Teen Options to Prevent Pregnancy (TOPP)
A nurse-delivered intervention intended to reduce rapid repeat pregnancies and sexual risk behavior among low-income, pregnant, and postpartum adolescent females using motivational interviewing techniques with contraceptive access.
Program Outcomes
- Sexual Risk Behaviors
- Teen Pregnancy
Program Type
- Counseling and Social Work
Program Setting
- Hospital/Medical Center
- Home
Continuum of Intervention
- Indicated Prevention
Age
- Late Adolescence (15-18) - High School
- Early Adolescence (12-14) - Middle School
- Late Childhood (5-11) - K/Elementary
Gender
- Female
Race/Ethnicity
- All
Endorsements
Blueprints: Promising
Program Information Contact
For curriculum and additional program information:
ETR
500 Westridge Drive, Suite 102
Watsonville, CA 95076
Tel : (800) 321-4407
Main Website: https://www.etr.org/
Program Website: https://www.etr.org/store/curricula/topp/
For training:
Gary Stofle, LISW-S, LICDC-CS, BCD
MINT Trainer
https://stofle.com/
Program Developer/Owner
Jack Stevens, Ph.D.
Nationwide Children's Hospital and Ohio State University Dept Pediatrics
Brief Description of the Program
This 18-month intervention is designed to reduce teen pregnancy and sexual risk behaviors with motivational interviewing, access to contraception, and social assistance. Pregnant or newly postpartum adolescent females receive monthly check-ins with registered nurses in addition to access to a part-time contraceptive clinic, transportation assistance, and social worker assistance.
This 18-month intervention is designed to reduce teen pregnancy and sexual risk behaviors with motivational interviewing, access to contraception, and social assistance. Pregnant or newly postpartum adolescent females receive monthly check-ins with registered nurses in addition to access to a part-time contraceptive clinic, transportation assistance, and social worker assistance.
Registered nurses use motivational interviewing during participant check-ins, which occur via telephone monthly and more often during initial months of pregnancy/postpartum or if a participant is actively seeking and adopting new forms of birth control. In these check-ins nurses help participants discuss past experiences with and beliefs about contraception and pregnancy, provide individualized education about birth control options (including abstinence) based on a participant's preferences, and guide interested participants toward effective contraception. Participants can also discuss relationship and diverse health issues with nurses during these interactions. To increase awareness of the types of contraceptive methods and services available, nurse educators plan at least one in-person visit with participants during which they use a "contraceptive bag" to educate participants on contraceptive options.
A specialized part-time contraceptive clinic is available to participants who are not already affiliated with another physician or who are struggling to receive timely or effective contraceptive care from that physician. Each FDA-approved method of contraception is available anytime postpartum, and condoms are regularly distributed (both at the clinic and in the home) to protect against sexually transmitted infections.
Free transportation via a van driven by nurses is available round-trip for contraceptive care at any local provider, including but not limited to the TOPP clinic.
Finally, the program provides a social worker to conduct brief psychosocial assessments and make referrals for a wide variety of community-based services.
Outcomes
Primary Evidence Base for Certification
Rotz et al. (2016) and Stevens et al. (2017) found at posttest, compared to the control group, intervention group participants reported improvements in:
- Repeat pregnancy
- Unintended repeat pregnancy
- Repeat birth
- Unprotected vaginal intercourse
- Use of long-acting reversible contraception
- Use of effective birth control method
Brief Evaluation Methodology
Primary Evidence Base for Certification
The one study Blueprints has reviewed meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). Smith et al. (2015), Rotz et al. (2016), and Stevens et al. (2017) conducted a randomized controlled trial in a large Midwestern city. Participants (n=598) were low-income adolescent females aged 10-19 who were either more than 28 weeks pregnant or within 9 weeks postpartum, and were recruited from obstetrics-gynecology clinics and the postpartum units of the local hospital system. Participants were randomly assigned to the intervention group or a usual care control group. Primary outcomes of interest included subsequent pregnancies and births as well as contraceptive use. Participants were assessed at 6 months (mid-intervention) and at 18 months (posttest) with no additional follow-up.
Study 1
Rotz, D., Luca, D. A., Goesling, B., Cook, E. Murphy, K., & Stevens, J. (2016) Final impacts of the Teen Options to Prevent Pregnancy Program. Washington, DC: U.S. Department of Health and Human Services, Office of Adolescent Health.
