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6 Preventive Interventions In the past I; years, there has been dramatic growth in the number and variety of interventions aimed at preventing teenage pregnancy and child- bearing. Many programs have been promoted and supported by the federal government, others have been initiated by states and local commu- nities, and still others have developed as a result of investments by private foundations and philanthropic groups. Virt~ly all represent strong un- derly~ng assumptions concerning the nature of the problem and what constitute the most appropriate and effective approaches to solving it. Preventive interventions are programs aimed at helping yoking women avoid unintended pregnancy and childbearing. They are of three general types (D:yfoos, 1983~: · those that impart knowledge or influence attitudes, · those that provide access to contraception, · those that enhance life options. The first two categories represent traditional approaches tO pregnancy prevention through increased knowledge and access to services; the ma- jonty of programs are of these types. They are aimed at enhancing young people's ability to avoid early childbeanng, and they are intended to directly influence the process of decision making by adolescent girls (and boys) at the time of choice (e.g., initiation of sexual intercourse, contra- cepove use, pregnancy resolutions Preventive interventions In the third category are Intended tO influence sexual decision making indirectly by developing and strengthening adolescents' "motivation to avoid early childbearing" (Dryfoos, 1984c). They are based on the assumption that 142
142 ADOLESCENT SEXUALITY PREG.~A.~CY AND CHILDBEARING broadening opportunities, especially through educational enhancement, will provide meaningful alternatives to childbeanng. In addition, efforts to coordinate arid strengthen prevention strategies at the community level have been launched by several coalitions and interest groups. Although many preventive interventions have been developed and implemented, few have been rigorously evaluated. There are several rea- sons for this lack of systematic information on effects and effectiveness. First, many programs have failed to clearly define objectives as a basis for measuring outcomes; they have also frequently failed to distinguish direct and misdirect outcomes. Deducing the number of early unintended preg- nanc~es, for example, is not an explicit objective of many preventive programs other than family planning services, even though it may be an unportant secondary outcome. Programs designed to increase knowledge and influence attitudes, as well as those intended to enhance life options, are frequently unable to show long-term changes in pregnancy rates. They may, however, significantly affect other factors, such as school achieve- ment and peer influences, which have been shown to be related to adoles- cent sexual behavior. Second, unlike a reduction in the number of births to teenagers, a reduction ~ the number of pregnancies is often difficult to measure. Because many pregnancies are terminated by abortion and some end In miscarriage, conceptions are frequently IlOt reported. Third, reductions in the number of pregnancies may resect a variety of factors other than or in addition to program effects, for example, changes In the age and racial characteristics of the local target population; eco- nomic changes, such as the opening or closing of a pelt that may alter locd employment and income opportunities; changes in local school policies and school populations, such as those caused by busing, school closings, and redistnci~ng; and the availability of other cornmun~ty health, social service, and income programs. All these kinds of factors can confound the results of evaluation in ways that are difficult to detect. Finally, in addition to methodological impediments to accurate evalua- tion of programs, there are several practical problems. Evaluation research is expensive (often as costly as the program itself), and project grants and contracts have all too often failed to include Mods earmarked for outcome measurement. Service providers typically lack the necessary research ~a~n- ing and technical skills to mount a sophisticated evaluation, and the time to COll6UCt it appropriately. Moreover, programs are oRen fended for 3- to 5-year periods, while the measurement of effects and effectiveness should
PREVENTIVE INTERVENTIONS 143 conimue over longer penods to generate useful information concerning outcomes. In short, knowledge about preventive interventions is incomplete, and assessments Eequently have not linked direct and indirect results. Yet accumulated program experience, along with a growing body of evalua- tion data, provides some insight into how venous approaches work, for whom, under what circumstances, at what costs, and with what intended and unintended consequences. The remm~g sections of this chapter summarize what is known about venous preventive interventions of the three specified types. PROGRAMS THAT IMPART KNOWLEDGE AND/OR INFI~VENCE ATTITUDES A vanety of programs has been developed tO impart knowledge about sexual behavior, human relationships, reproduction, and contraception and tO influence teenagers' attitudes about seniority and fertility. These have included sex education and family life education courses, assertive- ness and decision-making training, programs to encourage family com- mun~cation, teenage theatre projects, and popular media approaches. These programs are provided by an array of community institutions, including schools, churches, youth service agencies, and public health agencies. In some cases programs have been developed and implemented as discrete mtervennons; In other cases they have integrated more than one approach. Sex Education arid Family Lime Education Sex education (i.e., the communication of inforrnat~on concerning human reproduction and family relationships), once regarded as the rev sponsibiiity of parents and guardians, has tO some extent become an accepted part of public education. Despite occasional conflicts that Stat anse at the local level, a substannal majonty of the Amender public agrees that children should know about the reproductive process ~ order to develop the capability to make informed decisions about their own sexual behavior. Moreover, public opinion pods mBicate that most adults parents and nonparents alike favor sex education 3= schools (Gallup, 1978, 1980; NBC News, 1982; Smith, 1980~. Not surpns~gly, adoles- cents also express strong support for sex education programs (Norman
144 ADOLESCENT SEXUALI71; PREGNANCY: ACID CHILDBEARING and Harris, 1981~. This broad public support has become manifest in the politick process as wed. Over the past decade, state guidelines for sex education have become progressively more supportive. By 1981, only 7 of the 50 states discouraged and only ~ state prohibited instruction on specific topics (Kirby and Scales, 1981~. When conflict does anse, in general it is no longer over whether schools should play a role In sex education, but rather over the inclusion of specific controversial topics, such as contracep- tion, abortion, or homosexuality (Hottois and Milner, 1975~. As a result, sex education in schools is burgeoning. A 1982 national survey of 179 school ~istucts in large Sties, jointly conducted by the Urban Institute and the National Association of State Boards of Educa- tion, found that three-quarters of school ~istncts pronded some sex education in their high schools and junior high schools md two-thirds provided it in their elementary schools (Sonnenstein and Pittman, 1982). These reports are consistent with surveys of individual adolescents, three- quarters of whom report having had some sex education before leaving school (Zelcik and Kim, 1982~. While schools across the country demonstrate strong agreement on.the goals of sex education, they differ somewhat in the content and compre- hensiveness ofthe~r programs. One study reports that 94 percent of school districts agree that a major goal is to promote rational and wfonned decision making about sexuality; 77 percent agree that a goal is to increase a student's kIIowledge of reproduction; 25 percent report that a goal is to reduce the sexual activity of teenagers; and 21 percent say that a goal is to reduce teenage childbearing (Alan Guttmacher Institute, 1981, as refer- enced ~ Hofferth, Vol. Il:Ch. 9~. Most schools offer short programs, 10 hours or less, that tend to focus on the basics of anatomy, human reproduction, and physical and psycho- log~cal changes during puberty; they are often integrated with other courses, such as health or physical education. Very few schools offer comprehensive programs of more than 40 hours, and, even In schools that do over comprehensive programs, not aH students take the courses (Son- nenstem and Pittman, 1982~. Kirby (1984) estimates that less than 10 percent of ad students take comprehensive sex education courses. Although to date there has been no systematic renew of elementary school curricula, Kirby (1984) reports that very few schools Include sex education in the early grades. Those that do generally focus on correct names for body parts, reproduction in animals, family roles and responsi- bilities, and basic social skills In the fifth and sixth grades, many schools
PREVENTIVE INTER MENTIONS 143 do provide sessions on the physical and emotional changes that take place during puberty, but few cover social interaction such as dating and inter- course (Kirby, 1984~. Injunior high schools, many schools cover anatomy, the physical and psychological changes of puberty, reproduction, dating, responsibilities in interpersonal relations, and sexually transmitted dis- eases. A smaller proportion teach about contraceptive methods. High school programs typically include a wider variety of topics, ~nclud~g teenage sexuality, pregnancy, and childbirth, as well as those taught at the junior high school level (Orr, 1982~. About three-quarters of the separate courses at the high school level cover family planning, contraceptive methods, and abortion. About half include masturbation and homosexu- ality. Very few programs incillde inflation on sexual techniques (Kirby, 1984~. In general, the more comprehensive the program, the wider the variety of topics covered and the greater the depth of coverage of basic tOplCS. Instruction in values as a part of sex education has been controversial. Some educators have advocated a value-free approach in order to avoid offending individuals and families with different onentations and to en- courage teenagers to make decisions about sexual matters in light of their own values and beliefs. More recently, however, there has been a trend toward teaching what are regarded as basic universal values for example, "AD people should be treated with respect and Eighty"; "in~ivI3uais shows cannery consider the consequences of their actions for themselves, others, and for society" (Kirby, 1984~. Comprehensive programs typi- caDy devote more rime to ciari~g values ard increasing decision making and communication skids than shorter programs do. In addition to what is taught In schools, other community organiza- tions have developed and implemented programs: family planing agen- cies such as Planned Parenthood, churches, and other youth-serv~ng orga- n~zations such as the YWCA, Giris' Clubs, Boys' Clubs, Scouts, and the Salvation Army. Both ideologically liberal and conservanve organ~zanons now offer programs that reflect their particular values on issues of human sexuality. Among both school-based add commun~ty-based programs there is evidence of ~ncreas~g efforts to involve parents, on the assumption that improved parent-child communication on issues of sexual behavior, con- tracepiion, abortion, mamage, and childbearing may help teenagers make more rational decisions. Similarly, a few programs have begun to use peer counseling approaches that is, to train selected young people to talk
146 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING with peers an] serve as information resources- on the assumption that teenagers may find it less embarrassing tO ~iS=SS these matters among themselves and that they are likely to listen to and follow the example of other young people whom they admire and respect. Evidence of the effectiveness of these approaches is limited. Kirby (1984) found that among young childrerl, parent-child programs improved both children's and parents' perceptions of children's comfort in talking about sex and birth contro!in the short run, although their perceptions were not signifi- cantly Unproved in the long run. Among older children the program had fewer positive effects, but it still appears to have increased somewhat the comfort and frequency of parent-child conversations about sexuality. Peer approaches have not been carefully evaluated; however, Talbot et al. (1982) examined a broad range of peer advocate programs and found that they seemed to have a large effect on peer participants: they appeared to raise consciousness among those trained as peer educators, and these young people benefited from their responsibility to instinct and counsel others. The eject of these programs in actually reaching peers, especially males, however, seems questionable (Talbot et al., 1982; Dryfoos, 1985~. More recently, many schools and community organizations are teach- mg about sexuality in the broader context of family life education. While family life education vanes substantially in its content and focus, typically it includes attention to (~) the roles and responsibilities of families; (2) social problems in families, such as child abuse and sexual abuse, divorce, drug and alcohol use, and teenage pregnancy; (3) social and personal ~nteracuon with parents, peers, the opposite sex, and persons who are racially and culturally different; (4) the life course, including Important events and transitions Tom birth to death; (5) family Connation, including marriage, childbearing, and career and financial planning; (6) body struc- ture, functioning, hygiene, and disease; and (7) sexuality. In addition, family life education courses tend to emphasize values and attitudes (Muraskin and Jargowsky, 19851. Several recent studies of sex education and family life education pro- grams have shown them to be effective at increasing students' knowledge and understanding of these subjects (Kirby, 1984; Eisen et al., 1985; Finkel and Finked, 19841. Kirby (1984) found that younger students showed greater knowledge gains than oider students, although this may simply reflect the [act that they had more to ream. This study also found that longer, more comprehensive courses did not appear to have a signifi- cant~y greater impact on knowledge than did shorter courses.
