F Summaries of Evaluated Programs: Supplement to Chapter 8

Dana Hotra

Staff, Committee on Unintended Pregnancy

This appendix presents detailed information on the 23 programs profiled in Chapter 8.

Community of Caring

Summary: Several sites around the country providing prenatal care for pregnant adolescents, with an emphasis on planning for future goals, including prevention of repeated pregnancy.

Program: The Community of Caring program operated at 16 sites nationwide and targeted pregnant and parenting adolescents between the ages of 13 and 19. It was designed to help the teenager to have a healthy pregnancy, learn how to care for the baby, complete her education, and/or become employed. The program highlighted five themes (family, personal responsibility, sexual maturity and commitment, planning for future goals, and commitment to parenthood), although each site implemented the curriculum slightly differently.

Evaluation: Two of the sites were evaluated between 1985 and 1988: a hospital-based program in Boston, MA and a community-based program in Las Cruces, NM. Participants were not randomly assigned; instead, a quasi-experimental design was developed in which individuals with similar background demographics made up the comparison group. This design was complicated when some young women in the comparison group switched to the intervention group. The



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--> F Summaries of Evaluated Programs: Supplement to Chapter 8 Dana Hotra Staff, Committee on Unintended Pregnancy This appendix presents detailed information on the 23 programs profiled in Chapter 8. Community of Caring Summary: Several sites around the country providing prenatal care for pregnant adolescents, with an emphasis on planning for future goals, including prevention of repeated pregnancy. Program: The Community of Caring program operated at 16 sites nationwide and targeted pregnant and parenting adolescents between the ages of 13 and 19. It was designed to help the teenager to have a healthy pregnancy, learn how to care for the baby, complete her education, and/or become employed. The program highlighted five themes (family, personal responsibility, sexual maturity and commitment, planning for future goals, and commitment to parenthood), although each site implemented the curriculum slightly differently. Evaluation: Two of the sites were evaluated between 1985 and 1988: a hospital-based program in Boston, MA and a community-based program in Las Cruces, NM. Participants were not randomly assigned; instead, a quasi-experimental design was developed in which individuals with similar background demographics made up the comparison group. This design was complicated when some young women in the comparison group switched to the intervention group. The

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--> researchers designated three groups at each site: high treatment, low treatment, and a comparison group. A baseline pretest was given, as was a posttest following delivery. A third survey was administered at 1 year posttest (79 percent response rate). The two sites had different results at the 1-year follow-up. At the Las Cruces site, contraceptive knowledge had increased among the high-treatment group, but there was no significant difference in sexual behavior. At the Boston site, the low-treatment group scored consistently lower in knowledge, attitudes, and behavior than either the high treatment or comparison groups. The high-treatment group showed no statistically significant differences in behavior from the comparison group. Primary Reference: Miller BC, Dyk PH. Community of Caring effects on adolescent mothers: A program evaluation case study. Fam Relat. 1991;40:386–395. Condom Mailing Program Summary: Direct mail program for adolescent men designed to increase their knowledge about and access to condoms. Program: The Condom Mailing Program was a direct mail program initiated in 1987 that was designed to increase knowledge about condoms through an informational packet called The Man's World and to increase access to contraception through an order form for free condoms. The target population was low-income adolescent men aged 16–17. The actual population reached was primarily middle-income rather than low-income men. Evaluation: The experimental design was developed by randomly dividing a list of names purchased from a list broker into an intervention group (n = 985) and a control group (n = 1,033). The direct mail packet was sent to the intervention group. Both groups were interviewed by telephone 5 weeks after the mailing to elicit information on their knowledge, attitudes, and behavior. The researchers reached 86 percent of the sample by telephone. The experiment was doubleblind, in that the interviewer did not know which group the respondent was in, nor did the respondent probably realize that he was part of an experiment. At follow-up, 72 percent of the intervention group recalled receiving the materials; 91 percent of that group read the pamphlet, 36 percent discussed the pamphlet with their parents, and 44 percent discussed it with their friends. As compare d to the control group, men in the intervention group were more likely to be knowledgeable about contraception, sexually transmitted diseases, and pregnancy, although there were no differences in use of contraception. Receiving

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--> the materials and order form did not have a significant effect on whether the respondent had ever had intercourse, but those respondents who had read the materials reported fewer acts of intercourse (p < 0.05). Also, 9 percent of those men who had read the pamphlet ordered the free condoms, a response rate much higher than typical direct mail response rates. Primary Reference: Kirby D, Harvey PD, Claussenius D, Novar M. A direct mailing to teenage males about condom use: Its impact on knowledge, attitudes and sexual behavior. Fam Plann Perspect. 1989;21:12–18. Elmira Nurse Home Visiting Program Summary: Comprehensive program of prenatal and postpartum infancy nurse home visitation for low-income women bearing their first child. Program: Located in New York State during the early 1980s, this was a comprehensive program of prenatal and postpartum nurse home visitation for socially disadvantaged white women (47 percent of whom were adolescents) bearing their first child. Registered nurses who had participated in a 3-month training program helped women improve their prenatal health-related behaviors and infant caregiving skills, and encouraged the women to clarify their future plans. The advantages of various types of contraception were discussed with the women and their partners. Nurses visited one group of pregnant women in their homes during the pregnancy and another group during the pregnancy and through the following 2 years. Program objectives included encouraging the women to complete their education, identify vocational interests, and increase their interpregnancy interval. Evaluation: An evaluation was conducted with an experimental design. The researchers followed women in the two intervention groups and a control group for 4 years following the birth of their first child. (The results reported here contrast the women who were nurse-visited during pregnancy and infancy with women who were not nurse-visited at all.) During the first 22 months after delivery, low-income unmarried women visited during pregnancy and infancy (n = 72) had 33 percent fewer subsequent pregnancies than did their counterparts in the control group (n = 124). By 48 months postpartum, these women experienced 43 percent fewer subsequent pregnancies, and they postponed the birth of a second child an average of 12 months longer than did women in the control group. Among women in the intervention groups there was an 83 percent increase in the number of months that women participated in the workforce. The