Smith, K., Rotz, D., Goesling, B., Cook, E., Murphy, K., & Stevens, J. (2015). Interim impacts of the Teen Options to Prevent Pregnancy Program. Princeton, NJ: Mathematica Policy Research.
Stevens, J., Lutz, R., Osuagwu, N., Rotz, D., & Goesling, B. (2017). A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. American Journal of Obstetrics & Gynecology, 17(4), 423.e1-423.e9.
Gender Specific Findings
- Female
Subgroup Analysis Details
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Study 1 (Rotz et al, 2016; Smith et al., 2015; Stevens et al., 2017) found subgroup effects by using a homogenous sample with all females and with 75% or more of economically disadvantaged participants eligible for SNAP or WIC.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
The sample for Study 1 was all female, 48% white, 36% Black, and 6% Hispanic with an additional 9% identifying as another race/ethnicity or multiracial.
Motivational Interviewing Network of Trainers (MINT) Training
A MINT trainer delivers an initial two-day minimum workshop and preferably six months to one year of coaching. The trainer should be up-to-date on the latest motivational interviewing standards of practice, including the teaching in the latest edition of Motivational Interviewing: Helping People Change.
The initial training covers core motivational interviewing principles:
- The Spirit of MI - Partnership, Acceptance, Compassion, Evocation
- OARS - Open-ended questions, Affirmations, Reflections, Summarizations
- The Four Processes - Engaging, Focusing, Evoking, Planning
- Dealing with sustain talk and discord
A variety of training methods are used, including videos, role/real plays, demonstrations, PowerPoint presentations, and basic guides for handouts. The role/real plays in conjunction with offering a variety of activities and exercises to involve the learner in actual practice of the skills being trained are extremely beneficial to the trainees.
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Start-Up Costs
Initial Training and Technical Assistance
Training and ongoing coaching in Motivational Interviewing with a MINT (Motivational Interviewing Network of Trainers) trainer is essential for implementing the TOPP program.
Primary training for TOPP (initial 2-day) and ongoing MI coaching is available from Gary Stofle, LISW-S, LICDC-CS, BCD, who worked with the original TOPP study. Visit https://stofle.com/ for more information and to directly negotiate training costs.
Additional MINT trainers may be found here: https://motivationalinterviewing.org/.
Curriculum and Materials
ETR (Education Training Research) provides the program toolkit/manual which includes a program overview, the TOPP logic model, a chapter on the pedagogy and enabling factors, information on curriculum and program components (including worksheets and patient screening tools), and fidelity guidelines. Included with the TOPP implementation manual are 50 copies of the Birth Control Facts brochure as well as a Birth Control Quick Guide for facilitators' use and information. Cost is $299.
Licensing
None.
Other Start-Up Costs
Access to a contraceptive clinic should be provided to participants who are not already affiliated with another physician or who are struggling to receive timely or effective contraceptive care from that physician.
Free roundtrip transportation via a van driven by nurses should be provided for contraceptive care at any local provider.
For participant phone calls, nurse educators need a recording device. Recorded interactions with participants will be reviewed by the MINT trainer for coaching purposes.
Intervention Implementation Costs
Ongoing Curriculum and Materials
No information is available
Staffing
Registered nurses (RNs) act as nurse educators conducting ongoing visits with participants for the duration of the program. RNs experienced with women's health are preferred as they can best assist participants by recognizing potential problems that can occur during prenatal and postpartum periods. RNs can also provide education on contraceptive methods and administer medications necessary for the clinic setting and in-home care. The nurses should be rigorously trained and receive coaching in Motivational Interviewing from a certified Motivational Interviewing Network Trainer. The maximum caseload for a full-time TOPP nurse is 40 to 60 participants.
Social workers conduct brief psychosocial assessments and make referrals for a wide variety of community-based services such as such as housing, employment, education, food, diapers, formula and household goods.
A board-certified obstetrician-gynecologist should be available two afternoons per week to provide contraceptive services solely to intervention group participants.
Other Implementation Costs
No information is available
Implementation Support and Fidelity Monitoring Costs
Ongoing Training and Technical Assistance
The motivational interviewing expert consultant conducts ongoing coaching and technical assistance around motivational interviewing, generally on a biweekly basis.
Optional trainings provided by ETR
ETR offers science-based training, technical assistance and consultation services to strengthen and support program implementation and sustainability.
Training of Educators (TOE): A professional learning process that builds the knowledge and skills required of adult learners to implement a program, curriculum (EBP), or strategy with fidelity and germane adaptations.
