). Other literature reviews recommend public health leaders look to identify changes in adolescent’s sexual behavior that may provide insight and an understanding of the social forces, which influence behavior and motivation in the use or non-use of contraception (Kraft et al., 2010). Overall, public policy recommendations for pregnancy prevent.

1. Section 2- Literature Review and Problem Statement
*Synthesis of Peer-Reviewed Scholarly Resources
In the United States, teen pregnancy rates declined nine percent
from 2013 to 2013 but
adolescent teen pregnancy is still a pressing public health issue.
A synthesis of the literature
reflects the differences in state policies and the effect of
funding on reproduction and sexual
education and the availability of family planning and abortion
services (Beltz, Sacks, Moore &
Terzian, 2015). An overview of recent research and theory
concerning adolescent sexual and
reproductive health suggests that public health leaders
implement evidence-based teen pregnancy
prevention initiatives that expand access to low-cost or free
contraception and family planning
services and educational and media campaigns that promote safe
sexual activity (Thomas, 2012).
Thomas (2012) indicates that new research has shown that
efforts made by public health
leadership to expand rather than limit teen pregnancy

2. prevention policies, on a state and federal
level, could produce economic savings to taxpayers. A review
of the literature also suggest a
need for extensive social research to examine the deficiencies in
state-level policies that may
restrict access to abortion services, public assistance benefits
and contraceptive and reproductive
care for sexually active adolescents and use the data gathered to
support policy-level changes
(Thomas, 2012).
Santelli, Lindbergh, Fine & Singh (2007) examined the effect
of the overall effectiveness
of contraceptive use among sexually active adolescents as the
primary determinant of declining
teen pregnancy rates. The authors note that the call for
abstinence-only education programs
supported by leaders from the federal government has increased
since 1998, even though there is
a deficient lack of evidence-based research support for
abstinence –based programs for
reproductive and sexual health for adolescents (Santelli et al.,
2007). Based on their study, using
an overall pregnancy risk index and the combined impact of
changes in adolescent sexual

3. activity and effective contraception use, the author’s findings
showed a large decline in
pregnancy risk among 15 to 17 year olds, from 9.7 to 4.4 from
1995 to 2002 (Santelli et al.,
2007). The authors also suggested that public health leadership
in the United States that
promotes abstinence-based education as the primary strategy to
delay initiation of sexual
activity, prevent teen pregnancy, and sexually transmitted
illness (STIs) as a failure and
ineffective (Santelli et al., 2007).
Other literature reviews recommend public health leaders look
to identify changes in
adolescent’s sexual behavior that may provide insight and an
understanding of the social forces,
which influence behavior and motivation in the use or non-use
of contraception (Kraft et al.,
2010). Overall, public policy recommendations for pregnancy
prevention initiatives should be
comprehensive and promote the expansion of educational and
informational resources on
contraception and sexual behavior, support expanded available

4. and accessible effective
contraceptive supplies and resources and strengthen the value of
empowering adolescents to
make decisions, that increase safe sex options to decrease
unintended pregnancy and risk of STIs
(Kraft et al., 2010).
A review of scientific research has also shown that the use of
long-acting reversible
contraception (LARC) such as intrauterine devices and
subdermal implants are more effective,
reliable and user-friendly than user-dependent methods,
condoms and oral contraception
(Manlove, Karpilow, Welti, & Thomas, 2016). Use of LARC has
led to an 86% reduction rate in
adolescent pregnancy birth rates between 1995 and 2002
(Manlove et al., 2016). The authors
provided data to show the increased efficacy with LARC and
increased condom use and
utilization of hormonal methods such as the pill, patch and ring
for sexually active adolescents
(Manlove et. al, 2016).
Adolescents have faced obstacles when seeking to utilize