PREVENTIVE INTERVENTIONS 147 There is some evidence that sex education may influence attitudes, but as Hofferth (Vol. Il:Ch. 9) points out, research to date has documented only limited effects. Although it appears to make students more tolerant of others' attitudes and behavior, it has not been found to alter Endive duels ' attitudes and beliefs about nonmantal sexual activity, birth control, gen- der roles, sexuality ~ life, and the importance of family. Despite the fact that less than one-quarter of school districts cite fertility control as a program goal, there has been substantial public interest in how sex education affects behavior. Many critics have expressed concern that teaching sex education promotes early or more frequent sexual activity among teenagers. Others have womed that it may not be effective enough in promoting responsible contraceptive practice among sexually active young people (Zelnik and Kim, 1982; Kirby, 1984; Cooper, 1983). Available studies have found no association between the probability of initiating sexual activity and having had sex education (Zeinik and Kim, 1982; Kirby, 1984; Furstenberg et al., 1985a). Zeinik aIld Kim (1982) found that among teenagers who were already sexually active, those who reported receiving some sex education were somewhat more likely to use contraception and somewhat less likely to become pregnant. As Hofferth (Vol. Il:Ch. 9) points out, however, these data are based on survey responses with only a limited number of questions from which to infer the relationship between sex education and sexual decision making. Thus, while the results are useful, they are not de~itive. In contrast, In the programs he studied Kirby (1984) found no effects on contraceptive use (frequency of either intercourse without contraception or effective use of contraception) or on pregnancies. Again, however, some caution is required ~ generalizing from these results. Programs included for assessment ~ this study were not randomly selected but instead repro sensed the range of variation In approaches and providers. Preference was given to those considered "potendaDy effective." Opportunities for following participants long enough to detect change in pregnancy rates was seldom possible. Accordingly, as Hofferth (Vol. Il:Ch. 9) concludes, although helpful, the existing evaluation research on sex education is not sufficient to judge with absolute certainty the effects and effectiveness of these programs. Complete arid accurate COSt data for sex and fancily life education programs are DOt available. Yet, as D:yfoos (1984c) reports, they are low relative tO the COStS of many other prevention programs, and dramati- caDy Tower than the COStS of programs tO support adolescent mothers and
148 ADOLESCENT SEXUALITy PREGNANCY; AND CHILDBEARING their children. A recent study of the COStS of prevention services in Illinois reported the average cost per student at $10 per year (Reds, 1984~. Assertiveness and Decision-Making Training A second intervention intended tO impart knowledge arid change attitudes about sexual behavior is assertiveness and decision-making training. Several programs of this type have been developed in recent years, usually as an adjunct to sex education, not an alternative. In some cases the approaches embodied in these programs have been included as components of comprehensive sex education programs (Kirby, 1984~. Typically, their goal is to teach problem-solving skins, decision-making skills, and interpersonal communication skills in order tO help young people employ knowledge about reproduction and contraception in developing and implementing personal approaches tO sexual activity. These skills are taught through a variety of techniques that includes modeling, role playing, and rehearsal. Some programs take no explicit value position on sexual behavior; instead they encourage each partici- pant to develop his or her own objectives and carry them out (Schinke and Gilchnst, 1984; Schinke et al., 1981~. Others promote sexual absti- nence by counseling adolescent girls and boys on how to resist pressures to become sexually active before they are ready for such involvement. Many projects of this type employ peer counselors. Schunke et al. (1981) provide evaluation data for a small number of subjects who participated in the Life SkiDs Counseling program in Seattle, Wash. The results show that the young people who took part in the course had better problem-sol~ng and communication skills and more knowledge of reproduction and birth control than those who did not. They also had more favorable attitudes toward contraception, more diligent contraceptive practice, greater likelihood of contraceptive use at last intercourse, and greater reliance on more effective methods than did subjects in the control group. As Hofferth (Vol. Il:Ch. 9) notes, unfor- tunately no information was reported on sexual activity. In addition, while encouraging, these findings are based on a very small and probably self-selected group of participants. The approach would have to tee tested on larger and more representative populations before its effectiveness could be projected The Postponing Sexual Involvement program in the Atlanta, Ga.
PREVENTIVE INTERVENTIONS 149 public schools is aimed primarily at teenagers under age 16. Its purpose is to help young people delay the initiation of sexual activity until they are ready for such involvement. Ong~nally designed as an optional series of four 90-m~nute workshops for students and their parents, it is now being implemented as a mandatory s~x-week course for all eighth graders. Peer counselors are being used in some discussion groups. No evaluation data are currently available. As with the Seattle program, preliminary indica- tions are that this may be a promising approach, especially for girls; however, evidence to support broad claims of effectiveness does not currently exist. No cost data are available for programs of this tilde. Family Communication Programs J ~ Several programs are currently under way with support from the federal Office of Adolescent Pregnancy Programs (OAPP) to prevent or delay early sexual activity among young teens by improving parent-child communication. They are intended to develop and test approaches to " enable parents to better communicate their values and attitudes regard- ing sexual behavior to their children and to help their adolescents de- velop positive self-concepts and improved decision-making skills to en- able them to exercise greater responsibility over their sexual behavior" (Montana State University as quoted in Hofferth, Vol. IT:Ch. 9~. Many are based on Fundamental communications techniques for example, taking time to establish relationships, recognizing natural commu:iica- tion barriers, focusing on the adolescent's concerns and interests, and getting parents tO share their own thoughts and feelings. The majority of these projects have just begun and evaluation results are not yet available. Nevertheless, as Ho~erth (Vol. Il:Ch. 9) concludes from a renew of their evaluation plans, it seems unlikely that they will provide much evidence of effectiveness in preventing unintended pregnancies. Although most of the evaluations will measure effects on parent-child communication and related values and attitudes, few will actuary mea- sure impact on sexual activity among adolescent participants. Another program of this type, the Family Communication Program Implemented in San Francisco and Fresno, Calif., dunng 1981 and 1982, was aimed at increasing the frequency and improving the quality of parent-child commun~cai~on about sexuality and thereby ultimately re- ducing unintended pregnancies. Unlike the OAPP projects, this pro- gram made no attempt tO specify the content of parent-child communi
150 ADOLESCENT SEXUALITY; PREGNANCY; AND CHILDBEARING cations. Instead it mobilized a variety of community groups to work with parents and teenagers and developed a media campaign using radio and television advertisements as well as publicity and printed materials. An evaluation of the program found that it increased the number of parents who reported that they "use every opportunity" tO teach their children about sex and that these parents minated discussions of sexual- ity more often than their children. The evaluation also showed that television was more effective than other media forms in reaching the public (Public Response Associates, 1982~. In sum, research on the electiveness of family communication ap- proaches has shown that such programs or program components (e.g., within broader faintly life education programs) can be effective in the short run at increasing parent-child discussions of sexual topics. But there is no direct evidence of how long-lasting these gams are, nor of the effectiveness of these programs in reducing the madence of unintended pregnancy. Data on program costs are DOt available. Moreover, as dis- cussed in Chapter 4, support for the hypothesis that such cornmunica- tion actuary discourages early sexual activity is weak, but there is some evidence that mother-daughter communications may encourage contra- ceptiveuse (Furstenberg, 1976; Flaherty and Maracek, 1982; Fox, 1980, 1981). Teenage Thea tre In recent years, numerous community organizations have Initiated theatre projects in which brief skits portraying the negative conse- quences of early childbeanng are presented. Generally the projects m- volve teenagers themselves in preparing the scripts, staging the produc- tions, an] acting the parts. Some have involved live stage productions schools and community organizations; others have involved radio and television spots accompanied by information concerning local family planning, maternal and child health, or other relevant health and social services. Based on the assumption that peers can significantly influence teenagers' attitudes and behavior, teenage theatre projects have sought tO raise consciousness about sexual activity, pregnancy, add childbeanng among adolescents and to pronde outreach for local service agenaes and . . organizations. One particularly interesting example of this type of project is a 30- episode soap opera produced by the Tacoma-Pierce County, Wash.,
PRE~ENTIVEINTERVENTIONS 151 Health Department that was presented in 60-second spots on a local rock radio station. The soap opera, called "General High School," portrayed a typical sequence of circumstances requinug social dec~sion-mak~g skids by teenage boys and girls and then played out the consequences of the characters' decisions concerning their sexual and fertility behavior (Dryfoos, 1984c). No evaluation data are available to indicate the effectiveness of such projects ~ increasing teenagers' awareness and understanding of the issues associated with early sexual activity, pregnancy, and childbearing or in changing their attitudes or behavior. Nevertheless, they have increasingly attracted the interest and attention of youth leaders and health and somal sernce providers. Media Approaches A growing number of professionals, service providers, and concerned advocacy groups have begun to experiment with media initiatives to raise consciousness about the issues of adolescent pregnancy and child- bearing and to provide outreach to teenagers in need of support and services. These have taken the form of public seance announcements on radio and television as well as organized efforts to influence program- m~ng content on afternoon and evening television. in this regard, the Center for Population Options (CPO) has initiated a Los Angeles-based media project intended to serve as a factual resource for television programmers and to encourage more responsible presenta- tion of sexual content. In particular, the project has been concerned with the portrayed of male-female relationships and nonmantal sexual activity, as well as the lack of attention to pregnancy prevention and responsible contraceptive use. The project has not been formally evaluated, but CPO staff report that TV executives acknowledge the power of ratings in choosing programming content. While there is no general guide for the treatment of sexuality, network executives consistently avoid sub- Sects, such as contraception and abortion, that are riot considered "enter- t~in~g" and that seem likely to offend some significant proportion of viewers. The notable exceptions are several investigative news reports, talk shows, and caD-~n shows that have begun to address these topics ~ a more candid manner. While this kind of programming has helped create a growing awareness of the issues of early sexuality and fertility, it has focused on problem behavior, for example, sexually transmitted disease