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--> researchers argue that the reduction in subsequent pregnancy enabled the nursevisited women to participate in the workforce to a greater extent than their counterparts in the control group. Moreover, the intervention also reduced the rates of child maltreatment by 80 percent (19 percent in the comparison group compared with 4 percent in the nurse-visited group) among low-income, unmarried adolescents during the first 2 years postpartum. Although the program was designed to directly improve qualities of infant caregiving and reduce child abuse and neglect, the researchers attribute part of the positive effect of the program to the reduction in subsequent pregnancies, many of which would probably have been unintended. Primary References: Olds D, Henderson C, Tatelbaum R, Chamberlin R. Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics. 1986;78:65–78. Olds DL, Henderson CR, Phelps C, Kitzman H, Hanks C. Effects of prenatal and infancy nurse home visitation on government spending. Med Care. 1993;31:155–174. Olds DL, Henderson CR, Tatelbaum R, Chamberlin R. Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. Am J Public Health. 1988;78:1436–1455. Facts and Feelings Summary: Home-based abstinence program using sex education videotapes to encourage discussion between parents and early adolescents about sexual issues. Program: In the mid-1980s, families of seventh and eighth grade adolescents in northern Utah were asked to participate in a home-based program in which they received a series of sex education videotapes called ''Facts and Feelings." The objective of the program was to encourage discussion about sexual issues between the parents and the adolescent, and the long-term goal was to reduce early adolescent sexual behavior. The videotape did not include contraceptive information. This program was initiated in several communities in Utah among young adolescents who were not likely to have already initiated sexual intercourse. Evaluation: Using an experimental design, 548 families were randomly assigned to receive either the videotapes and a newsletter, the videotapes alone, or no videotapes or newsletter. A pretest, posttest, and delayed posttest (at 1 year) were administered by program staff in the home. The questionnaire focused on parent-child communication, knowledge, values, and sexual activity. Although

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--> intervention groups did experience significantly increased communication between parents and adolescents, similar rates of adolescent sexual activity (3 to 5 percent had begun having intercourse) were found across the three groups at 1-year follow-up. Primary Reference: Miller BC, Norton MC, Jenson GO, Lee TR, Christopherson C, King PK. Impact evaluation of Facts and Feelings: A home-based video sex education curriculum. Fam Relat. 1993;42:392–400. Girls Incorporated Preventing Adolescent Pregnancy Summary: Nationwide sexuality education program divided into four age-appropriate components. Program: Preventing Adolescent Pregnancy is a sexuality education program developed in the 1980s by Girls Incorporated, a national organization serving girls and young women. The program is divided into four age-appropriate components. The first component, Growing Together, focuses on parent–daughter communication for young girls and encourages delaying sexual initiation. The second component, Will Power/Won't Power, targets 12- to 14-year-olds, using a series of fun, skill-building exercises focused on assertiveness training, again encouraging postponement of sexual intercourse. Taking Care of Business, the third component, uses the life options model to target adolescents ages 15–17 and focuses both on the delay of sexual intercourse and on contraceptive use. The fourth component, Health Bridge, is patterned on the school-linked health clinic model, including access to reproductive health services and contraceptives. Some young women participated in more than one program component, and the Will Power/Won't Power component had the highest enrollment. Evaluation: Two evaluations are summarized here: one evaluates Growing Together and Will Power/Won't Power together; the other compares the impact of participating in one or more program components with no program participation. Growing Together and Will Power/Won't Power were evaluated by using a quasi-experimental design. The sample consisted of girls ages 12 to 14 who had participated in the programs for at least 1 year and had never had sexual intercourse (n = 295). The control group consisted of eligible girls who did not enroll in either program (n = 117). Background characteristics of the Growing

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--> Together group differed from the background characteristics of the control group in that on the basis of sociodemographic characteristics, intervention participants appeared to be less likely than control participants to have begun having sexual intercourse. Background characteristics of Will Power/Won't Power participants appeared similar to those of the control group. Evaluation results indicated that significantly fewer Growing Together participants began sexual intercourse during the follow-up period. There was no difference in rates of initiation of sexual intercourse among Will Power/Won't Power participants and controls. Additional analysis suggests that those girls who participated in Will Power/Won't Power for a longer period were significantly less likely to initiate sexual intercourse than were those who participated for a shorter period or those in the control group. Another evaluation used a quasi-experimental design to establish three groups: adolescents who had participated in two or more components, adolescents who had participated in only one component, and the control group. As in the other evaluation, members of the control group were young women eligible for the program but who did not enroll. The intervention group totaled 237, and the control group totaled 106. Demographic characteristics were similar for the three groups. Evaluation results were mixed. For example, adolescents who participated in one program component were more likely to have had sexual intercourse without contraception than were adolescents who had participated in two or more components or in no components (i.e., the control group). There was no difference in the rate of unprotected intercourse between participants in two or more components and adolescents in the control group. Young women who participated in one or more program components were less likely to report becoming pregnant than those in the control group. This finding was marginally significant. Primary References: Girls Incorporated. Truth, trust and technology: New research on preventing adolescent pregnancy . Indianapolis, IN; Girls Incorporated; October 1991. Nicholson HJ, Postrado LT. A comprehensive age-phased approach: Girls Incorporated. In preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992. Postrado LT, Nicholson HJ. Effectiveness in delaying the initiation of sexual intercourse of girls aged 12–14: Two components of the Girls Incorporated Preventing Adolescent Pregnancy Program. Youth Soc. 1992;23:356–379.