5. reproductive health services in
the United States, including limited access to confidential
reproductive health services,
contraceptive supply, and cost of contraception (Miller et al.,
2014). Reproductive and sexual
health services has been an issue of debate between federal and
national leaders, some in support
of abstinence-based education programs and others for
expanded reproductive and contraceptive
services for teens that promote autonomy and protect
confidential rights for adolescents
(Philliber, 2015). Using a situational leadership approach to
pregnancy prevention, leadership on
a national and state level, should support policies that provide
for the increased use of low-cost
and free LARC and publicly funded government based insurance
and family planning services in
schools and community health organizations across states
(Miller et al., 2014). The creation of
the Teen Pregnancy Prevention Program in 2004 by the Office
of Adolescent Health (OAH) and
federal funds in 2010, has been an important contribution to
increase awareness using a national
campaign to implement support for teen pregnancy prevention

6. initiatives (Philliber, 2015).
Under President Obama’s administration, the Patient Protection
and Affordable Care Act
of 2010, provides all Federal Drug Administration (FDA) -
approved contraceptive methods
without cost (Peipert, Madden, Allsworth, & Secura, 2012).
Challenges to the federal legislation,
have been seen in both federal and state courts by business and
religious organizations opposed
to mandates to pay for contraceptive services and supply
(Eisenberg, McNicholas, & Peipert,
2013). Despite the legal and political barriers, the Federal Drug
Administration (FDA) gave
approval for over-the-counter sales of the emergency
contraception pill (ECP) without a
prescription and purchase without age restrictions in 2009 and
in 2013 (Upadhya, 2013). Even
with a decline in adolescent pregnancy rates, public health
leaders should continue to implement
teen pregnancy prevention programs and policies that fund
community-based programs and other
public health organizations (Kearney & Levine, 2015). Effective
transformational leadership is

7. needed to promote access to confidential reproductive and
contraceptive services, education and
resources that motivate and support strategies for long-term
sexual behavior and activity change
in contraceptive use, and counseling for STI and HIV screening
and treatment (Kearney &
Levine, 2015).
*Description of Theoretical Gaps in the Research
Several studies have shown that teen pregnancy prevention
programs are more effective
when public health leaders and strategic partners, which include
health care providers, teachers
and parents and policy advocate collectively, to promote
policies that implement reproductive
services and contraceptive resources to make a positive impact
on the reduction of adolescent
pregnancy (Aaro et al., 2014). Leaders that use a theoretical
approach to understand social and
behavioral cognition, specifically in the development of
interventions that motivate and empower
teens, can increase positive sexual and reproductive health
outcomes among adolescents and are
more effective as predictors of sexual behavior and sexual

8. decision-making (Aaro et al., 2014).
Brindis, Sattley, and Mammo (2005) expressed a need for a
strategic approach to teen pregnancy
prevention, which included abstinence counseling,
contraception education, access to adolescent
family-planning clinics, and programs that incorporate youth
mentorships and volunteer
opportunities. The authors supported the use for further
exploration of theoretical applications
and frameworks to provide a comprehensive evaluation and
development of effective teen
reproductive health initiatives. According to Brindis et al
(2005), there has been limited
exploration of program strategies to determine the impact of
factors that influence adolescent
behavior, self-esteem and motivation to use contraception or
delay sexual activity. The authors
also note the lack of research studies which examine the
application of theoretical frameworks to
support the complexities of teen pregnancy and reproductive
health (Brindis et al., 2005).
Gottschalk and Ortayli (2014) reported that recent literature
reviews did not adequately

9. capture effective contraceptive service initiatives and
prevention interventions, especially in low
and middle-income countries. The authors provided
recommendations for intervention programs
and identified gaps in the evidence-base to guide future studies
(Gottschalk & Ortayli, 2014).
The authors reported that both user-sided and provider-sider
interventions that targeted both
adolescent behavior and change and the service delivery system
that includes training for
providers to provide effective contraception counseling and
making contraceptive free for
adolescents, could improve adolescent’s use of contraception,
knowledge and attitudes, and
access to contraceptives (Gottschalk & Ortayli, 2014).
Aiken, Gold & Parker (2005) also conducted research to
compare attitudes, perception
and awareness about EC use in adolescent females and found
that provider training and
education to increase awareness about EC, could lead to a
positive changes in attitudes and use
in young women in 2002. Similar studies about the use of EC
among adolescents has shown that