152 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING (unpublished CPO memorandum, April 23, 19851. In short, although media project staff report that telension programmers sometimes call to check the accuracy of some matenal, they have been slow to change their programming approach to sexuality issues. Public sernce announcements represent another avenue for using radio and television to raise consciousness about adolescent pregnancy and childbeanug and for reaching out to teenagers in need of health and social services, especially family planning services. Although the pane] discovered several projects that had prepared and distributed public service announcements primarily to radio stations, the number was remarkably few. None has been carefully evaluated, although the Center for Population Options initiated one project in 1982-1983 that included an evaluation design: the Adolescent Media Project was intended to determine the relative effectiveness of reaching Washington, D.C., youth with sexuality and family planrung information through public sernce announcements, bus cards, and handout fliers. Each advertised a CPO telephone hot line for teenagers to cat for information, counsel- ing, or referrals to area family planning clinics. Three types of public seance announcements were prepared and distnbuted to local youth- onentedradio stations? including (~) tapes featunugprom~nent rock and athletic stars promoting responsible sexual behavior among young peo- ple and citing the hot line telephone number; (2) "live copy," to be read on the air by radio staff, featunug commonly held "myths" about sexuality and fertility and urging listeners to call the hot line for addi- tional information; and (3) live copy that was less explicit in its language about security aIld contraception and conveyed the message that absti- nence is acceptable, urging listeners to caD the hot line for additional . . . in: :ormatlon. The Adolescent Media Project did Dot produce scientific ewdence, but it did provide several interesting insights. [first, many stations were unwilling to play the tapes, preferring live copy for their disc jockey to read. Second, station public service directors were frequently unwilling to air the messages (live or recorded) dunug prime listening hours. Third, station public service directors were most receptive to public sernce announcements that addressed the issues of adolescent sexuality and fertility much less explicitly. Overall, the radio public service mes- sages were more frequently cited as the source of referral to the hot line than either the bus cards or the handouts, suggesting the potential electiveness of such merlin campaigns, if they are able to present their
PREVENTIVE INTERVENTIONS 153 content so that it appeals to teenagers but does not offend radio execu- tives. A third media approach 20 increasing adolescent awareness of sexual responsibility and the use of contraception is contraceptive advertising. As discussed in Chapter 3, television networks and radio stations in the United States have been reluctant to advertise nonprescription contra- ceptive methods for fear of offending some of their audience. Yet the experience in Europe offers some interesting points of comparison in this regard. Alan Gutemacher Institute researchers report that in the Nether- lands and Sweden, where nonprescription methods are advertised openly on television and in the popular media, teenagers, when questioned, demonstrate a greater awareness of alternative means of birth control. Although there is no scientific evidence that contraceptive advertising has actually increased contraceptive use among teenagers in these coun- tnes, the researchers found that adolescents believed these methods were easily accessible to them (Alan Guttmacher institute, in press). Media approaches, especially through public service announcements, seem to be relatively undeveloped and potentially effective infonnation and outreach tOOiS. Simiiarly, contraceptive advertising on television and radio may be a useful means of raising teenagers' awareness of the need for contraception and of making them fee] that contraceptive methods are easily accessible. However, evaluation of these types of intervention is problematic, since it is difficult to determine what proportion of the target youth population is actually reached by such messages. PROGRAMS THAT PROVIDE ACCESS TO CONTRACEPTION Family planning services include a variety of health, educational, and counseling sernces related tO birth control, including contraceptive seances, pregnancy testing and counseling, and information and refer- ral. Family planning services are available to teenagers from organized health service providers, such as public health departments, local hospi- tal outpatient clinics, school-based clinics, and private, freestanding clime facilities, as wed as from priorate physicians. Some family planning service providers offer a All range of reproductive health services, inciud- ing testing and treatment for sexually transmitted diseases, obstetncs, abortion, and sterilization. However, most refer obstetrical, abortion, or sterilization patients to specialized hospital and clinic facilities or to . · . pnvate p. :lyslclans.
154 ADOLESCENT SEXUALITY; PREGNANCY; AND CHILDBEARING Contraceptive Services Oral contraceptives, diaphragms, and intrauterine dewces (lUDs, rarely used by teenagers) must be obtained through a physician In private practice or in family planning or other health care clinics. Condoms and spermicides can be purchased at pharmacies, and, in some areas, other types of stores. In 1982, 73 percent of teenage women using contracep- tives relied on the pill, an JUD, or a diaphragm; of these, 90 percent used the piL (Bachrach, 19841. Of those teens who had used any farruly plating sernces, 45 percent had last used a private physician, 49 percent a clinic, and 6 percent a counselor. Teenagers' first source of contracep- tive services was slightly more likely to have been a clinic (~3 percent) than a private physician (41 percent) (Pratt and Hendershot, 1984~. Black teens are more likely to rely on a clinic as their first source of prescription contraception than to visit a priorate physician (72 versus 28 percent), while white teenagers rely almost equally on both sources (48 versus 52 percent) (Zeinik et al., 1984~. In 1983, there were S,200 family planning clinics ~ the United States (Table 6-~. AH but 5 percent of sexually active adolescents lived in a county with at least one clinic, although 14 percent in nonmetropolitan counties had no cynic nearby (Table 6-21. In 1983, 5 million patients were served in these climes; about one-th~rd of them (~.6 million) were under age 20. Of these teenage clinic patients, 57 percent were ages 18-19 and 43 percent were under age 18 (Table 6-3~. TABLE 6-! Number and Percent Distribution of Family Planning Clinic Services ~ the United States, 1983 __ HealthPlanned TotalHospital DepartmentParenthoodOcher Agencies2,462275 1,419182;86 (lOOj(11) (58)(7)(24) Clinic sites:,174377 2,9286981,171 (100)(7) (57)(13)(23) Panents (thousands)4,966oo1 1,9741,3881,053 (100)(11) (40)(28)(21) Average number of paiieD:s per site9601,462 ~ 9B9~9 SOURCE: A. Torres and J.D. Forrest, 198S, "Family Planning Clinic Seduces in the United States, 1983," Family Planmng Perspectives 17~1~:32, January/Febru~y. Rev printed by perniission.
PREVENTIVE INTERVENTIONS 133 TIBIAE 6-2 Teenagers and U.S. Counties Without Family Planning CTimcs, 1983 Total Metro Nonmetro Number of counties with no provider and as percentage of all U.S. counties Women under age 20 at risk of unintended pregnancy (thousands) and as percentage of all women under age 20 at risk 7~7 (24) 249 (5) 57 (8) 79 (2) 700 (29) 171 (14) SOURCE: A. Torres and ].D. Forrest, 1985, "family Planning Clinic Services in the United States, 1983," Family Planning Perspectives 17~1):31, lanuary/February. Red printed by permission. Public health departments served 40 percent of all patients, Planned Parenthood clinics served 28 percent, and hospital clinics served Il percent; clinics run by a variety of other community-based organizations served 21 percent (e.g., neighborhood health centers, women's health centers, community action groups, etc.) (Table 6-~. The core of services provided to teenagers at an initial Visit to a family planning cImic includes: information concerning the range of contracep- ti~re methods, their use, eRectiveness, and potential risks; counseling in the choice of an appropriate method; medical assessment mVOlV3ng a pelvic exam, breast exam, blood pressure check, blood test, and a Pap smear. About two-thirds of all first nsits include a pregnancy test and urinalysis to test for possible contraindications to the use of some contra- cep~ve method. In addition, about two-thirds of all first visits include testing for sexually transmitted disease (Torres and Forrest, 1985~. Al- though many clinics have made attempts to reach and serve young men as well, they have generally had little success. Family planning clinics tend to be female-onented in their approach and In the primary health and social services they offer, and therefore are rarely Visited by young men unless they are accompanying a female partner. Family planning clinics are generally more willing to provide contra- ceptive services to unmamed adolescents under age 18 without parental consent or notification than are private physicians. Among organized providers, only ~ percent of Planned Parenthood affiliates have consent or notificat~or~ requirements, while 10 percent of public health depart- ments and other providers and 19 percent of hospitals require that parents are either informed or give permission for minors to receive services. A somewhat larger proportion offamily planning agencies have
156 ADOLESCENT SEXUALITY; PREGNANCY; AND CHILDBEARING TABLE 6-3 Number of Patients Under Age 20 Served by Family Planning Providers, 1969-1983, in thousands YearPatients Under Age 20 Patients Ages 18-19 Patients Under Age 18 . 1969214 N/A N/A (20) - 1970300 N/A N/A (21) ~ - 1971460 N/A N/A (24) - - 1972691 460 231 (27) (18) (9) 1973855 oo3 302 (28) (18) (10) 197494; 581 358 (29) (18) (11) 19751,17; 725 450 (30) (18) (12) 19761,237 734 503 (30) (18) (12) 19771,303 747 ;36 (31) (18) (13) 19781,451 804 647 (32) (18) (14) 19791,478 810 668 (33) (18) (15) 19801,;32 8SO 682 (33) (18) (lo) 1981- 1,508 823 68o (33) (18) (15) 1982N/A N/A N/A 19831,~68 89o 673 (32) (18) (14) NOTE: Numbers in parentheses indicate percentage of all patients. °Data provided are for fiscal years through 1974, and for calendar years thereafter. SOURCE: Alan Gut~macher Institute, 1984, Organized Family Planning Services in the ZJnited States, 1981-1983, New YorI;, AGI. Repnnted by permission. parental consent or notirScation requirements for teenagers under 15 (Torres et al., 1980~. Data from a national sample of private physicians show that 86 percent of obstetnc~an-gynecologists, general practitioners, an] pe~iatncians are willing to provide contraceptives to adolescent women. However, only
PREVENTIVE INTERVENTIONS 137 59 percent indicated a willingness to serve unmarried minors without parental consent. Obstetrician-gynecolog~sts are more likely to serve teenagers than the other physician specialists and are likely to have fewer policy restrictions. Pediatricians were found least willing to serve teen- age family planning patients and were most likely to refer them to other sources of care (Orr, 1984b; Orr and Forrest, 198;~. Physicians' willing- ness to serve unmarred minors without parental consent is somewhat related to state policies. In 29 states and the District of Columbia, minors are specifically authorized to give their own consent for family planning services. In the other 21 states, either there are no such laws or the laws are ambiguous. Physicians in states that do not have explicit consent laws for minors were found significantly less likely to serve unmamed teenag- ers on their own authority (Orr, 1984b). Thus, in practice, young teenagers have less access to contraceptive services through private phy- sic~ans than through clinics. Researchers at the Alan Guttmacher Institute estimated that in 1981 more than 5 minion young women ages 15-19 were at risk of an unintended pregnancy; 57 percent of them received family planning services during that year-approximately 30 percent from organized programs and 21 percent from pnvate physicians (Torres and Forrest, 1985~. Family planning agenaes offer a variety of seances in addition to contraceptive counseling and service (Table 6-4~. Almost aD offer preg- nancy testing and counseling and testing for sexually transmitted dis- ease. Between 40 and 50 percent provide prenatal care, special training for staff working with teenagers, teen outreach, and programs for parents of teenagers and for teenage mothers. Only 20 percent have programs for boys, however, and only ~ percent of the caseload is male. Family planning clinic patients are predominately poor, reflecting the intent of these programs, most of which receive Title X funding, to make services available to disadvantaged women. In 1983, 83 percent of patients reported incomes below 150 percent of poverty and 13 percent were receiving public assistance (Torres and Forrest, 19851. The number of adolescents using family planning clinics increased dramatically be- tween the program's beginning in 1969 and 1983 from 214,000 to t.6 million. The proportion ofteenage clinic patients increased quickly from 20 percent in 1969 to 27 percent in 1972, 30 percent in 1975, and 33 percent In 1979; subsequently, it has been stable at 32-33 percent. Patients under age 18 accounted for nearly all of the increase from 9
