Teen Pregnancy Prevention Programs

Teen Pregnancy Prevention Models

Gabriela Alcalde

Teen pregnancy and STD/HIV infection in the adolescent population is a costly problem in economic, personal and social terms. All states currently operate reproductive health programs and services for adolescents, using various sources of federal funds to support their efforts. Despite the vast number of programs that address teen reproductive health issues, little scientific research has been conducted to evaluate their effectiveness. There are many schools of thought on what is effective. Most approaches are based on theories of human behavior and ways to modify behavior. The three factors recognized as vital in changing health behavior are:

an individual's intention to exhibit a particular behavior;
environmental factors that prevent or resources that aid the behavior; and
an individual's skills or ability to execute the behavior.(1)

Effective approaches take these factors into account and work at all three levels to change an individual's health behavior. Dr. Douglas Kirby, an expert in the field of adolescent reproductive health, states in his book, No Easy Answers, that "reducing adolescent pregnancy is possible but challenging" and recommends implementing those programs and approaches which have shown promise or success and focus broadly on the risk-factors for teen pregnancy and risky sexual behavior.(2) The following is a brief description of the approaches commonly used in teen reproductive health efforts and of programs and curricula which have been evaluated for their effectiveness and show promising outcomes.

1. Access programs: programs that facilitate access to contraceptives, contraceptive counseling and information, HIV and other STDs services, and other reproductive health services. Studies conducted have shown that large numbers of teens do access these programs and receive contraceptives from them.(3) It is assumed that these contraceptives prevent teen pregnancies that might have occurred otherwise. Analyses of the recent drop in teen pregnancy rates point to increased and more effective contraceptive use as a key factor in the decline.(4) The Alan Guttmacher Institute estimates that almost 400,000 pregnancies are avoided each year among teen girls age 15-19 as a result of family planning programs providing access to contraceptives.(5) Although results from evaluation studies are not consistent, contraceptives represent a low-cost option for preventing a very costly outcome.

Tailoring Family Planning Services to the Special Needs of Adolescents: New Adolescent Approach Protocols. This is a family planning, clinic-based access program for children under the age of 18. This is a six-week program. A questionnaire (Personal Information Form) is filled out by teens to gauge their needs and to identify high-risk teens before any visits take place. Initial visit involves counseling and education, with a second visit scheduled for a medical examination and contraceptive prescription. Counseling is provided on a one-on-one basis and involvement of family-members, partners and friends is encouraged, although confidentiality is maintained. A follow-up visit takes place six weeks later. Key components of this intervention are the behavioral skills development, contraceptive education in conjunction to access, sexuality/STD/HIV education, adult involvement and the use of visual aids for education. All program staff are trained in adolescent psychological and sexual development, as well as in program and protocol administration. A study of over 1,200 teens attending six family planning clinics showed program participants had an increased knowledge and use of contraceptives, higher than the comparison group at the six- and 12-month evaluation points. The program participants also had fewer pregnancies in the year following their participation.

2. Media campaign programs: use media channels to increase knowledge and awareness of issues, services and programs that address teen reproductive health issues. Evaluations of media campaigns show that this type of approach can be very effective in changing individual attitudes, knowledge and behavior, social norms and even public policy.(6) Elements of a successful media campaign include(7):

Long-term commitment
Clear objectives
Testing message(s) prior to release
Targeting audience
Selecting media channels carefully to fit the purpose of the campaign
On-going monitoring and evaluation of media impact
Campaign parallels and complements activities at the community, individual or policy level

According to a 1998 National Campaign to Prevent Teen Pregnancy report, at least 40 states are developing or have developed media campaigns to prevent teen pregnancy.(8)

3. Education programs: provide knowledge and skills on reproductive health, contraceptives, pregnancy, STD/HIV and AIDS, general health, human development, sexuality, human relations, culture etc. Some education programs are abstinence-only, which discuss sex in the context of marriage and address contraceptive use in terms of failure rates. Abstinence-plus programs include abstinence education but also address contraceptive use, and other sexuality and reproductive health issues. The teaching of contraceptive methods and sexuality has been somewhat controversial and some parents and policymakers are concerned that this is a parent's responsibility not the schools'. However, a survey by the Advocates for Youth and the Sexuality Information and Education Council of the United States (SEICUS) found that 80 percent of adults surveyed believed that sexually active youth should be provided with contraceptive, STD/HIV and abstinence information and options.(9) Currently, 34 states and the District of Columbia mandate STD/HIV prevention education at schools; 19 states and the District of Columbia require schools to teach sexuality education, 13 requiring contraceptive information to be included; and 33 states have laws to allow parents to excuse their children from such classes.(10) At the school level, about 70% of school districts have a policy to teach sexuality education.(11) Of these, almost nine in ten require an emphasis on abstinence, with 35 percent requiring an abstinence-only approach.(12) Approximately 14 percent of school districts require a comprehensive approach to sexuality education.(13) Factors influencing the type of policy the district established ranged from state directives to teacher support and funding, with state directives cited most frequently (74 percent).(14)