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--> Group Cognitive Behavior Curriculum Summary: School-based sexuality curriculum using group cognitive behavior theory to personalize accurate information about sexuality and contraception. Program: This curriculum used group cognitive behavior theory to implement an adolescent pregnancy prevention program in 1979. Trained college staff helped adolescents to personalize and act on accurate information about sexuality and contraception. The program used a four-step process: (1) accurate information about reproductive health, contraceptive methods, and sexuality in adolescent development was made available; (2) program staff ensured that information had been accurately perceived by using small groups to test and reinforce students' knowledge; (3) information was personalized so that the transition was made from knowledge to decision-making; and (4) behavioral skills necessary to implement decisions made on the basis of the new information were practiced. Evaluation: Using a small sample size of 36 students, the researchers made random assignments to intervention and control groups. The intervention group received the program outlined above. Questionnaires were completed at baseline, immediately postintervention and 6 months postintervention. At the 6-month follow-up, intervention group participants were practicing more effective contraception than controls. A second evaluation with a larger sample size (N = 107) did not show any significant difference between the intervention and control groups, although intervention group participants were better able to raise and discuss contraceptive issues. Primary References: Gilchrist LD, Schinke SP. Coping with contraception: Cognitive and behavioral methods with adolescents. Cognit Ther Res. 1983;7:379–388. Schinke SP, Blythe BJ, Gilchrist LD. Cognitive-behavioral prevention of adolescent pregnancy . J Couns Psychol. 1981;28:451–454. Schinke SP, Gilchrist LD, Small RW. Preventing unwanted adolescent pregnancy: A cognitive-behavioral approach. Amer J Orthopsychiatry. 1979;49:81–88. McCabe Center Summary: Alternative public school for pregnant students providing prenatal and postnatal education, with an emphasis on delaying rapid repeat pregnancy.

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--> Program: The Polly T. McCabe Center in New Haven, CT, was an alternative public school for pregnant students, one objective of which was to delay subsequent childbearing. The center stressed intensive, health-focused prenatal and postnatal education by nurse practitioners and counseling services for pregnant and recently delivering adolescents. The program provided case management by nurses and social workers for up to 4 months after delivery. Such care included follow-up counseling about contraceptive choices made at the hospital in order to be confident that the young mothers felt comfortable with their contraceptive choices and knew how to use their methods most effectively. Approximately 120 young women were served each year in the 1980s. Evaluation: The demonstration project was evaluated by examining the 1979–1980 birth cohort using a quasi-experimental, longitudinal design. The evaluation did not compare pregnant adolescents who attended the school with those who did not, but compared adolescents who spent different lengths of time at the school. Students who were permitted to remain at the school for more than 7 weeks postpartum were compared with those who returned more quickly to their regular school (this was due to administrative procedures and was not by the student's choice, and essentially randomized the students). A total of 102 women participated in the 18-month follow-up, and 99 participated in the 5-year follow-up. Students who were permitted to remain at the school for more than 7 weeks postpartum were significantly less likely to have another child within 2 years (p < 0.005) and within 5 years (p < 0.015). The researchers note that "the most surprising finding in this study was that relatively brief postnatal intervention with new adolescent mothers significantly reduced their likelihood of subsequent childbearing over the next five years." They suggest that the critical period is the second month following the birth of the child, in that this typically marks the end of the postnatal recovery period and sexual activity often then resumes. Primary References: O'Sullivan A, Jacobson B. A randomized trial of a health care program for first-time adolescent mothers and their infants. Nurs Res. 1992;41:210–215. Seitz V, Apfel N. Effects of a school for pregnant students on the incidence of low-birthweight deliveries. Child Develop. 1994;65:666–676. Seitz V, Apfel NH. Adolescent mothers and repeated childbearing: Effects of a school-based intervention program . Amer J Orthopsychiatry. 1993;63:572–581.