158 ADOLESCENT SEXUALITY; PREGNANCY AND CHILDBEARING TABLE 6-4 Services Provided by Family Planning Agencies, 1983 Service or Program . . . Percentage Pregnancy Testlog Counseling Sexually Transmitted Diseases Testing treatment Infertility Counseling Treatment Prenatal care Genetic counseling Community education Special stalk Mining for helping teenagers Teen outreach Programs for parents Programs for adolescent mothers Programs for young men 99 92 go ~1 60 19 46 32 79 47 44 ~0 39 20 SOURCE: A. Torres, 1984, `'The Effects of Federal Funding Cuts on Family Plan- ning Services, 198~1983," Family Planning Perspectives 16(~):137, May/June. Re- prmted by permission. percent ~n 1972 to 15 percent in 1979. The proportion of 18- to 19-year- old clime patients remained constant at 18 percent (Torres and Forrest, 1983~. Data concerning changes in the number of adolescents obta~n~g contraceptive services from private physicians are not available. Data from the National Surveys of Young Women show increased use of clinics between 1976 and 1979. In 1976, clinics were the first source of contraceptives for 45 percent of never-mamed teenagers who had ever used the pip. In 1979, 53 percent of aD teenagers who had ever used the piD, diaphragm, or IUD had ong~naDy obtained it from a clinic. This change was due primarily to the increased reliance of black teens on clinics (Zeinik et al., 1984~. Among teenagers seeking contraceptive services from organized pro- viders, a majority "are sure" or "think" their parents know they are coming to a clinic 59 percent. A significant minority, however, 41 percent, report that their parents are not aware of their clinic attendance. Among teenagers who report that their parents know of their clinic attendance, the majority indicate that they voluntarily informed their parents; most of the remainder indicate that their parents suggested the
PREVENTIVE INTERVENTIONS 159 ViSit. Adolescent girls age 15 and younger were most likely to report that their parents suggested the visit. Only a smut minority say their parents were informed because the clinic required it (Torres et al., 19801. Among those who say that their parents don't know, a majority indicate that they would not come to a family planning clinic if parental notification were required. While many of these adolescent girls report that they wood use drugstore or other nonprescription methods of contraception under these circumstances, some say that they would use no method. Only a very small proportion suggest that they Would abstain from having sex (Torres et al., 1980~. Twenty-s~x percent of teenage clime patients said they came to a clinic rather than a inmate physician because they were afraid the doctor would ted their parents (Chamie et al., 19821. Thus it appears that parental consent or noti~ca- tion requirements are one factor affecting whether some teenagers will obtain contraceptive sernces and where they will go for them. Another factor is cost. Fees charged by private physicians are signifi- chatty higher than those charged by clinics, arid fewer private physicians will accept Medicaid payment for services. Orr md Forrest (1985) esti- mated that In 1983 the average fee charged by private physicians for aI1 initial family planning nsit was $42, and only 17 percent would reduce the fee for low-income patients. This fee does not include the cost of the prescnbed contraceptive. Birth control piss, the most commonly pre- scnbed method for adolescents by both climes and private physicians, COSt between $8.75 and $15.00 per cycle (Hofferth, Vol. Il:Ch. 9~. In contrast, ~ 1984, average clinic fees for an Stir nsit and three-month supply of pills ranged from zero to $5l, depending on the patient's income and age. About half of all family planning agencies charged patients under 18 nothing or less than they would a comparable older woman (Torres, 19841. In 1982, 41 percent of teenage clinic patients received services free or had them paid for by Medicaid. The average fee among parents who paid was about $~! (Change et al., 1982~. Corm over, women who obtain prescription contraceptives through a clinic often do so at a significantly reduced cost (Hofferth, Vol. Il:Ch. 91. Only 53 percent of physicians who wiD give teenage patients contra- ceptives accept Medicaid reimbursement, although most of those who do not accept this fortes of payment indicated that they wiD refer eligible adolescents to other sources (Orr, 1984b). In contrast, virtually aD organized family planning service providers will accept Medicaid pay- ment. Charme et al. (1982) found that the primary reason adolescent
160 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING clinic patients give for choosing a clinic rather than a private physician is cost (65 percent); the second most frequently cared reason is that the physician might tell her parents (26 percent). Estimates of the unit costs of providing contraceptive services to adolescents in Illinois (including clinic visits and prescnptions) were $75 per patient per year (Reds, 1984~. Almost all agencies providing orga- nized family planning services receive federal funding, and half receive Finning from their state and/or Tocai government; almost all collect fees Mom patients, and 4 in 10 have funding from other, private sources (Table 6-51. On average, federal funding accounts for almost two-thirds of the income of family planning agencies; other government funds represent I? percent. The largest source of federal funding is Title X of the Public Health Service Act. In fiscal 1983, $~17 minion was spent by the federal govemment for contraceptive sernces under Title X (Gold and Nestor, 1985~. Title X fiends are used in every state. Most states (39~0 in fiscal 1983) also used funds from the Maternal and Child Health (MCH) block grant for family planning services, $19 million ir1 fiscal 1983, which includes both federal funds and a relatively small amount of state match- ing funds. Only 28 percent of agencies receive these fiends, however, and they account for only 7 percent of average agency income. Funds from TABLE 6-5 Sources of Funding for Rainily Planning Agencies, 1983 - Mean Percentage Source Percentage Receiving of Funds Received Federal 98 63 Title X 77 33 Title XIX 90 10 MCH block grant 28 7 Social Services block grant 4o 13 State and local government 52 17 Panent fees 92 13 Other private 41 7 Total 100 100 NOTE: Percentages may add to more than 100 because most agendas received funds Dom more than one source. SOURCE: A. Torres, 1984, "The Ejects of Federal Funding Cuts on Family Plan- n~g Services, 198~1983," Family Planning Perspectives 16~3~:13~136, May/June. Reprinted by permission.
PREVENTIVE INTER VENTIONS 161 the Social Sernces block grant were used for family planning services in about half the states in fiscal 1983: 45 percent of agencies received these funds, which amounted to 538 million. Ninety percent of agencies serve Medicaid-eligibie patients and receive reimbursement from Title XIX of the Social Security Act (Medicaid). In fiscal 1983, $108 million of Medi- caid fiends were tlsed to reimburse organizations and private physicians for contraceptive services. Family planning agencies accounted for about half this amount, and Medicaid reimbursements represented an average of 10 percent of their income (Gold and Nestor, 19851. ~7 As discussed in Chapters 2 and 4, sexually active adolescents who practice contraception are less likely to experience an unintended preg- nancy than those who do not (Zeinik et al., 19811. Those who use a prescription method (i.e., pills or an {UD) are significantly less lilcely to become pregnant than those who use nonprescription methods (i.e., condom, foam, rhythm, withdrawal) (Ory et al., 1983; Koenig and Zelnik, 1982). Next to sterilization, the pill is the most effective contra- ceptive when properly used. Effectiveness of use varies by age of user, socioeconomic status, and experience with a method. Younger women tend to have higher contraceptive failure rates with virtually all meth- ods, and for most methods, women under age 22 are about twice as likely to experience an unintended pregnancy as women age 30 or older. This difference is probably due lo a combination of factors: younger women are generally less expenenced users; they have less accurate info`~ation about side effects; they are more fertile; and they may have more difficulty obtaining contraceptive services. Women under age 22 have approximately a 4.7 percent failure rate with the pill, compared with a 9.1 percent failure rate with the JUD, a 20.6 percent failure rate with the condom, and 32~1 percent failure rates with aL other meth- ods, incIudir~g the diaphragm and rhythm (Ory et al., 1983~. (Note: These rate estimates are based on use among married women between 1970 and 1976.) Although many teenagers express concern about the negative health effects of pi] use, for women age 15-19 who do not smoke, oral contraceptives carry the lowest mortality risk of any method except for barrier methods backed up by abortion: an est~rnated 0.; deaths per 100,000 nonsterile women. The mortality risk associated with pill use is significantly lower than that associated with pregnancy and childbear- ing. The risk associated with condom use and other barrier methods is in fact the risk associated with unintended pregnancy and childbirth. How
162 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING ever, the mortality risk associated with the use of any method is ex- tremely low for women under age 30 (Ory et al., 1983~. Among pill users, a variety of minor symptoms, including nausea, breast enlargement, weight gain, and dizziness are common complaints not requiring hospitalization. Although these typicaTiy disappear with continued use, they are often disturbing enough to cause many women, especially teenagers, to discontinue use out of fear that they may fore- shadow more major complications, such as cardiovascular problems, benign liver tumors, and gas bladder disease. Hospitalizations associate] with these complications do occur among women who take pills with higher doses of estrogen, among those with histories of impaired liver function, gall bladder disease, hypertension and thromboembolic disor- ders (e.g., phIebitis), and among those age 35 and oider. They are, however, extremely rare among women under age 25: only 4 per 100,000 pill users. In addition, the pill affords protection against several health complications that frequently lead to hospitalization, including benign breast disease, utenne and endometrial cancers, ectopic preg- nancy, and ovarian retention cysts. The protection appears to persist long after pill use is discontinued aIld may provide protection to women in their forties and fifties when the risk of these conditions is relatively high (Ory et al., 1983~. Health risks associated with the JUD are significantly greater than those associated with the pill and relate mainly to pelvic inflammatory disease. The major problems requiring hospital- ization that are attributable to the use of barrier methods aids rhythm are the complications of pregnancy due to method failure (Ory et al., 19831. Both clinics and priorate physicians are likely to recommend prescnp- tion methods that cannot be obtained without a medical visit. clinics prone clients with information concerning the variety of contraceptive methods end provide all reversible methods at the clinic. Only 11 percent of pnvate physicians who will prescribe contraceptives for adolescent womeI1 prescribe all three methods that must be obtained from a physi- cian or clinic: 90 percent prescribe oral contraceptives, 61 percent will fit a diaphragm, and 23 percent will insert an IUD (Orr, 1984b). Among new family planning clinic patients under age 20, 70 percent were using no method of contraception before their fist visit, compared with 12 percent after the nsit. Those using no method include girls who were already pregnant, who chose IlOt to use contraception, or who chose not to be sexually active. As Table 6-6 shows, 70 percent of all new patients chose the pill (representing 80 percent of those who left the clinic with a