TOE Booster: Follow-up sessions intended to assist implementers with identifying and breaking through implementation barriers, strengthening implementation skills, and networking with colleagues through professional learning networks.
Program Enrichment Training: Tailored professional learning processes focused on topical areas found to be of greatest need during the implementation phase and intended to boost and support program success. Enrichment packages include virtual or in-person trainings on enrichment topics specific to site needs during the implementation phase.
Tailored Technical Assistance (TA)/Consultation: Tailored guidance to meet the specific needs of the site through collaborative communication between an ETR specialist and site staff. Assistance takes into account site-specific circumstances and culture and, depending on the complexity of the need, can be delivered during a one-time interaction or through a long-term consultancy.
Fidelity Monitoring and Evaluation
The TOPP program manual includes a Fidelity Toolkit.
The motivational interviewing expert consultant listens to audio recordings of nurse-participant interactions, codes for fidelity, and provides appropriate feedback based upon the fidelity assessments.
Ongoing License Fees
No information is available
Other Implementation Support and Fidelity Monitoring Costs
No information is available
Other Cost Considerations
No information is available
Year One Cost Example
No information is available
Program Developer/Owner
Jack Stevens, Ph.D.Nationwide Children's Hospital and Ohio State University Dept PediatricsJack.Stevens@nationwidechildrens.org
Program Outcomes
- Sexual Risk Behaviors
- Teen Pregnancy
Program Specifics
Program Type
- Counseling and Social Work
Program Setting
- Hospital/Medical Center
- Home
Continuum of Intervention
- Indicated Prevention
Program Goals
A nurse-delivered intervention intended to reduce rapid repeat pregnancies and sexual risk behavior among low-income, pregnant, and postpartum adolescent females using motivational interviewing techniques with contraceptive access.
Population Demographics
Adolescent females who are currently pregnant or recently gave birth.
Target Population
Age
- Late Adolescence (15-18) - High School
- Early Adolescence (12-14) - Middle School
- Late Childhood (5-11) - K/Elementary
Gender
- Female
Gender Specific Findings
- Female
Race/Ethnicity
- All
Subgroup Analysis Details
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Study 1 (Rotz et al, 2016; Smith et al., 2015; Stevens et al., 2017) found subgroup effects by using a homogenous sample with all females and with 75% or more of economically disadvantaged participants eligible for SNAP or WIC.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
The sample for Study 1 was all female, 48% white, 36% Black, and 6% Hispanic with an additional 9% identifying as another race/ethnicity or multiracial.
Other Risk and Protective Factors
Individual
- Knowledge of and access to contraceptives
Risk/Protective Factor Domain
- Individual
Risk/Protective Factors
Risk Factors
Protective Factors
*Risk/Protective Factor was significantly impacted by the program
See also: Teen Options to Prevent Pregnancy (TOPP) Logic Model (PDF)
Brief Description of the Program
This 18-month intervention is designed to reduce teen pregnancy and sexual risk behaviors with motivational interviewing, access to contraception, and social assistance. Pregnant or newly postpartum adolescent females receive monthly check-ins with registered nurses in addition to access to a part-time contraceptive clinic, transportation assistance, and social worker assistance.
Description of the Program
This 18-month intervention is designed to reduce teen pregnancy and sexual risk behaviors with motivational interviewing, access to contraception, and social assistance. Pregnant or newly postpartum adolescent females receive monthly check-ins with registered nurses in addition to access to a part-time contraceptive clinic, transportation assistance, and social worker assistance.
Registered nurses use motivational interviewing during participant check-ins, which occur via telephone monthly and more often during initial months of pregnancy/postpartum or if a participant is actively seeking and adopting new forms of birth control. In these check-ins nurses help participants discuss past experiences with and beliefs about contraception and pregnancy, provide individualized education about birth control options (including abstinence) based on a participant's preferences, and guide interested participants toward effective contraception. Participants can also discuss relationship and diverse health issues with nurses during these interactions. To increase awareness of the types of contraceptive methods and services available, nurse educators plan at least one in-person visit with participants during which they use a "contraceptive bag" to educate participants on contraceptive options.
A specialized part-time contraceptive clinic is available to participants who are not already affiliated with another physician or who are struggling to receive timely or effective contraceptive care from that physician. Each FDA-approved method of contraception is available anytime postpartum, and condoms are regularly distributed (both at the clinic and in the home) to protect against sexually transmitted infections.