10. easier access to EC, lower cost and increased knowledge can
lead to higher utilization of EC to
reduce unintended teen pregnancy (Alford et al., 2010). Barriers
to adolescent use of EC are cost,
lack of provider confidentiality, and lack of insurance to defray
the cost for male and females
seeking EC (Johnson, Nye, & Cohall, 2010). Overall, gaps in
evidence-based research show the
need to identify approaches that are adaptive and effective for
reaching sexually active
adolescents and that successfully address how to provide
reliable contraceptive methods,
counseling and education (Gottschalk & Ortayli, 2014).
Problem Statement
*Explanation of the specific problem that addresses identified
gaps within
the literature
In the United States, the cost of adolescent pregnancy in 2010,
accounted for an estimated
9.4 billion dollars in public health expenditures related to foster
care, low education and

11. socioeconomic status and health care costs (Centers for Disease
Control and Prevention [CDC],
2016). In 2014, adolescent females, aged 15-19 years, gave
birth to 249.078 babies for a birth
rate of 24.2 per 1,000 women (CDC, 2016). Although birth rates
for 15-19 year olds dropped to
9%, the birthrate for adolescent females is still higher than
other developed counties with noted
racial/ethnic and geographical disparities (CDC, 2016). The
CDC (2016) cites that non-Hispanic
blacks and Hispanic teen birth rates in 2014, were still more
than two times higher than the
birthrates for non-Hispanic white teens. Each year, birthrates
show geographical differences
within and across states with the unintended and highest rates
seen amongst women with low
socioeconomic status, lower levels of education, and
adolescents in the foster care system (CDC,
2016).
Studies that show states that show support for public health
policies that promote access
to reproductive and contraceptive services, education and birth
control methods for adolescents

12. are associated with lower teen birth rates (Manlove et al.,
2016). Evidence has shown that the
provision and use of LARC methods has been cost-effective,
user-friendly, and consistent with a
less than 1% typical-use failure rate that can assist in the
reduction of unintended teen pregnancy
(Modi et al., 2013). A literature review has also demonstrated
the emphasis for effective public
health leadership to advocate for legislation and intervention
programs to provide increased
public health funding for education, reproductive health
counseling, and publicly funded
government insurance-based and family-planning programs
(Peipert et al., 2012).
*Explanation of how the problem statement incorporates
implications for positive social
change
There are notable differences in how state policies can
influence trends in teen birth rates
based on reported data, availability of reproductive and abortion
services, and the amount of
public health funds available for education and impact the
delivery of adolescent reproductive

13. and family-planning services and the gap that exists in the
approach to making effective wide-
spread social change (American Congress of Obstetricians and
Gynecologists [ACOG], 2015).
Evidence –based research methodology has shown the need for
effective leadership strategies to
use both behavioral and social cognitive theories along with
concrete intervention modalities that
include education, counseling and the provision of trained
health care providers and access to
effective birth control methods to reduce teen pregnancy
(Gottschalk & Ortayli, 2014).
Leadership that seeks to develop and expand policies and
programs to support adolescent
reproductive and sexual health could impact positive social
change by transforming the social
norms of acceptance for risky teen sexual behavior and
practices (Ott, 2014). The implications
for social change could result in an increased adoption of free
or low-cost programs that build
motivation, empowerment and decision-making skills to help
assist teens make better
reproductive health choices and increase utilization of effective
birth control methods to (Ott,

14. 2014). Current public health policy should be expanded to
reduce eligibility for Medicaid family-
planning eligibility for healthcare providers to provide no-cost
or free contraception such as
LARC. Overall, public health leaders should be agents for
social change by acknowledging the
need for adolescent’s autonomy for reproductive health care,
provide confidential and balanced
sexual health care education, and continuing to expand
advocacy and policy initiatives that
increase funding for access to education and contraceptive
services to reduce unintended teen
pregnancy (Ott, 2014).