Evaluations of education programs so far have provided mixed results.(15) Abstinence-only programs have not shown a delay in sexual initiation so far. Further evaluation should be conducted of existing programs. Abstinence-plus education and comprehensive sexuality education, results were mixed, although a few conclusions were drawn(16): programs that discuss sexuality, contraception and STD/HIV do not increase sexual activity or accelerate its onset. Several studies have shown positive effects on the delay of intercourse, frequency of intercourse, number of sexual partners and use of condoms and other contraceptives.(17) Common characteristics were identified among successful and effective programs.

CHARACTERISTICS OF EFFECTIVE

EDUCATION PROGRAMS

Focus clearly on one behavior.
Elements are appropriate to age, culture and sexual experience.
Based upon theoretical models shown to be effective in altering other health-risk behavior.
Programs are long enough to complete important activities adequately.
Use of diverse teaching methods designed to involve participants and help personalize the information.
Provide basic, accurate information.
Activities address social pressures.
Provide modeling of positive behavior and practice communication, negotiation and refusal skills.
Teachers/peer counselors believe in the program and are trained appropriately.

Source: Kirby, Douglas. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. The National Campaign to Prevent Teen Pregnancy. March 1997. Washington, DC.

Teen Talk. Teen Talk is a school and community health center-based education program that provides sex and contraception education. The program is organized into two lecture sessions and four group discussion sessions, together lasting about 12 to 15 hours over the period of two to three weeks. The two lecture sessions cover contraception, reproductive physiology and contraceptive effectiveness. During the remaining four small group sessions, teens discuss the risks and consequences of teen pregnancy in a manner that personalizes the material. The groups then develop and practice skills that can help them make abstinence a viable choice for them and discuss ways to obtain contraceptives. Group sessions include activities such as games, role- playing and short films that motivate discussion. The sessions are lead by a lecturer and a group discussion leader. Both of these people participate in a two-day intensive workshop to train them on conducting effective group discussions and on the format and content of the program. The program is based on two theoretical models, the Health Belief Model and the Social Learning Theory. Specific program content includes: presentation on information in a factual manner; group discussion of factual information; group discussion of values, feelings and emotions; and making decisions and taking personal responsibility for those decisions.

Evaluation of this program in both rural and urban communities in California and Texas showed very promising results. The evaluations included both boys and girls of diverse ethnic and racial backgrounds. Male participants had particularly positive results leading to delay of the onset of sexual activity among sexually inexperienced males, and to the increased use of more effective contraceptives among sexually experienced males.

4. Youth development programs: based on the notion that improving youth's education and work opportunities will decrease their chance of risky behavior, such as unprotected sex and pregnancy. These programs are intended to develop life-skills without targeting reproductive health as the primary issue. Research conducted both in the U.S. and internationally support the conceptual framework of youth development programs. For many years now, programs to educate young girls and provide them with increased work opportunities in developing countries have yielded a common result: decreased fertility.(18) In the U.S., a strong relationship exists between educational and career plans and prospects and teen pregnancy.(19) In addition, trends in this country imply the potential success of this type of approach: during the decades of the 50's, 60's and 70's, when women were postponing marriage and childbirth for the sake of pursuing education and careers, teen pregnancy rates fell dramatically.(20) Research conducted on youth development programs has provided us with mixed results. However, there have been many positive evaluations of existing programs, and further research is needed to fully understand the impact of this type of program on teen pregnancy and sexual behavior.

Teen Outreach Program (TOP).(21, 22, 23) TOP is a program that takes a holistic approach to the reduction of teen pregnancy and STD/HIV infection by addressing 'broad developmental tasks of adolescence.'(24) It can be used as a school-based program or adapted to out-of-school environments. Teens ages 12 to 17 are involved in the program and the curriculum has different levels for the different ages. TOP has three overarching goals:

Promote healthy behavior for success in school and achievement of life-long goals
Help youth develop life-skills to allow for growth into healthy, self-sustaining adults
Give youth a sense of purpose by providing opportunities to contribute to their communities

The program has two major components: a) the service learning component; and b) the classroom-based component. The service learning part consists of preparing to and volunteering at the youth's school or community. The teens then share their volunteer experience through discussions, research activities, writings and creative presentations. Throughout their volunteer experience, youth are given consistent messages about the values underlying the program. Each TOP site identifies potential sites within their community and then allows the youth to select where they would like to do their service. The classroom component uses small groups for discussion of topics of interest and relevance to teens. Each class session is about 30-50 minutes long, and there are approximately 30 to 40 sessions. Sessions provide teens with knowledge and skills related to self-esteem, values, relationships, decision-making and communication skills, human growth and development, parenting and family relationships among others. TOP uses a program coordinator and classroom facilitator, both of whom are trained. TOP also requires community involvement and consistent financial support. The TOP curriculum is now available in Spanish.