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--> New Chance Summary: National demonstration program offering comprehensive services for low-income parenting adolescents and young adults. Program: New Chance was a national demonstration program that tested a model offering young parents intensive and comprehensive services including education, training, personal development counseling, parenting support, and case management. Intended to improve the employment prospects of participants, to improve their parenting skills, and to enhance the development of their children, it also sought to delay repeat pregnancies. Those eligible to participate were mothers ages 16–22 who were high school dropouts, received Aid to Families with Dependent Children (AFDC), and gave birth to their first child before age 20. The demonstration project began in 1989 and ended in 1992. The model was put in place in 16 local sites, of which 12 are still in existence; sites operated on a small scale to create a warm and supportive environment. The intervention was divided into two phases. Phase I focused on education, career exploration and pre-employment skills, parenting, life skills, and family planning (including arranging visits to family planning providers), and phase II centered on skills training, work experience, and job placement assistance. Evaluation: The evaluation involved the random assignment of young women meeting the eligibility criteria either to an intervention group, whose members were eligible to received the treatment described above, or to a control group, whose members could not participate in New Chance, but could have received other services available in their communities. An evaluation (published in 1994) was based on follow-up interviews with 2,088 members of both groups conducted 18 months after random assignment; a subsequent round of follow-up is being conducted at 42 months after random assignment. At the 18-month point, comparable rates of repeat childbearing were found in both intervention and control groups (approximately 25 percent). Participants in the intervention group reported a higher rate of pregnancy (57 versus 53 percent) as well as a higher rate of abortion (15 versus 11 percent). Primary References: Manpower Demonstration Research Corporation. New Chance: A New Initiative for Adolescent Mothers and Their Children. New York, NY: Manpower Demonstration Research Corporation; April 1993. Quint J, Musick J, Ladner J. Lives of Promise, Lives of Pain. New York, NY: Manpower Demonstration Research Corporation; January 1994. Quint JC, Fink BL, Rowser SL. Implementing a Comprehensive Program for Disadvantaged Young Mothers and Their Children. New York, NY: Manpower Demonstration Research Corporation; December 1991.

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--> Quint JC, Polit DF, Bos H, Cave G. New Chance: Interim Findings on a Comprehensive Program for Disadvantaged Young Mothers and Their Children. New York, NY: Manpower Demonstration Research Corporation; September 1994. The Ounce of Prevention Fund's Parents Too Soon Program Summary: Statewide program for pregnant and parenting adolescents using home visiting and parent groups. Program: The Ounce of Prevention Fund's Parents Too Soon Program is a state-wide network of 27 community programs for pregnant and parenting adolescents to encourage young women to complete their education, increase their employability, improve their parenting skills, and reduce their rates of repeat childbearing. The programs serve adolescents for 2 years and provide different types of support according to individual needs. The two primary services are home visiting (to reduce isolation) and parent groups (a peer-support model). These programs are currently ongoing, and are supported by the Illinois Department of Children and Family Services. Evaluation: A sample of 1,004 young women who entered the program between June 1985 and July 1987 was compared with a sample (n = 790) from the National Longitudinal Survey of Youth (NLSY). Program participants who were under age 20 at program entry and had participated in the program for at least 12 months were matched with a sample of NLSY women who were also adolescent parents. The baseline point was considered to be date of program entry for the Parents Too Soon participants and date of birth of the first child for the NLSY comparison group. Follow-up data were measured at 12 months post-baseline for both groups. When age at first birth, ethnic background, living arrangements, level of education, school enrollment, and employment status at baseline were controlled, participants in the NLSY comparison group were 1.4 times more likely to experience a subsequent pregnancy than the intervention group. Although the use of national data is an innovative way to address the problem of identifying a comparison group, there was a serious inadequacy in using the NLSY group because the NLSY survey had not always asked about subsequent pregnancies. Therefore, the number of subsequent pregnancies was determined by noting subsequent births, leaving a wide margin for undercounting of subsequent pregnancies in the NLSY group.

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--> Primary Reference: Ruch-Ross HS, Jones ED, Musick JS. Comparing outcomes in a statewide program for adolescent mothers with outcomes in a national sample. Fam Plann Perspect. 1992;24:66–71, 96. Postponing Sexual Involvement Summary: School-based curriculum encouraging middle school students to delay initiation of sexual intercourse in combination with a human sexuality and contraception component. Program: Postponing Sexual Involvement: An Education Series for Young Teens began in 1983 as one of two components of a hospital-based outreach program. It is given in combination with a component on Human Sexuality that provides students with basic health and reproductive information, including contraceptive use. The Postponing Sexual Involvement component was developed in response to an early evaluation of the human sexuality component, which indicated that this unit alone was not effective in reducing the rate of sexual activity or adolescent pregnancy. Based on the social influence model, Postponing Sexual Involvement uses older adolescent leaders to teach young adolescents to practice specific attitudes and skills related to decision-making about their sexual behavior. The Postponing Sexual Involvement component emphasizes that abstinence is the best choice for young adolescents. The Postponing Sexual Involvement Educational Series is being used in multiple sites throughout the United States, Canada, and England. The Human Sexuality component is used elsewhere but not as widely. Evaluation: A quasi-experimental design was used to evaluate the program. The intervention group consisted of low-income eighth-grade students from one school district, and the control group consisted of low-income students from three adjacent school districts who did not participate in the experimental program (N = 536). Data were collected by telephone interviews at baseline and postintervention, at the end of the eighth grade. Longer-term follow-up data were collected by telephone interviews at the end of the ninth and twelfth grades. The following findings in the intervention group were significant at the p < 0.05 level: less initiation of intercourse at postintervention and at the end of ninth grade follow-up; less frequency of intercourse among those who were sexually inexperienced at pretest but initiated sex by the end of ninth-grade follow-up; more contraceptive use among those who were sexually inexperienced at pretest but initiated sex by end of ninth-grade follow-up. The significance of the intervention was most apparent at the end of eighth-grade posttest and the