Free transportation via a van driven by nurses is available round-trip for contraceptive care at any local provider, including but not limited to the TOPP clinic.
Finally, the program provides a social worker to conduct brief psychosocial assessments and make referrals for a wide variety of community-based services.
Theoretical Rationale
A substantial portion of teenage births are concentrated among low-income adolescent females with at least one child already. This program targets this high-risk group for increased contraceptive education and access. The program uses motivational interviewing with the belief that contraceptive behavior can be changed by equipping young women to make their own informed choices about birth control and pregnancy.
Brief Evaluation Methodology
Primary Evidence Base for Certification
The one study Blueprints has reviewed meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). Smith et al. (2015), Rotz et al. (2016), and Stevens et al. (2017) conducted a randomized controlled trial in a large Midwestern city. Participants (n=598) were low-income adolescent females aged 10-19 who were either more than 28 weeks pregnant or within 9 weeks postpartum, and were recruited from obstetrics-gynecology clinics and the postpartum units of the local hospital system. Participants were randomly assigned to the intervention group or a usual care control group. Primary outcomes of interest included subsequent pregnancies and births as well as contraceptive use. Participants were assessed at 6 months (mid-intervention) and at 18 months (posttest) with no additional follow-up.
Outcomes (Brief, over all studies)
Primary Evidence Base for Certification
Rotz et al. (2016) and Stevens et al. (2017) found at posttest, compared to the control group, intervention participants reported significantly higher use of long-acting reversible contraception, significantly higher use of an effective birth control method, and significantly lower rates of unprotected vaginal intercourse. Intervention group participants also reported significantly lower rates of repeat pregnancy, unintended repeat pregnancy, and repeat birth compared to control group participants.
Outcomes
Primary Evidence Base for Certification
Rotz et al. (2016) and Stevens et al. (2017) found at posttest, compared to the control group, intervention group participants reported improvements in:
- Repeat pregnancy
- Unintended repeat pregnancy
- Repeat birth
- Unprotected vaginal intercourse
- Use of long-acting reversible contraception
- Use of effective birth control method
Mediating Effects
Not examined.
Effect Size
Not presented.
Generalizability
One study meets Blueprints standards for high quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 1 (Rotz et al, 2016; Smith et al., 2015; Stevens et al., 2017). The sample included pregnant and postpartum low-income adolescent females in a large Midwestern city, in which the intervention group was compared to a usual-care control group.
Endorsements
Blueprints: Promising
Program Information Contact
For curriculum and additional program information:
ETR
500 Westridge Drive, Suite 102
Watsonville, CA 95076
Tel : (800) 321-4407
Main Website: https://www.etr.org/
Program Website: https://www.etr.org/store/curricula/topp/
For training:
Gary Stofle, LISW-S, LICDC-CS, BCD
MINT Trainer
https://stofle.com/
References
Study 1
Certified Rotz, D., Luca, D. A., Goesling, B., Cook, E. Murphy, K., & Stevens, J. (2016) Final impacts of the Teen Options to Prevent Pregnancy Program. Washington, DC: U.S. Department of Health and Human Services, Office of Adolescent Health.
Certified Smith, K., Rotz, D., Goesling, B., Cook, E., Murphy, K., & Stevens, J. (2015). Interim impacts of the Teen Options to Prevent Pregnancy Program. Princeton, NJ: Mathematica Policy Research.
Certified Stevens, J., Lutz, R., Osuagwu, N., Rotz, D., & Goesling, B. (2017). A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. American Journal of Obstetrics & Gynecology, 17(4), 423.e1-423.e9.
Study 1
Summary
Smith et al. (2015), Rotz et al. (2016), and Stevens et al. (2017) conducted a randomized controlled trial in a large Midwestern city with 598 adolescent females aged 10-19 who were either more than 28 weeks pregnant or within 9 weeks postpartum. Participants were randomly assigned to the intervention group or a usual care control group. Primary outcomes of interest included subsequent pregnancies and births as well as contraceptive use. Participants were assessed at 6 months (mid-intervention) and at 18 months (posttest) with no additional follow-up.