~E~ ^~ ~ ~ ~ TABLE 6-6 Contraceptive ~etbods Used ~ New F~1\ Planolog CD~c Patients Under Age 20, 1980 (in percent) ~etbo] Connie Di~bra~ IS . . . Shooed condom Namrd ~ml~ pl=~ng/rbythm Otb~ None Eta Before First Visit ARer Fast Visit 21 1 1 70 1~ 70 4 11 12 100 Less than 0.5 Echo SON: A. ~ NOD. Fog, 1983, "Fag ~ Sac Sag He Oath Stated 1981/' If P~ -~ 15:278. Repduted By pension. contIacept~e method) and 13 percent of those Hobo obtained co~ac~- dyes chose spe~idJes or condoms or both. zebik et at. (1984) found that teenagers Hobo received contraceptive Maces Tom ~ cUnk me more Eked than those Hobo use pdvae push 6ansto be poor' Black, and to have been younger at Erst intercourse. They found that cynic padents Caere more likely to experience as untn- tendeJ prefix tub those Hobo obtained ~ method Tom ~ puke physki~n, but Beer they introauceacontro~ for race and age ~ Best use of contraception, the was no sift Lawrence in s~sequenl preg- n~n~yrates. The pattern of prior contraceptive use, race, and sodoeco- nomads status are more Big dGcant Actors than source oEcon~aceptive ser~cesba~sse~t~gtbe risk ofu~intended pregnant hiorerese~cb has been done on tbelmpac1 ofusing [~u~yIJ~nzing d~zic~ but no other work bastave~igatedtbeseparatedupactofuslogp ~ atephysidansfor coneacept~se~ices. CUnk ~tend~nceforconcacepti!eserdc~ does baveaposhi~eeB)= oncontracepdvebob ~ on anegativeeB>= onb~tb rates, and presumiEtF ~ negati~eeB>ct on tbeinddence ofunintended pregnancy (PoIIe~ et ~ - 19817 Citric pahents aro more Uketr tin tb6i co ~ terp~s~'bo are notinf~ndly pbuning progla~asto use more rebukable methods ana less ~ etyto use no method at ED (Porrestet d., 1981). ltesearcb OD clonic a~endancesbo~'stbatsever~ Actors are important in attracting adolescents to organized 6 mily planning 6cDRdes. O ne
164 ADOLESCENT SEXUALITy PREGNANCY AND CHILDBEARING indicator of effectiveness in drawing teenagers is mean delay between first intercourse and first clinic visit (Kicker, 1985~. On average, teens first visit a clinic or doctor for contraception I! months after they have first had sexual intercourse (ZeInik et al., 1984~. About one in Eve teenage family planning clinic patients first comes to the clinic for a pregnancy test (Chamie et al., 1982~. As Hofferth (Vol. Il:Ch. 9) re- ports, among the most significant determinants of clinic attendance are those related to outreach and community relations, convenience, and the clinic's competition in providing contraceptive services. Thus, clinics that offer a community education program for teenagers in combination with the provision of contraceptive services (physical examination and prescnption) have a Tower mean delay between first intercourse and first nsit. Those that obtain the support of local church groups, develop active relationships with local youth organizations, are open on week- ends and in the evenings, accept walk-in clients, are conveniently lo- cated, require less counselor time per patient, and provide fewer services have a lower mean delay Mean delay is also Tower in Planned Parenthood clinics, in facilities of medium size (l,00~2,SO0 clients), and in those locate] in more prosperous areas where mean levels of schooling are higher. Mean delay is greater if local drugstores make nouprescnption contraceptives easily available; however, the number of local private physicians who are willing tO serve adolescent family planing patients does not appear to have any significant effect on clinic attendance (Kicker, 1985~. Continued attendance at a clinic is closely related tO contraceptive continuation, although it is not synonymous (Shea et al., 19841. Adoles- cents who return to the clinic at regularly scheduled integrals (usually three months and six months after the iDiti~ visit) were found to be more reliable contraceptors. Those who did not keep scheduled follow- up appointments dunug the first six months were found more likely tO be inconsistent contraceptive users. Adolescents who made more than the regularly scheduled follow-up nsits, particularly in the first two months, were frequently found to be having ~if~cuity with their contra- cepn~re method. These patients, despite their repeated msits, were more likely to become discouraged and either switch methods or discontinue contraceptive use altogether. Another study revealed that there may be many reasons why adolescents do not continue as clinic patients, and those who stop corroding are not necessarily at greater risk of pregnancy (Coughlin, 1978~. A significant proportion of those who were followed
PREVENTIVE INTERVENTIONS 165 up after a six-month absence reported that they were not sexually active; others were pregnant; stir] others had changed providers or switched to a nonprescription method. Less than 20 percent of the respondents in this study indicated that they were still sexually active but using no method at all (Coughlin, 1978~. In sum, continued attendance at a clinic does not necessarily mean that teenagers are contracepting effectively and contin- uously. Sim~iarly, because an adolescent girl does not continue to attend the same clime at regularly scheduled intervals does not necessarily mean she is not contracepting. Many of the factors associate] with continued attendance are the same as those associated with reasons for first atten- ~ance (Kicker, 1985~. Satisfaction with the prescribed or recommended contraceptive method also appears to be an important determinant of whether teenagers will return for regularly scheduled follow-up nsits (Shea et al., 1984~. Cntics of family planning programs suggest that the availability of contraceptive services has caused higher rates of sexual activity, unin- tended pregnancy, abortion, and births to unmarried teenagers. Indeed, the penod of significant increase ~ teenage sexual activity 3unng the 1970s was paralleled by a significant growth in the availability of contra- ceptive services for both adult women and adolescents. However, whether there is a causal connection or whether both trends were re- sponses to the same changing social context and mores is unclear. Using data for California. Kasun (1982) concluded that increased spending on contraceptive sernces led to increased levels of sexual activity and, as a result, increased pregnancies, abortion, and births outside marriage. However, as Hofferth (Vol. Il:Ch. 9) pomrs out, associations do not show causation, and Kasun (1982) did not control for initial differences between Califorma and the rest of the United States, did not conduct a rigorous statistical analysis controlling for other factors that might affect levels of sexual activity among different subgroups or at different points time, and did not measure sexual activity. In contrast, Moore and CaldweD (1977) found no association between the availability of family planning services and the probability that an adolescent girl would initiate sexual intercourse, net of other factors (age, socioeconomic status, family structure, urban/rural residence, religiousness, birth cohort). However, as Hofferth (Vol. Il:Ch. 9) con- cludes, more research is needed on this issue. Research on the Impact of furrily planning programs on teen preg- nancy is also limited because of the lack of abortion and pregnancy data.
166 ADOLESCENT SEXUALI7~ PREGNANCY AND CHILDBEARING Births, however, are more readily measured. Hofferth (Vol. Il:Ch. 9) reports only one study that has addressed this issue. Using data from the 1971 National Survey of Young Women, Moore and Caidwell (1977) found that black teenagers ages 16-18 living in areas with the most subsidized contraceptive services were significantly less likely to become pregnant than their peers. This finding did not apply to other sub- groups. According to these investigators, however, black teenagers are overrepresented among users of subsidized contraceptive services com- pared with whites and therefore may be more affected by the availability of such services. Condom Distribution Programs Programs aimed at condom distribution are more narrowly targeted toward young men than traditional contraceptive services prowded by family planning agencies. Although many clinics have initiated efforts to involve young men In their programs, there is little ewdence of success. Before oral contraceptives were widely available, condoms were the contraceptive method of choice among many U.S. men and women. However, the advent of the piD caused many to regard birth control as a "womer~'s issue," and the condom feD out of fashion (Scales and Beck- stem, 1982~. In recent years, many family planning prodders and public health officials concerned about pregnancy prevention and the reproduc- tive health of adolescents have once again begun to promote condom use. Two factors are espemaDy relevant to their renewed interest ~ condom use by teenagers: (~) recognition that the vulnerable penod between first intercourse and first use of prescription contraception methods by adolescent girls is frequently as long as a year and (2) concern about the spread of sexually transmitted diseases, especially genital her- pes and more recently the acquired immune deficiency virus. Although the international family planning literature descnbes a number of am preaches to condom distribution in developing countries, few domestic program models have emerged (Dryfoos, 1985~. Studies of male attitudes about contraception and, in particular, con- dom use have shown that a majority of adolescent boys believe that "sexually active teenagers have a harder time" obtaining contraceptive methods than do addicts, that "use of birth control makes sex seem preplanned," and that "only females should use both control" (Finke! and F=kel, 1975~. However, a majority of boys in the same survey
PREVENTIVE INTERVENTIONS 167 believed that a male who uses a condom "shows respect for his girlfriend." Simiiarly, a study of black males who attended an adolescent clinic in Baltimore found that more than 90 percent believed they share responsibility for preventing pregnancy with their partners (although less than 20 percent believed that the fills or major responsibility was theirs). Approximately 40 percent believed condoms were very good at preventing pregnancy, and the same number reported use of a condom at last intercourse (Clark et al., 19841. In this regard, Finkel and Finkel (1975) found that over 90 percent of the boys they surveyed who reported use of a condom at last intercourse also reported that they always or sometimes used one, indicating an inclination toward condom use. While acknowledging the general problem of adolescent male atti- tudes about contraceptive responsibility, Clark et al. (1984) conclude that the substantial level of condom use among the inner-c~ty population they studied suggests a good basis on which to build contraceptive programs targeted at males. However, many boys and girls apparently still believe that condoms win interfere with sexual pleasure. Therefore, programs need to address attitudes toward condom use (Dryfoos, 1985~. Condom distribution programs have been implemented by a Variety of organizations, including public health departments, Planned Parent- hood affiliates, and university hospitals. Distribution has been managed by orgaIiizatiorls raIlging from family planning providers and public health organizations to youth organizations, public employment pro- grams, and labor unions. Locations of distribution have included clinics, emergency rooms, pharmacies, recreation centers, union haDs, pool haps, barber shops, restaurants, bars, and gas stations. Some programs have employed male outreach workers to counsel adolescent males on condom use and to hand out instructional matenals along with free samples; others have relied on less assertive approaches, simply making condoms available in places where young men congregate. In some communities, free-standing storefronts have been established for dissem- inating literature, counseling on reproductive health and contraceptive use, and condom distribution. The Rubber Tree in Seattle, Wash., is a prototype of such a program (Parke and Neville, Vol. Il:Ch. 7~. In other places condom advocates have organized a National Condom Week around Valentine's Day to launch a public awareness campaign. Re- cently, in Oakland, Catif., pharmacies were encouraged to advemse, hand out coupons and free samples, and to sell condoms at reduced pnces.