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--> to male students and took female students to the county family planning clinic. Later, for a short period, contraceptives were provided in a school-based clinic; still later, they stopped being provided in any way at the school. Although the school nurse and school-based clinic were funded by sources different from those that funded the education–media program, the contraceptive services were an integral part of the total intervention. Evaluation: Two evaluations of this program have been made. The first evaluation used a quasi-experimental design and compared pregnancy rates for women aged 14–17 in the intervention area with adolescent pregnancy rates in a nonintervention portion of the same county as well as in three other demographically similar counties. In the 2 years following the intervention, adolescent pregnancy rates in the intervention area dropped significantly (p < 0.05) as compared to the nonintervention areas. A later reanalysis of the data selected comparison areas by matching preprogram adolescent pregnancy rates in addition to socioeconomic variables, and extended the time period during which adolescent pregnancy rates were examined. The reanalysis confirmed that the adolescent pregnancy rate in the intervention area dropped during the early intervention years (1984–1986). However, it found that the rate rose during the later intervention years (1987–1988) to levels that were not significantly different from the preprogram rates. The reanalysis differed from the original evaluation in that it included an examination of the provision of contraceptive counseling and services as part of the total intervention. The authors of the reanalysis suggest that the educational program combined with the provision of contraceptive counseling and services accounted for the initial decrease in adolescent pregnancy rates. They also suggest that the cessation of the contraceptive counseling and services in the school, together with a loss of momentum of the educational program, explained the subsequent rise in adolescent pregnancy rates to preprogram levels. Primary References: Koo HP, Dunteman GH, George C, Green Y, Vincent M. Reducing adolescent pregnancy through a school- and community-based intervention: Denmark, South Carolina, revisited. Fam Plann Perspect. 1994;26:206–211, 217. Vincent ML, Clearie AF, Schluchter MD. Reducing adolescent pregnancy through school and community-based education. JAMA. 1987;257:3382–3386.

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--> Self Center Summary: Full reproductive health services as well as health education and counseling services provided through a school-linked clinic. Program: The Self Center program in Baltimore, MD, combined school and clinic operations and provided full reproductive health services as well as health education and counseling services; some of these services were offered through the Self Center clinic, and others through counselors and educators sent in to the school. The pregnancy prevention program began in November 1981, and the clinic opened in January 1982; services were provided through June 1984. The target population included all students in the two local junior and senior high schools in an urban, low-income neighborhood. Most services were offered in a school-linked clinic located close to both schools. Educational and counseling services were provided by health and social work professionals through in-class presentations, small group and individual counseling in schools, formal and informal after-school discussions, peer groups, and group and individual counseling in the clinic. Activities were designed to widen access to information about sexuality and contraception. Contraceptive services and other reproductive health services (such as pregnancy testing and treatment for sexually transmitted diseases) were provided in the clinic and were free of charge. Evaluation: The program was evaluated using both pretest/posttest and experimental control methodologies that allowed the researchers to assess changes in knowledge, attitudes, and sexual behavior over time. The control groups consisted of students at similar junior and senior high schools that were not associated with the special health clinics. Questionnaires were administered at pretest and annually for 3 years. The analysis was done as a multiwave study, and the sample size ranged from 3,646 students completing baseline questionnaires to 2,950 students completing the final survey 3 years later. Methodological problems unique to a school-based sample, such as no two schools being truly comparable and the use of the entire school as the relevant sample, were addressed. At follow-up, significantly more students in the intervention schools attended a clinic before the initiation of sexual activity; significantly more students in the intervention schools also attended a clinic during the first months of sexual activity. Young men in the intervention junior high school were as likely to attend a clinic as were the young women. A significant delay in the initiation of sexual intercourse for young women in the intervention schools (p < 0.01) was noted; the median delay was 7 months. In addition, a significant increase in the use of contraceptives at last intercourse was noted among both adolescent women and men. For example, after exposure to the intervention, the percentage of young women using oral contraceptives increased significantly

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--> among all grade levels, particularly among the younger girls. Follow-up showed a significant reduction of pregnancy rates among the older adolescents relative to those in the control schools (a decrease of 30 percent and an increase of 58 percent, respectively). A small decrease in the pregnancy rates among younger adolescents was found, although the pregnancy rates in the control school increased dramatically. The researchers note that a longer follow-up period to the program would be useful in monitoring pregnancy rates. Primary References: Zabin LS, Hirsch MB. Evaluation of Pregnancy Prevention Programs in the School Context. Lexington, MA: Lexington Books; 1987. Zabin LS, Hirsch MB, Smith EA, Streett R, Hardy JB. Evaluation of a pregnancy prevention program for urban teenagers. Fam Plann Perspect. 1986;18:119–126. Zabin LS, Hirsch MB, Streett R, Emerson MR, Smith M, King TM. The Baltimore Pregnancy Prevention Program for Teenagers. I. How did it work? Fam Plann Perspect. 1988; 20:182–192. Six School-Based Clinics Summary: School-based clinics providing comprehensive health care to students located in six sites around the country. Program: A group of six school-based clinics that provided comprehensive health care to students in the mid-1980s framed the basis of a program analysis. Although the sites were located all around the country (Gary, IN; San Francisco, CA; Muskegon, MI; Jackson, MS; Quincy, FL; and Dallas; TX), all six served low-income populations. The services and supplementary education offered at each site differed substantially. For example, the Gary site placed a strong emphasis on treating medical problems but did not consider preventing pregnancy a major goal, and therefore did not prescribe or dispense contraceptives; the San Francisco site emphasized pregnancy prevention as well as preventing AIDS and other sexually transmitted diseases, although contraceptives, including condoms, were not prescribed or distributed; the Muskegon site emphasized pregnancy prevention in the classroom as well as the clinic and provided vouchers for contraceptive pills; the Jackson site focused on risk-taking behaviors (including unprotected intercourse), encouraged abstinence, and dispensed contraceptives; the Quincy site emphasized sexuality and reproductive health education, including the benefits of abstinence, and dispensed contraceptives; and the Dallas site focused on health care, including reproductive health care, and provided contraceptives.