Evaluations of the TOP program have yielded very positive and promising results. Evaluations consistently show a decrease in pregnancy rates for participants during the duration of the program.(25) A ten-year evaluation of TOP in 25 sites nationwide by Philliber Research Associates found: a 60 percent lower school drop out rate; a 33 percent lower pregnancy rate; an 18 percent lower rate of school suspension; and an eight percent lower school course failure rate.(26)

5. Multi-faceted programs: these programs are diverse, but all use multiple components to achieve their goals.(27) Programs are considered multi-faceted if they involve two or more of the approaches described above.

Note: See http://aspe.hhs.gov/hsp/get-organized99/index.htm#vol1 for a comprehensive review of approaches by the Department of Health and Human Services Resources.

Principles for Designing Effective Intervention

Principle	Specifics/Examples
Intervention should be evidence-based	Addressing risk factors such as poverty, early school failure, early behavior problems, non-voluntary sex and family problems and dysfunction Using approaches that have been evaluated and found effective
Positive and negative sanctions should be used	Positive reinforcement/Rewards Mandatory attendance
At-risk youth need interventions starting prior to puberty	Negative behavior patterns begin in early childhood The greater the risk, the earlier the intervention should begin
Programs should work with families and communities	Involving adolescents in planning process Involving parents, potential funders and providers Involving community in defining problem and target population
Adjust level of intervention to specific needs of each group and individual	Adjusted from no intervention to comprehensive, long-term intervention Use resources wisely
Design and implementation of program should be culturally-appropriate	Recognize differences in values, roles and attitudes about sex, contraceptives and childbearing
Programs should be age-appropriate	Addressing varying cognitive, social and emotional stages of development
Recognize sexual risk-taking as part of a constellation of risk-taking behaviors	Sexual risk-taking and early pregnancy are strongly associated with smoking, delinquency, use of illicit drugs and other risky behavior
Recognize the role of non-voluntary sexual behavior in teen sex, pregnancy and parenthood	60% of girls age 15 and younger report their first sexual intercourse as non-voluntary
Involve males, realizing not all male partners of teen girls are teens	Statutory rape issues Involving men in decision-making process Economic and emotional responsibility
Conduct process evaluations for all organized programs, impact evaluations where possible	Process evaluations: who receives services and in what amounts Impact evaluations: very expensive; provide valuable information on effectiveness and impact of the program
Source: Moore, Kristin and Sugland, Barbara. Next Steps and Best Bets: Approaches to Preventing Adolescent Childbearing. Child Trends, January 1996. Washington, D.C.

1. Kirby, Douglas. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. The National Campaign to Prevent Teen Pregnancy. March 1997. Washington, DC, 11.

2. Ibid. 48.

3. Ibid. 37.

4. Darroch, Jacqueline E. and Singh, Susheela. Why is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use. (New York: Alan Guttmacher Institute, December 1999), 12.

5. The Annie E. Casey Foundation. When Teens Have Sex: Issues and Trends. URL= http://www.aecf.org/kidscount/teen/overview/overview2.htm. World Wide Web.'

6. The National Campaign to Prevent Teen Pregnancy. Just Say Know: How Public Service Media Campaigns Change Attitudes and Behaviors. (press release, February 11, 1998.)

7. Ibid.

8. Guiden, Mary. Teen Pregnancy Prevention, A Legislator's Guide.

9. O'Connor, Matthew. Sexuality Education. Legisbrief. NCSL. November/December 1999.

10. Ibid.

11. Landry, David and Kaeser, Lisa and Richards, Cory. "Abstinence Promotion and the Provision of Information About Contraception in Public School District Sexuality Education Policies." Family Planning Perspectives 31, no. 6. (November/December 1999): 280.

12. Ibid.

13. Ibid.

14. Ibid. p 294.

15. Kirby, Douglas. No Easy Answers. 31.

16. Ibid.

17. Ibid.

18. Ibid.

19. Ibid.

20. Ibid.

21. Ibid.

22. Resource Center for Adolescent Pregnancy Prevention. Effective Practices: Beyond Curricula. URL= http://www.etr.org/recapp/practice/top.htm. World Wide Web.

23. Cohen, Marie. Tapping TANF. 23.

24. Ibid.

25. Kirby, Douglas. No Easy Answers. 42.

26. Resource Center for Adolescent Pregnancy Prevention. Effective Practices.

27. Kirby, Douglas. No Easy Answers. 42.