168 ADOLESCENT SEXUALITY PREG.~ANCY ACID CHILDBEARING None of these approaches has been rigorously evaluated, although data from a condom distribution program sponsored by the University of North Carolina population program in the late 1960s tracked use over a year (Arnold, 1973~. That program operated through an antipoverty summer youth program and used male outreach workers to establish distribution points in pool halls, barber shops, a restaurant, and a gro- cery store. As reported by D~rfoos (1985), a study of program opera- tions found that consumers used distribution sites near their homes, although the location itself was insignificant, and that more condoms were distributed `during the week than on weekends. Users were found to be similar to the general population in the target area. After a year, the majority (69 to 81 percent) of respondents reported use of a condom at last intercourse, and fertility rates among black adolescent girls residing in the target area declined significantly (19 percent) compared with those in similar communities in the county that were outside the target area. Although these findings suggest the potential usefulness of new efforts to implement and test condom distribution programs, they do not provide any conclusive evidence of the effectiveness of such an approach. As Dryfoos (1985) suggests, evaluation of the effectiveness of programs of this type is difficult in most communities today because of the large number of other factors that influence fertility rates. School-Based] Clinics Family planning clinic attendance has grown among teenagers over the past decade. Nevertheless, concern on the part of advocacy groups and health and education professionals that many teenagers lack suf6- cient access tO health services has generated a growing number of school- based clinics, many of which include family planning sernces. Dunng the past fire years, 43 such programs have been initiated in junior and senior high schools in 24 different communities. The Center for Popula- tion Options has identified an additional 50 communities that are now beginning to develop school-based programs (Kirby, 1985~. A wide range of organizations has taken responsibility for establishing and oper- ating clinics, including hospitals and medical schools, commum~y clin- ics, public health departments, and Planned Parenthood affiliates. In general, the goal of school-based clinics is to improve the overall physical and mental health of teenagers, including the reduction of teenage pregnancy. However, none considers adolescent family planning
PREVENTIVE I^~TERVEhTIONS 169 to be its sole purpose. Most offer a variety of services, including athletic physicals, general health assessments, treatment for minor illnesses and injuries, laboratory and diagnostic screenings (e.g., sickle cell anemia and sexually transmitted diseases), immunizations, first aid and hygiene, Early and Periodic Screening, Diagnosis and Treatment testing, family planning counseling and referral, prenatal and post-partum care, drug and alcohol abuse programs, nutrition and weight reduction programs, family counseling, and information and referral for health and social services not provided. Because of the range of services that most clinics provide, they serve both boys and girls. Some involve boys in family planning, typically when they come in for athletic physicals and are asked to provide information concerning sexual activity as a part of their medical history. Clinics vary in the range of services they offer, in some cases because of the differing needs of their students, in other cases because of the availability of funding or state and local restrictions. Clinics also vary in the scope of their family planning services. At a minimum they all provide counseling, make referrals to family planning clinics or private physicians, and do follow-up after referrals. Approxi- mately three-quarters of those currently in operation conduct pelvic exams and write prescriptions for contraceptive methods. Several actu- aDy distribute contraceptives at the clinic. Kirby (198;) observes that clinic policies concerning birth control are often consistent with their policies about other treatments: if they write prescriptions for other medications, they also generally write prescnptions for contraceptives; if they dispense other medications, they typically dispense contraceptives as well. None of the existing school-based clinics performs abortions. Kirby (1983) reports that while some will present a pregnant student with all the legal options, few, if any, make referrals to abortion pro- v~ders. School-based clinics are intended to capitalize on many of the features that existing research has shown are associated with teenagers' atten- dance at family planning clinics, including convenience, comfort, confi- dentiality, and cost. Located within the school building or on school grounds, clinics are accessible. Students don't have tO take a bus or drive tO another part of town or request their parents assistance In getting them tO the seances. Most clinics operate dunng school hours and do not require appointments. Because they are visible entities in the school, skiing staff become familiar to students and vice versa. In addition, because the programs are geared tO the needs of adolescents and students
170 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING are aware that their friends use the services, school-based clinics seem more approachable to many young people than doctors' offices, hospi- tals, or freestanding adult clinics. Most if not all school-based clinics require written consent from parents before students can receive medical services. Generally parents are asked to sign a blanket permission form at the beginning of the academic year, but they are not informed when students come to the clinic for services. Nor are patient records accessible to teachers or school officials. Moreover, because the clinics provide a wide range of services, the reason for an indim~uaT's visit cannot be automatically assumed. In most clinics, sernces are provided free to registered students, although several charge a nominal annual fee (aver- age $12) to help offset operating costs (Kirby, 19851. The annual costs of school-based clinics vary dramatically depending on their size, staffing, and range of services. Kirby (1985) reports that they range from about $25,000 to $250,000 per year, averaging about 5125 per student. Clinics are supported by a variety of sources, including venous federal and state funds, local funds and in-kind support, and private foundation and corporation grants. An evaluation of the effectiveness of approximately 10 school-based clinics is now under way by the Center for Population Options. Data from the St. Paul, Minn., Maternal and Infant Care Project, which began in 1973, show that the fertility rate in schools with clinics has dropped substantially from 79 births per 1,000 in 1973 to 26 births per 1,000 in 198~1984 (Edwards et al., 1980~. These figures compare favorably with national statistics that showed a birth rate of 45 per i,000 for whites in 1977 and in 1982. Unfortunately, as Hofferth (Vol. Il:Ch. 9) points out, no information is available from the St. Paul project on the trend in pregnancies and abortions, so we don't know how much of the decline in births is due to a decrease in pregnancies and how much to an increase in abortion. The 12-mor~th and 24-month contraception contin- uanon rates (after the initial visits were also quite favorable: 93 percent and 82 percent, respectively, by 1976-1977. Moreover, the dropout rate among girls who delivered and kept their babies declined from 45 per- cent to i0 percent between 1973 and 1976-1977 (Edwards et al., 1980~. These findings are extremely encouraging and to some extent are responsible for the current and interest in school-based clinics. The Select Committee on Children, Youth and Families (U.S. Congress, House, 1986), ~ a recent report on adolescent pregnancy stror.g~y recommended the establishment of school-based clinics. However, the
PREVENTIVE INTERVENTIONS 171 evidence requires further corroboration. As Dryfoos (1984b) reports, while fertility rates are still decreasing in the St. Pan] schools with clinics, no comparisons have been made with matched high schools or populations. Study designs for the programs included in the evaluation wig vary somewhat from clinic to clinic, but the major strategy is to administer questionnaires in both program and matched nonprogram schools at two points in time as well as to search birth records and academic files. This study is expected to pronde valuable understanding of the costs, ejects, and effectiveness of these programs. Although the school-based mode] seems intuitively sensible and ap- pears to have a number of advantages over other health delivery models for adolescents, it also has some limitations. First, school-based clinics are generally restncted to serving teenagers enrolled in school. Most cannot serve students who have dropped out, many of whorls have significant health care needs. Second, many school-based clinics operate only dung the academic school year and thus are not open to students over weekends, on holidays, an] during vacations Third, clinics that do not fill prescriptions (e.g., birth control piss) force students to go elsewhere to obtain contraceptives, which may deter some teens from effective contraceptive practice. The evaluation that is now under way will help in assessing the seriousness of these limitations. A variation on the school-based clinic mode] aimed at overcoming some of these limitations is suggested by the Self Center in Baltimore, Md. This program, established and directed by the Johns Hopkins School of Medicine, imrially focused its sermces on the students at a predorr~inantly black, inner-city senior high school and junior high school. The program combined sex education with family planning and counseling services. Located in a storefront adjacent to, but clearly separate Tom, the two schools, the center was not constrained by the school calenciar or schedule in its days and hours of operation. Both boys and girls could use the clime and were eligible for services as long as they remained in one or another of the two schools. Ad services were free. Center staff, Ming a nurse practitioner and a social worker, were visible figures in the schools, providing sex education classes, individual counseling, and clinic outreach. Dunng after-school hours, the same staff were available in the cynic tO conduct rap sessions and educational groups. Teenagers who attended the clime for contraceptive services were followed up through the schools. Those who expenenced pregnan- cies were referred to the30hns Hopkins Adolescent Pregnancy Program
172 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING for comprehensive prenatal health care and social services or to an abor . .. . tlon clinic. The Self Center was developed as a three-year demonstration project with an e~raiuation component. Data were collected by self-administered questionnaires at the outset and periodically throughout the period of operation to assess changes in student knowledge, attitudes, and behav- ior. Students in the program schools were compared with students in two other urban schools; the control sample was carefully matched for race and socioeconomic status. The researchers measured program ef- fects according to clients' length of exposure to the program (Zabin et al., 1986~. Among the significant findings from the first report of the evaluation are improvements in levels of knowledge, especially among younger students. In particular, girls showed a substantial increase in knowledge about the fertile time in their monthly cycle. Both boys and girls showed improvement in their understanding of contraceptive methods. The program had little effect on students' attitudes about teenage pregnancy, the ideal age for childbearir~g, or the acceptability of sex between two people (Zabin et al., 1986). Most interesting, however, are the findings concerning effects on behavior. Despite very high baseline levels of sexual activity, the evalua- tion showed a postponement of first intercourse that averaged seven months for gigs who were exposed to the program for the full three years. Those with less exposure showed much shorter delays, suggesting the importance of early intervention before the initiation of intercourse to effect change. If such delays can be replicated in other similar school- based or school-related~ clinics, they refilte the argument that easy access to services encourages early intercourse (Zabin et al., 19861. The most dramatic behavioral change, however, was in clinic atten- dance. The proportions of sexually active students hanng attended a clinic rose for students of both genders and at all grade levels. In addi- tion, the proportion of girls with no sexual experience who attended in preparation for first coitus and those who attended in the early months after initiation of sexual activity increased markedly. Perhaps especially significant for itS implications for future interventions is the high level of male attendance among junior high school students. More than half of the junior high program registrants were boys (Zabin et al., 1986~. Changes in contraceptive use were also significant, with upward trends for JI groups. However, younger students' use increased more