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--> Evaluation: Program implementation at four of the six sites was already under way by the time that evaluation began, so closely located comparison groups with similar social and demographic characteristics were identified for each of the four sites. The other two sites had not yet begun their programs, so it was possible to collect preclinic and postclinic data from the populations served. Data collection consisted of administering surveys to the entire student body or, in some cases, large samples. The surveys measured social and demographic characteristics, clinic use, general use of medical services, risk-taking behavior, sexual activity, contraceptive use, and pregnancy. Some evaluation results varied among sites. Among males, there was no significant relationship between clinic presence and the initiation of intercourse at five of the sites; at one site, clinic presence was associated with a lower proportion of male students having initiated sexual intercourse. Among females, there was no relationship at four sites, a positive relationship at one site, and a negative relationship at one site. At all sites, clinic presence was not significantly related to frequency of intercourse either among males or females. Overall, substantial proportions of students who were at sites that dispensed contraceptives used the clinics to obtain contraceptives. Among males, clinic presence was not significantly related to condom use at four sites; it was positively related to condom use at two sites. Among females, clinic presence was not significantly related to contraceptive use at five sites; it was positively related to contraceptive use at one site. Clinic presence was not significantly related to pregnancy rates at any of the sites. The researchers note that although sites that dispensed contraceptives obviously increased access to contraceptives for far more students than the other sites, providing contraceptives alone may not have been enough to increase contraceptive use. However, school and community programs and a combination of education, counseling, contraceptive provision, and careful follow-up may have increased contraceptive use. Primary Reference: Kirby D, Waszak C, Ziegler J. Six school-based clinics: Their reproductive health services and impact on sexual behavior. Fam Plann Perspect. 1991; 23:6–16. St. Paul School-Based Health Clinics Summary: One of the first school-based health clinic systems in the country providing comprehensive health care, including reproductive health care. Program: One of the first school-based health clinic systems in the country, the clinics in St. Paul, MN, have been in operation since 1973. Comprehensive health care that included reproductive health care was provided at six sites. Such

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--> services included education, counseling about how to make decisions about sexual behavior, physical examinations, contraceptive prescriptions, and pregnancy testing. A nearby hospital agreed to fill the contraceptive prescriptions for free. Nearly three-quarters of the students used the clinics for health services such as sports physicals, care for minor injuries, immunizations, personal counseling, nutrition counseling, and testing and treatment for sexually transmitted diseases. The clinics were easily accessible to the students. The clinics were staffed by nurse practitioners, social workers, medical assistants, health educatiors, and part-time physicians. Evaluation: This program has been evaluated twice, in the late 1970s and the late 1980s. The earlier evaluation found higher contraceptive use and lower birth rates among the students attending the schools with school-based clinics. This evaluation has been criticized for making comparisons over time based on a single baseline year rather than multiple baseline years, for computing birth rates on estimates made by clinic staff, and for not calculating tests of significance. The later evaluation calculated annual birth rates at each school separately (sample size ranged from 1,838 to 2,988 depending on the year). To do so, the total number of female students in each school was used as the denominator, and only those female students whose names could be matched with birth certificates were used in the numerator. The data indicated that birth rates fluctuated between individual schools and at each school for different years. The researchers could not find any evidence that the school-based clinics reduced birth rates. Contraceptive use was not addressed in the second evaluation. Primary References: Edwards L, Steinmann M, Hakanson E. Adolescent pregnancy prevention services in high school clinics. Fam Plann Perspect. 1980; 12:6–15. Kirby D, Resnick MD, Downes B, et al. The effects of school-based health clinics in St. Paul on school-wide birthrates. Fam Plann Perspect. 1993;25: 12–16. Success Express Summary: School- and community-based program emphasizing abstinence for middle school students. Program: Funded through the Adolescent Family Life Act, Success Express was an abstinence-only school-based program for sixth through eighth graders who were from primarily low-income and minority families. The curriculum was implemented across 20 sites (in schools and community centers) and emphasized attitudes, skills, and behaviors consistent with premarital abstinence. The