Rotz et al. (2016) and Stevens et al. (2017) found at posttest, compared to the control group, intervention group participants reported improvements in:
- Repeat pregnancy
- Unintended repeat pregnancy
- Repeat birth
- Unprotected vaginal intercourse
- Use of long-acting reversible contraception
- Use of effective birth control method
Evaluation Methodology
Design:
Recruitment: Over a period from October 2011 to January 2014, participants were recruited from 7 obstetrics/gynecology clinics and 5 postpartum hospital units in a large Midwestern city. Inclusion criteria were: English-speaking, aged 10-19, at least 28 weeks pregnant or less than 9 weeks postpartum, access to telephone service, and enrollment in Medicaid. A total of 598 female adolescents were enrolled in the study.
Assignment: Individuals were randomized into either the TOPP intervention condition (n=297) or a usual care control condition (n=301). Both conditions were given standard educational hand-outs on birth control options, sexually transmitted infections, and ideal inter-pregnancy intervals at the beginning of the study. While control group participants had standard access to health care, including contraception, the treatment group had much greater access to and counseling related to both long-acting and emergency contraception.
Attrition: The posttest occurred 18-months after assignment, at the end of the program. There was an overall retention rate of 78% at posttest (from 598 to 472). According to the tables in Rotz et al. (2016), individual outcome measures had additional missing data.
Sample:
Participants were predominantly 18 years or older (72%). The sample was approximately 48% white, 36% Black, and 6% Hispanic with an additional 9% identifying as another race/ethnicity or multiracial. Approximately 44% had at least a high school diploma with only 5% having no high school education at all. A majority of the sample was using SNAP or WIC (91%) and approximately half of the sample did not live with either parent (48%) at the time of the study. Only a quarter of the sample was pregnant at the time of the baseline survey, with the remainder postpartum.
Measures:
The primary outcome of interest was future births; statewide birth certificate data files were pulled to determine live births for 6-30 months after program enrollment if participants were aged 18 or older at baseline. For younger participants, pregnancy and births came from self-reports at the 18-month posttest. Participants also completed interim (6 months post-baseline) and posttest surveys on self-reported contraceptive usage, sex, and pregnancy intentions.
Analysis:
The effects of the program were evaluated using OLS regression with covariates for randomization status, random assignment strata, age, race, and baseline outcome measure (if available). Rotz et al. (2016) did much the same analysis but also made adjustments for multiple tests.
Intent-to-Treat: The authors stated that they used intent-to-treat analyses and appear to have used all available data. Those lost to follow-up had either withdrawn consent or did not respond to the survey.
Outcomes
Implementation Fidelity:
An outside expert assessed approximately 10% of audiorecorded sessions for fidelity using the Motivational Interviewing Treatment Integrity rating system and found fidelity to be moderate overall, with approximately 74% of recordings falling in the range of acceptable. About 96% of participants received a call, 84% received an assessment, and 44% received a home visit.
Baseline Equivalence:
Rotz et al. (2016) used the analysis sample (N = 472) for tests of baseline equivalence. Only one difference emerged across conditions in 36 tests. Stevens et al. (2017) used the full randomized sample (N=598) for their tests. The tests in both articles similarly show that the conditions were equivalent at baseline except for one difference in beliefs: The control group had a slightly more favorable belief regarding the trustworthiness of doctors when it comes to birth control.
Differential Attrition:
There was an attrition rate of 22%. Stevens et al. (2017) stated that there were no differences in rates between the intervention and control groups but provided no other information. Rotz et al. (2016) compared baseline measures for responders and non-responders, finding only 2 of 36 significant differences. Using the analysis sample (excluding dropouts), Rotz et al. (2016) found only 1 significant difference in 36 tests (Tables II.1, II.2, and II.3).
Posttest:
At posttest, compared to the control group, Stevens et al. (2017) reported significantly higher use of long-acting reversible contraception, significantly higher use of an effective birth control method, and significantly lower rates of unprotected vaginal intercourse. Intervention group participants also reported significantly lower rates of repeat pregnancy, unintended repeat pregnancy, and repeat birth compared to control group participants. However, there was no impact on future pregnancy intentions, an outcome that was independent of increased contraception use and was directly targeted by the motivational interview portions of the intervention. Last, there was no effect on measures of school enrollment and high school completion.
Rotz et al. (2016) reported similar results for pregnancy, sexual risk behavior, and education, but Appendix C added results for mediating risk and protective outcomes. Program participants were no different than control participants at 18 months on measures of attitudes, knowledge, and intentions. They did score significantly higher on access to contraceptives. The authors noted in the discussion that the program benefits came primarily from access to low-cost LARCs.
Smith et al. (2015) reported results only for the 6-month interim assessment.
Long-Term: No long-term follow-up was conducted.