PREVENTIVE INTERVENTIONS 173 the longer their exposure to the program, suggesting that early risk can be reduced with early access to services. Finally, increased and prompt clinic attendance and increased use of contraception appear to have had a significant impact or1 pregnancy. While conceptions increased dramati- cally in the control group schools during this period (from 32 to 51 percent), in the program schools, conceptions dropped by 26 percent (Zabin et al., 19861. The Self Center model differs somewhat from the typical school-based clinic. Nevertheless, if these results can be replicated in other settings, they give solid support to the school-based clinic movement. This pro- gram suggests that the provision of free proximate contraceptive sernces that are linked to a strong education component may accelerate contra- cepti~re behavior among sexually active teenagers without encouraging sexual intercourse among those who are not personally ready for such involvement. Further efforts to test this model and compare it with the typical school-based clinic model are needed. Pregnancy Testing and Counseling Pregnancy testing is available to teenagers in public health centers, hospitals, family planning clinics, and abortion clinics, from private physicians, and even at many drugstores. This service is generally pro- nded at little or no cost to the client. In addition, home pregnancy tests are becoming increasingly popular among teenagers as well as adult women, because they afford an opportunity to detect a suspected preg- nancy in privacy, at relatively low cost. Although they are not a substi- tute for laboratory testing and a peinc exam, home tests are generally an accurate indicator of pregnancy when properly used. Teenagers fre- quently delay testing for pregnancy either because they do not recognize the early physical signs of pregnancy or because they are reluctant to wfor~ parents and do not know where to go for testing As a result, mmy girls who are pregnant do not get confirmation until they are well into or beyond the test trimester of pregnancy. This delay has serious Implications for their receiving adequate prenatal care, which in tub has Implications for the health of their children. In addition, it affects their opi3ons for pregnancy resolution. If a pregnancy test is positive, most adolescent girls need non- judgmental counseling to outline the a, fable options for pregnancy resolution as well as necessary referral to prenatal and maternity care,
174 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING social services, financial support, or abortion services, and subsequent foDow-up. If the test is negative, they usually need contraceptive coun- seling and referral for birth control. Adherence to pnnciples of volunta- nsm and informed consent require that facilities provide their patients with an account of the possible risks, benefits, and consequences of maternity and abortion, the available alternatives, including adoption, and the resources available for needed care (Alan Guttmacher Institute, 1981~. Nevertheless, where a girl goes for pregnancy testing may affect the mount and type of pregnancy counseling she receives. Since nearly 20 percent of family planning clime patients first come to the facility because of a suspected pregnancy, most clinics have established preg- nancy testing and counseling programs (Alan Gut~macher Institute, 1981~. Clinics receiving federal support under Title X are required by law to inform patients of their fug range of legal options. Private pro-life organizations, such as Birthright, provide pregnancy testing, but gener- a~y do not discuss or refer a teenager for contraception if she is not pregnant and do not present pregnancy termination as an option or refer clients to abortion services (Alan Gut~macher Institute, 1981~. Most school-based climes pronde pregnancy testing and counseling, but few discuss abortion or refer students to abortion providers (Kirby, 1985~. Abortion climes also perform pregnancy testing and counseling; while there may be some bias in the message provided by counselors ~ these settings, it also seems likely that most patients at such clinics have already decided how to resolve their pregnancies. No ngorous study of pregnancy testing and counseling services has been done, nor has any careful assessment of how the auspices of service delivery affect decisions concerning pregnancy outcome for different clients. Available studies of decision making, however, suggest that Marty teenagers have already made up their minds about whether to abort or carry to term before they seek pregnancy testing and counseling services and therefore choose service providers on this basis (Rosen, 1980~. Hot Litter Telephone hot lines that teenagers can use anonymously tO obtain accurate information about contraception, pregnancy, abortion, sexu- aDy transmitted diseases or other reproductive health problems, and adoption alternatives have developed in several cities. Hot ~ e operators caI1 dispel myths about contraceptive methods, symptoms of disease, pregnancy care and complications, etc. arid can provide outreach for
PREVENTIVE INTER YE~-TIONS 175 local clinics and other service providers. Hot lines are typically operated by public health departments, family planning and adolescent health clinics, or local advocacy organizations and youth-serv~ng agencies. Typically they are staged by trained volunteers who can connect directly with health and mental health professionals when emergency situations anse. The experience of several hot lines offers interesting insights. The Cleveland Program for Sexual Learning's hot line Sexline was developed in response to the need for general ~nfo~`ation and referral as expressed by venous parent and community groups (Nickel and Delaney, 19851. Over a three-year period the service answered more than 32,000 cars, although there was no tracking system to determine how many resulted In clime visits or contraceptive use. In New York City, a similar hot line to pros e information and referral linked callers directly to clinics by scheduTir~g appointments for those who expressed interest in obtaining . ~ contraceptive services. Hot lines appear to be a potentially effective means of providing teenagers tenth information and refemug them to sernces. However, evidence of the effectiveness of these programs ~ increasing contracep- tive use and reducing unintended pregnancies and births among adoles- ce$~ts is not currently available. PROGRAMS THAT ENHANCE LIFE OPTIONS The availability of information, education programs, and family plan- r~ing services has increased adolescents' capability to prevent early ur~- tended pregnancy and childbeanug. For maIly highly motivated teenag- ers these programs have prodded the basic tools for making informed decisions about their sexual behavior and receiving the necessary health and social sernces to control their fertility. Unless young people are motivated to avoid pregnancy, however, these programs may have little positive effect. A variety of initiatives have been established tO enhance young people's sense of their future their sense of self-worth, their understanding of the value of education, and their awareness of work and career options. Programs to Improve Life Planning Programs to 3rnprove life planning are based on the assumption that the motivation to delay parenthood is closely related to decisions con- cern~g life goals and an understanding of how early childbeanug will
176 ADOLESCENT SEXUALITY PREGNANCY; AND CHILDBEARING affect one's ability to achieve one's goals. Most of these interventions have been directed at adolescent girls; very few have been directed at boys Most have been organized through various youth-sermng agen- c~es, for example, Girls' Clubs and Boys' Clubs. Project Choice is an extracurncular club organized and run by volun- teer youth leaders. It is intended to help at-nsk young women explore future career options other than motherhood and to understand the necessary steps in achieving alternative career goals. Meetings are held weekly after school, and activities involve information-shanng discus- sion to help participants establish personal goals. I~eaders provide sup- port in the form of encouragement and reinforcement to move teenagers along their chosen paths. Information concerning contraception and access tO contraceptive services is prodded, but altering contraceptive behavior is neither the only nor the primary goal of the program (Alex- ander, 1984~. An evaluation of Project Choice did not pronde cor~nuc- ing evidence of its effectiveness, although as Hofferth (Vol. Il:Ch. 9) suggests, the research design was not very rigorous (e.g., poorly selected control groups, abstract outcome measures) and the stated goals of the program were not clearly delineated. In addition, because only a small number of girls participated in the program, there is little evidence of its effectiveness and generalizability. SiTrularly, the Teen Outreach Project sponsored by the Junior League in St. Louis, Mo., in~rol~red an after-school program in two high schools anned at improving self-esteem and reducing the incidence of unin- ten~e~ pregnancy and dropping out of school. High-risk students were meted to join discussion groups and to act as volunteers in community sernce programs. The program was replicated in eight Aries and evalu- ated. Preliminary results suggest that the program was successful in lowenng pregnancy rates and reducing course failure; however, it had little effect on the likelihood of being suspended from school (Phihiber, 1985~. A second approach to ~mpronng life planning skills is represented by the Life Planning Project developed by the Center for Population Op- Ions. Its curricular materials link vocational choice with family design and pregnancy prevention. The program, which is currently being tested in three cities, involves the intensive participation of a broad range of youth-serving organizations in each community, whose staff were trained by CPO consultants to use the curricular materials to prone their adolescent members with more accurate infonnation and sensitive
PREVENTIVE INTER MENTIONS t 77 guidance related to adolescent reproductive health. The major objective of the project is to help teenagers prevent pregnancy, especially as a part of understanding and planning for their personal and economic fixtures (Center for Population Options, 19841. In a related effort, the Giris' Clubs of Santa Barbara, Calif., developed a workbook for adolescent girls entitled Choices. The workbook pro- ndes teenagers with problem-solving exercises that require sexual decision-making and life-planning skills. The purpose of the exercises is to help girls think about their futures in the areas of family life and work outside the home. The exercises are structured to enhance the develop- ment of skills and to present teenagers with an understanding of the social and economic consequences of early childbearing, in particular the likely effects on educational attainment and occupational choice (Quinn, ~19851. Choices is currently being evaluated. A comparable workbook for boys, entitled Challenges, has also been produced. In addition, the Choices workbook is being incorporated into a more comprehensive experimental program that will be implemented by Girls' Clubs at eight sites across the country (four experimental anc] four control). The program will include four age-related components and will be aimed at girls ages 12-18. The fist component will involve mother-daughter workshops tO foster communication about sexual be- hanor and values among young teenagers. The second component, modeled after the Postponing Sexual Involvement program ~ Atlanta, will encourage young teenagers to delay sexual intercourse, teaching them how to say "no." The third component, to be directed at 15- to 18-year-olds, wid apply the Choices curnculum to help g3ris develop educational and career aspirations. And the fourth component, also intended for older girls, will link club members to clinic sernces. The program will involve both pretest and posttest questionnaires to mea- sure effects on girls' attitudes about education, work, and family for~a- tion as wed as on their sexual, contraceptive, and fertility behavior. This evaluation is expected to significantly increase knowledge of the effects and effectiveness of life planning approaches. Role Model arid Mentoring Programs Role mode] and mentonng programs are organized tO pronde indi- ~ridual support, counseling, and tutoring for teenagers by trained peer counselors, mentors, and adult community volunteers. Some have preg