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--> curriculum focused on family values and self-esteem, pubertal development and reproduction, communication strategies and interpersonal skills about ''how to say no," examination of future goals, the effects of peer and media pressures, and complications of premarital sexual activity, adolescent pregnancy, and sexually transmitted diseases. Evaluation: Two evaluations were made of Success Express, both of quasiexperimental design (the first evaluation sample size was 320 students and the replication was 528 students), in the mid- to late 1980s. In both evaluations, the intervention sample consisted of five health education classess that received the Success Express curriculum; the comparison groups were students in health education classes with traditional curricula. Matched questionnaire data were collected at the baseline and after the 6-week intervention. Separate analyses were made for students who were sexually experienced at pretest and those who were not. In the first evaluation there was an increase in precoital sexual behavior among intervention participants, especially among male participants. The second evaluation found a similar trend among those male participants who had not initiated sexual intercourse. Primary References: Christopher FS, Roosa MW. An evaluation of an adolescent pregnancy prevention program: Is "just say no" enough? Fam Relat. 1990;39:68–72. Roosa MW, Christopher FS. A response to Thiel and McBride: Scientific criticism or obscurantism? Fam Relat. 1992;41:468–469. Roosa MW, Christopher FS. Evaluation of an abstinence-only adolescent pregnancy prevention program: A replication. Fam Relat. 1990;39:363–367. Thiel KS, McBride D. Comments on an evaluation of an abstinence-only adolescent pregnancy prevention program. Fam Relat. 1992;41:465–467. Summer Training and Education Program Summary: Summer school program combining work experience with educational skills and information about responsible sexual decision-making. Program: The Summer Training and Education Program (STEP) combined work experience with educational skills and information about responsible sexual decision-making. Its target audience was young adolescents (ages 14–15) from economically and educationally disadvantaged backgrounds. Students spent classroom time on mathematics and reading skills. They also received instruction that emphasized the value of planning life goals and delaying early parenthood and included information about contraception. Part-time employment was provided as part of the federal summer jobs program. The summer program was

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--> supplemented by adult mentors who met with the students bimonthly during the academic year. The program began in 1984 with five demonstration sites and 1,500 participants. It has been replicated throughout the country at 150 sites across 19 states and has served more than 40,000 adolescents. Evaluation: The evaluation at the demonstration sites used an experimental design. Adolescents were assigned to an intervention group or a control group (N = 4,800). A baseline questionnaire and follow-up questionnaires (annually for 5 years) were administered. Although students in STEP gained significant life skills knowledge, no significant differences were noted in the sexual behaviors between the two groups during longitudinal follow-up. The researchers hypothesize that once the involvement ended "there was no vehicle to reinforce and continue STEP's positive impacts … and a brief, modest intervention is no match for life and school performance problems that were already well-formed." To address the need for multiyear program involvement, Public/Private Ventures has designed developmentally appropriate options for STEP graduates. Primary Reference: Walker G, Vilella-Velez F. Anatomy of a Demonstration: The Summer Training and Education Program (STEP) from Pilot through Replication and Postprogram Impacts. Philadelphia, PA: Public/Private Ventures; 1992. Teenage Parent Demonstration Summary: Large-scale field test of a change in welfare rules and services, increasing self-sufficiency through enhanced services. Program: The Teenage Parent Demonstration was a large-scale field test of a change in welfare rules and services, similar to changes made by a provision of the Family Support Act of 1988 that mandated work-oriented activities for recipients of AFDC. The three demonstration sites instituted new eligibility requirements for low-income parenting adolescent women and included Project Advance in Illinois (Chicago) and Teen Progress in New Jersey (Newark and Camden). Approximately 5,300 young women participated in a demonstration of the new welfare policies between 1987 and early 1991. To be eligible to receive the maximum AFDC grant, the adolescents were required to participate in the demonstration project: half were randomly assigned to the regular social and support services associated with AFDC benefits, and the other half were assigned to receive enhanced services. Enhanced services included special activities oriented toward self-sufficiency, such as completing education or becoming employed, and were based on a case management system. All three

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--> sites required participants in the enhanced services group to attend workshops on personal and parenting skills, on reproductive health (including information about contraceptive methods), and on preparation for continued education and job training. The demonstration projects were held accountable for keeping the participants engaged in some useful activity such as school, work, or job training. If the participant chronically failed to engage in such activities, program staff were required to issue a request for the participant's AFDC grant to be reduced by approximately $160 a month. The primary objective of the program was to promote self-sufficiency, but one of the secondary goals was to delay subsequent pregnancy directly through knowledge acquired at the workshops and indirectly through expected increases in school enrollment, job training, and employment. Evaluation: An evaluation using an experimental design was conducted to measure a wide range of outcomes. The focus of one evaluation track was on factors that contribute to contraceptive use and repeat pregnancy. In this component, the sample consisted of the 3,400 adolescents who completed the follow-up survey at least 23 months after intake; 1,721 of these young women received the enhanced services described above, and 1,691 of them received regular AFDC benefits. Contraceptive use among participants in both the enhanced and regular services groups increased during the program: at baseline, 54 percent of the participants did not use contraception; this dropped to 17 percent by follow-up. Use of oral contraceptives increased from 29 to 49 percent, and condom use increased from 11 to 24 percent. However, as a consequence of method misuse and failure as well as substantial nonuse, 64 percent of participants had at least one repeat pregnancy within 29 months; 21 percent had two or more repeat pregnancies. Women receiving enhanced services were no more or less likely to use contraception than women receiving regular services. The likelihood of repeat pregnancy varied across the sites. For example, young women receiving enhanced services in Camden were significantly less likely to have a repeat pregnancy than those receiving regular services; young women in Newark and Chicago were significantly more likely to have a repeat pregnancy. The researchers suggest that the current strategy of offering reproductive health workshops and ensuring access to family planning services is not powerful enough to reduce the incidence of repeat pregnancies. Primary References: Hershey A, Rangarajan A. Implementing employment and training services for teenage parents. Princeton, NJ: Mathematica Policy Research, Inc.; 1993. Maynard R, ed. Building self-sufficiency among welfare-dependent teenage parents: Lessons for the Teenage Parent Demonstration. Princeton, NJ: Mathematica Policy Research; June 1993.

