(Computer-Assisted Motivational Interviewing Plus Home Visiting)

Program Components

• Counseling sessions conducted from six-weeks until two years postpartum, four times per year
• Computer-assisted motivational interviews to assess each teen's sexual behavior and contraceptive use prior to each counseling session
• 20-minute counseling sessions with a trained, paraprofessional counselor, using the results of the computer-assisted interview
• Biweekly to monthly home visiting by the CAMI counselor
• Parenting training, using a 16-module curriculum
• Case management
•  Training and continuous supervision of CAMI counselors

For Use With

• Pregnant and parenting African American adolescent females
• Urban African American adolescent females who are pregnant or have recently given birth

Evaluation Methodology

• Experimental, randomized controlled trial, including two treatment and one control condition in Baltimore, Maryland
• Urban, African American female teens, ages 12 through 18, at 24 or more weeks of gestation (n=235), randomly assigned to CAMI+ treatment (n=80), CAMI-only treatment (n=87), and control (n=68) conditions
• Structured interviews at baseline and 24-month postpartum follow-up
• Birth data from the Maryland Department of Health & Mental Hygiene Vital Statistics Administration

Evaluation Findings

• Reduced incidence of repeat births

Evaluators' Comments: Motivational interviewing aims to highlight discrepancies between current behaviors and personal goals, thereby promoting an intention and optimism for change... This computer assisted motivational intervention, conducted by paraprofessionals in community-based settings, is effective in reducing a subsequent birth within 24 months to low-income, African American teenage mothers... Findings suggest that a motivational intervention ... is effective but its impact may be attenuated when insurance coverage is inadequate.
Source: Barnet, Liu, DeVoe et al., 2009

Program Description

This program uses computer-assisted motivational interviewing along with regular home-visiting to encourage low-income, urban, African American teenage mothers to avoid a rapid repeat birth (occurring within two years of the previous birth). Motivational interviewing emphasizes the individual's personal goals and self-efficacy in relation to her health behaviors. The program uses algorithms based on the trans-theoretical model. Using a laptop, the teen mother answers questions about her current sexual relationship(s), if any, and her contraceptive and condom use behaviors and intentions. The program then computes the teen's stage of change for contraceptive and condom use, producing a summary readout to show whether she is at low, medium or high risk for pregnancy and STIs. The counselor then conducts a 20-minute interview to enhance the teen's motivation to use contraception and to avoid pregnancy. CAMI sessions begin at six-weeks postpartum and continue quarterly through 24-weeks postpartum, usually in the teen's home and in conjunction with scheduled home visits.

Participants receive biweekly to monthly home visits, parent training, and case management from their CAMI counselor. CAMI counselors are African American paraprofessional women, members of the communities where the teens live, and chosen for their empathetic qualities, rapport with adolescents, and knowledge of the community.

The counselors begin developing a relationship with each teen as soon as they are assigned and prior to the teen's giving birth. The counselors provide parent training using a 16-module curriculum that is grounded in social cognitive theory and created specifically for urban African American teenage mothers. Modules address age- and developmentally-appropriate feeding, growth, play, and discipline of infants and toddlers. In addition, three modules focus on safer sex, partner negotiation, and setting goals. Finally, the counselors provide case management, assisting each teenage mother successfully to negotiate the complex social and health care services she and her infant often need.

Evaluation Methodology

The randomized, controlled trial occurred in Baltimore MD, where the adolescent birth rate is twice the national average. Between February 2003 and April 2005, evaluators recruited participants from five prenatal clinics serving low-income, predominantly African American communities. Adolescents were eligible to participate if they were ages 12 to 18 and if their pregnancy was at 24 or more weeks of gestation. Adolescents were subsequently excluded if the pregnancy did not result in a live birth or if the infant died during the neonatal period. After the teen and her parent gave informed consent, she completed a baseline interview and was randomly assigned to one of three conditions (CAMI+, CAMI-only, and usual care control). Because service delivery was an important goal of the evaluation, more teens were assigned to the two intervention groups than to the control group. More than 80 percent of eligible adolescents agreed to participate. Those refusing to participate were similar in age to participants.

Participants completed baseline interviews prior to randomization. The interview measured characteristics associated with repeat pregnancy, factors that might influence full participation, demographic characteristics, insurance status, living arrangements, relationship with the baby's father, school attendance, parity, future contraceptive and pregnancy intentions, sexual decision-making competence, depressive symptoms, substance use, and social support. Participants were then randomized to one of three conditions:

• CAMI+ -- Eighty-two adolescents were randomized to this condition. Two were later excluded when one gave birth to a stillborn child and second's infant died at two months postpartum (finding of sudden infant death syndrome or SIDS). Thus, 80 were included in primary analysis of the intervention's efficacy.
• CAMI-only – Eighty-seven were included in primary analysis of the intervention's efficacy.
• Usual care control – Sixty-eight were included in primary analysis of the intervention's efficacy.

Thus, the final sample comprised 235 participants.

CAMI counselors completed an initial 2.5 days of training and participated thereafter in biweekly group meetings during the first four months of the project. Counselors initiated CAMI sessions by six weeks postpartum. However, evaluation found that most of the CAMI counselors began their scheduled home visits (CAMI+ condition) soon after a teen was assigned as part of their caseload. CAMI sessions continued quarterly through 24 months postpartum. Evaluators defined full CAMI adherence as receiving seven or more CAMI sessions; however, participants might have received as many as nine sessions.

Two-thirds of CAMI+ and CAMI only sessions occurred in the teen's home. The remainder occurred in community-based settings because of safety concerns related to drug trafficking in the teen's home. Each CAMI counselor carried an equivalent case load. CAMI+ counselors had a maximum case load of 25 adolescents because they visited the teens biweekly or monthly and provided parenting training and case management as well as the quarterly CAMI counseling. CAMI-only counselors met quarterly with 60 adolescents because they provided no additional case management, parenting training, or home visits. If a participant in either the CAMI+ or the CAMI-only groups experienced a pregnancy, she received no further CAMI sessions. To measure intervention adherence, CAMI counselors completed standardized forms at each encounter. The evaluation measured repeat births only and not changes in attitudes, knowledge or behaviors.

Long-Term Impact

• Reduced incidence of repeat birth—Evaluation found that 43 participants experienced a repeat births by 24 months postpartum. Compared with mothers in the control group, mothers in the CAMI+ group were significantly more likely to defer a repeat birth (P<.05).

Compared with those in the control group, CAMI+ participants showed a trend toward fewer repeat birth (25.0 versus 13.8 percent; P=.08). Compared to controls, those in the CAMI-only group also showed a statistically insignificant trend toward fewer repeat births (25.0 versus 17.2 percent; P=.32). The 80 adolescent mothers in the CAMI+ group experienced 11 repeat births within two years of the index birth; the 87 mothers in the CAMI-only group experienced 15 repeat births; and the 68 mothers in the control group experienced 17 repeat births.

Note: Evaluation also found that continuous insurance coverage was independently associated with a lower risk of repeat birth (P<.05) among adolescent mothers exposed to CAMI+. Continuous insurance coverage moderated the risk for repeat birth among CAMI+ mothers (P<.05) versus CAMI+ mothers without continuous insurance (P=.63).

For More Information, Contact

• Beth Barnet, MD, Department of Family & Community Medicine, University of Maryland; This e-mail address is being protected from spambots. You need JavaScript enabled to view it