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--> Maynard R, Rangarajan A. Contraceptive use and repeat pregnancies among welfare-dependent teenage mothers. Fam Plann Perspect. 1994;26:198–205. Teen Outreach Program Summary: School-based program involving students in community volunteer service, designed to reduce adolescent problem behaviors. Program: The Teen Outreach Program is a school-based program involving students in community volunteer service and is designed to reduce problem behaviors such as school suspension, failure of courses in school, dropping out of school, and adolescent pregnancy. The program, which began in St. Louis, MO, in 1978, is implemented by local junior leagues or other community groups, and has served more than 4,000 students ages 11–19 at more than 130 sites nationally. The program consists of two major components: student volunteer involvement in the community and facilitator-led small group discussions. It has been suggested that the program's emphasis on volunteerism applies the "helper-therapy" principle and also increases the identification of adolescents with adults in the larger community, thus fulfilling the social development needs of the adolescent. The curriculum component of the program focuses on life options and includes topics on life planning, communication skills, family relationships, and community responsibilities. Although the curriculum contains some traditional sex education information, such information is not its primary emphasis. Evaluation: A national evaluation system has been maintained since 1984. Evaluations of 5 academic years (1984–1985 to 1988–1989) suggest positive results for intervention students. For example, when the five academic years are analyzed together, program students had significantly lower pregnancy rates than the comparison students (3.2 versus 5.4 percent, respectively). These results remain after analyses have controlled for grade level, gender, racial/ethnic status, parents' level of education, household composition, and problem behaviors at the start of the program. (Although the overall evaluation is quasi-experimental, an experimental study within the larger evaluation indicates that the program results for the students who were randomized did not differ from program results obtained from those who were not randomized.) Over time, the evaluation emphasis has moved beyond the traditional focus of program outcomes by attempting to link specific program components with various effects for students at different ages. For example, sites that most fully implement the volunteer service component are more successful in decreasing problem behaviors than those sites that do not. The program also appears to be more effective for older students. Most recently, another small study was again

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--> embedded in the larger evaluation; data were collected from 66 sites and more than 2,000 students. In this study, promotion of student autonomy and feelings of relatedness were predictive of reduced levels of problem behaviors in the younger students. A self-reported high quality, although not quantity, of volunteer work was also related to positive results in the younger students. Primary References: Allen JP, Kupermine GP, Philliber S, Herre K. Programmatic prevention of adolescent problem behaviors: The role of autonomy, relatedness, and volunteer service in the Teen Outreach Program. Am J Commun Psychol. Forthcoming. Allen JP, Philliber S, Hoggson N. School-based prevention of teen-age pregnancy and school dropout: Process evaluation of the national replication of the Teen Outreach Program. Am J Commun Psychol. 1990;18:505–524. Philliber S, Allen JP. Life options and community service. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992. Teen Talk Summary: Sexuality education program based on the health belied model and social learning theory. Program: The Teen Talk sexuality education program was based on the health belief model and social learning theory. The target population was adolescents (ages 13–19), 80 percent of whom were low income or from inner-city families in California and Texas. The 12- to 15-hour curriculum was designed to make adolescents aware of the seriousness of adolescent pregnancy and the probabilities of such a pregnancy happening to them, as well as the benefits of and barriers to abstinence and contraceptive use. Content areas included discussion about reproductive and contraceptive information, values, feelings and emotions, decision-making, and personal responsibility. Small group discussion format was a key feature, and lectures, leader-guided discussions, role-playing, refusal skills, script-writing, and guided practice were used to implement the program. The program was staffed by trained family planning educators and school staff. Evaluation: Between June 1986 and September 1988, the evaluation compared the program with several publicly funded community-based and school-based interventions. Using an experimental design, the researchers randomly assigned either individuals or classroom units (N = 1,444) to intervention and control

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--> groups. The intervention and control groups completed questionnaires at baseline, postintervention, and 1 year after the end of the program. Some 62 percent of the original sample completed the 1-year follow-up questionnaire. Investigators measured a variety of personal factors and attitudes (such as perceived probability of pregnancy occurring, feelings about the seriousness of a pregnancy, etc.) and then related these factors to the outcome measures. Males in the intervention group were significantly more likely to remain abstinent than males in the control group (p < 0.05) at the 1-year follow-up. There did not appear to be a similar program effect on women. Among participants who became sexually active following the program, women in the control group were significantly more likely to have used contraception at last intercourse (p < 0.01). Among participants who were sexually active before the program, all groups showed significantly more contraceptive use at the 1-year follow-up; however, men in the intervention group were significantly more likely to use contraception than men in the control group (p < 0.05). The researchers suggest that the program appeared to have the most positive effect on high-risk young men, but was less useful for young women in general and for young women making the transition to sexual intercourse in particular. Primary References: Eisen M, Zellman GL. A health beliefs field experiment. In Preventing Adolescent Pregnancy: Model Programs and Evaluations. Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Newbury Park, CA: Sage Publications; 1992. Eisen M, Zellman GL, McAlister AL. Evaluating the impact of a theory-based sexuality and contraceptive education program. Fam Plann Perspect. 1990; 22: 261–271.