178 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING nancy prevention (or prevention of a repeat pregnancy) as an explicit goal; others are aimed arpronding models of desirable socialbehawor, of which sexual and fertility behavior are only part. Among many youth- ser~ng organizations this has long been an accepted approach, for exam- ple, Big Brothers and Big Sisters, and it has been used with both boys and girts. More recently, the National Urban League has initiated a program through Kappa Alpha Psi, the national black fraternity. CoDege-age fraternity brothers serve as role models and mentors to inner-city boys ages 11-15. They spend three evenings a week with the young male participants, one-to-one or one-to-two, in a diverse program of school remediation, recreation, and community service activities. Special atten- tion is given to encouraging responsible sexual behavior. A similar program through Delta Sigma Theta, a national black soronty, has recently been organized. The use of "community women" in Project Redirection is discussed in Chapter 7. No data are currently available to assess the effectiveness of such role mode] and mentonng programs in reducing adolescent pregnancies. The Kappa Alpha Psi and Delta Sigma Theta programs will be evaluated as a part of the Too Early Childbearing Network, and this information should provide insights concerning effects on school retention, achieve- ment, dec~sion-making skills, and aspirations and attitudes as well as on sexual and fertility behavior. Programs to Improve School PeJormance Based In part on concern that low achievement and school dropout rates are associated with adolescent fertility and that young women who give birth before graduation are less likely to Wish school, many school systems have begun to develop programs to bolster achievement and to keep adolescents enrolled ~ school. Over the past 20 years an eno'~ous body of research has developed on issues of effective schooling (Garbanno and Asp, 1981; Averch et al., 1972; Tyack, 19741. Among those factors most often cared as key to secondary school success are (~) a stu~ent's perception of the connection between present schooling aIld prospects for their future life options and (2) mastery of basic cognitive and social skills. An adolescent who regards competent perfonnance in the role of student as a precondition for successful transition to the roles of adulthood has the necessary motivation for school (Garbarino arid Asp, 1981; Stinchcombe, 1964)
PREYE^VTIYE INTERVENTIONS 179 Unfortunately for many socially and economically disadvantaged youth, these connections are not evident (Greer, 1972~. In addition, mastery of basic cognitive and social skills has been shown to significantly affect students' level of motivation (Garbarino and Asp, 1981; Gold, 1969~. Doing well reinforces the desire to do well. Conversely, failure fre- quently diminishes the perception of one's ability to perform and one's identification with the role of student. Academic achievement and school retention are related to socioeconomic status. Research has shown that the quality of schools (as measured by staff traming, the availability of learning resources, teacher/student ratios, etc.) affects achievement and school retention, especially among disad- vantaged groups the poor and racial and ethnic minorities (mutters 1983~. As a result, some 2,500 alternative schools Especial programs to improve school performance) have been established throughout the United States (Dryfoos, 1983~. They are located within regular second- a~y schools, in separate facilities, and even ~ the workplace. The purpose of the programs is to provide educational opportunities that are respor~- sive to the special needs of at-nsk students, particularly those who are behmd grade level and are experiencing behavior and attendance prob- lems. Most of these programs stress mdindualized learning, counseling, social supports, and remedial education, and they often include work- stu~y arrangements. An essential ingredient is strong interpersonal rela- tions between the staff and the students. Assessments of the outcomes of special programs to improve school performance indicate that they can be effecnve in keeping young people In school and boosting achievement. There are no data, however, on whether such programs lower fertility rates. Studies that focus on how and to what extent such programs influence adolescent sexual and fertil- ity behavior are needed. Youth Employment Programs Concern about high youth unemployment rates, especially among m~nonties, has led tO the development of numerous programs over the past 20 years to enhance the employability of young people by teaching job skills and job search skills, by providing incentives to employers to hire disadvantaged youth, and by actuary placing individuals in jobs. Many of these were large-scale programs supported by the U.S. Depart- ment of [abort Most were intended to address the employment prob
~ 80 ADOLESCENT SEX UALITY; PREGNANCY; AND CHILDBEARING lems of young men, not young women. Delaying family formation or preventing repeat childbearing has not been a primary goal of youth employment programs, and few have given any attention at all to the family responsibilities of program participants (Simms, 1985~. Despite the vast literature on the effects and effectiveness of such interventions, there is little ewdence of their impact on adolescent sexual and fertility behavior. Only the evaluation of the Job Corps program has specifically addressed the issue. Participation in this program appeared to delay family fo' citation and reduce the incidence of nonmantal childbeanng. In addition, the positive effects of the program on employment, earnings, educational attainment, and welfare receipt were larger for women without children than for those with children (Mallar et al., 1978~. A study, which is now under way using data from the federally supported Youth incentive Entitlement Pilot Projects (YlEPP), prom- ises to yield additional information on the impact of youth employment programs on family formation. This program provide~jobs to 16- tO }9- year-olds enrolled in school if they met specified attendance and perfor- mance standards (Simms, 1985) Although preliminary Endings suggest that the program had no effect on the high rate of childbearing, the current study wiD analyze these data in greater detail, looking specifi- cally at the effects on particular subgroups of participants. Two other demonstrations that are currently under way or recently completed should pronde useful information concerning the potential for youth employment programs to help delay childbeanug. First, in 1985, Public/Pnvate Ventures initiated the Summer Training and Edu- cation Program (STEP), a summer employment and remedial education demonstration program for 14- and tS-year-olds. The short-te~ goals of the program are to (~) produce learning gains (rather than declines) dunng the summer months and (2) improve knowledge of birth control and the consequences of teenage pregnancy and childbearing. I~onger- ter~ goals include (~) improved school performance and high school graduation, (2) improved labor market performance, and (3) reduced adolescent childbearing. The program has been implemented in five U.S. cities and w~11 involve 3,000 young people randomly assigned to treatment and control groups. The program is planned to continue through the summers of 1986 and 1987 and a longitudinal phase of the study will follow treatments and controls through 1992 six months beyond their scheduled dates of high school graduation (Branch et al., 1986~. Preliminary findings from the first summer indicate that the
PREVENTIVE INTER MENTIONS 181 impact of participation in STEP vaned by sex, race, and site. Overall, treatment youth outscored their controls in reading and math by ap- prommately one-quarter of a grade equivalent. Giris showed even greater gains, and Hispanic teenagers, whose high school 6[OpOUt rates are significantly higher than for both blacks and whites, appear to have beneEted most. Hispanic boys and girls in the treatment group out- scored their controls in both reading and math by half a grade equivalent (Branch et al., 1986~. The other demonstration is the Teen Fathers Collaboration Project, sponsored by Bank Street College between April 1983 and March 1985. The program involved 400 teenage fathers in eight cities across the country These young men received job training, counseling and referral services, educational counseling, and parenting education. The goal was to improve their educational status, labor market participation, and parenting skills and behavior. Pretest and posttest data were collected, but no results are yet ava~labie (Hofferth, Vol. Il:Ch. 9~. As with alternative school programs, more research is needed on the effects of youth employment programs on adolescent sexual and fertility behavior. In part that means making the delay of childbeanog an explicit goal of such demonstrations. As Moore et al. (1984) report, most young people, even minority members and those from disadvantaged back- grounds, have high occupational aspirations. Many of them, however, fad! to understand the implications of early family formation for achiev- ~ng their goals. Comprehensive Community-Based Prevention Programs Several community-based programs have been established in recent years to provide educational, vocational, recreational, legal, health, and social services to disadvantaged young people in an integrated services setting. Pregnancy prevention is usually only one (although an impor- tant one) of the goals of these support programs. Most are located in youth centers and offer a variety of services oIl-site. Typically, for serv- ices they are not equipped to provide, staff refer clients to other agencies and resources within the community (e.g., abortion clinics) and. provide appropriate follow-up. These programs generally emphasize a coordi- nated youth-oriented approach, which recognizes that many of the yoking people they serve come from multiproblem families and require more than one type of support or service. The two most weD-known examples of this type of intervention are
182 ADOLESCENT SEX UALITy PREGNANCY AND CHILDBEARING The Bndge Over Troubled Waters, located in the heart of Boston's troubled "Tenderloin" distnct, and The Door, located in lower Man- hattan. Both are multiserv~ce centers that serve young people, boys and girls, ages 12-21. No systematic evaluation of either of these programs has been done; thus there are no data beanug specifically on the question of their short- and iong-terrn effects on sexual and fertility behavior. Nor are there any available cost data. Hofferth (Vol. Il:Ch. 9) reports, how- ever, that an evaluation of The Door is now in the planning stages. COALITIONS AND INTEREST GROUPS A variety of national, state, and local coalitions has been foe in recent years to address the problems of teenage pregnancy and childbear- ing. A major objective of these groups and organizations has been the development and implementation of effective prevention strategies. Typically, these coalitions have sought tO involve a wide range of rele- vant public and private agencies, advocacy organizations, and service providers ~ needs assessment, program planing, implementation, net- working, and evaluation activities. The major premise behind such coalitions is that effective solutions must come from collective owner- ship of the problems and cooperative efforts to identify and mobilize available resources to address them. Among the most visible national interest groups to have formed adolescent pregnancy coalitions are the Children's Defense Fund and the National Urban League. The Chil~en's Defense Fund has directed its efforts toward (~) consciousness raising among black women's groups and religious consutuenc3 es, (2) information sharing about proms outreach and service delivery approaches, (3) gathering and dissem~nat- ~ng research information, (4) advocating public policy initiatives, and (5) examining the role of the media and itS messages to minority youth. In conjunction with four other major national org~nwations (i.e., the Association of Junior Leagues, the National Council of Negro Women, the National Coalition of 100 Black Women, and the March of Dimes Birth Defects Foundation), the Children's Defense Fund has launched itS Adolescent Pregnancy Childwatch Program tO stimulate and support local communities' efforts tO address the problems of adolescent preg- nancy and child~beanng, especially as they pertain to minority youth. A manual presenting a framework for assessing local needs, identifying and mobilizing available service resources, generating local support, and analyzing program outcomes was developed. Teams from 44 communi
PREVENTIVE INTERVENTIONS 183 ties across the country were trained tO implement the program. The Children's Defense Fund staff will continue to provide coordination, technical assistance, and support for these local initiatives as well as tO . - mOnltOr t. self success. The National Urban League has similarly established a network of 10 adolescent pregnancy programs, three focused on alternative approaches to prevention, including parent-child communication and mentoring, and seven focused on alternative strategies tO help teenagers who are already pregnant. All of these projects participate in the Too Early Childbearing Network, a data gathering and information system. At the state level, numerous coalitions and task forces have been established to focus attention, energy, and resources on the problems of teenage pregnancy and childbearing. These initiatives vary: some in- volve the coordination of state-level public agencies; others involve private advocates, interest groups, and service providers. Some are pub- lic initiatives; others are voluntary. Some focus on developing policies and programs and coordinating the allocation of state-level and state- wide resources; others stress coordination between state-level agencies and local program planning efforts. One of the most important fi~nc- tions of a] these efforts is to build networks and promote communica- tior: among public- and private-sector groups who share concern about pregnancy prevention. The Reagan adminastration's effort to diminish federal responsibility for health and human services during the past several years has put the spotlight on the states. State-leve! commission- ers of health and welfare acknowledge that they currently have the opportunity and responsibility to provide policy and program leadership on these issues. lit ~] be Occult to measure the impact of these ties of coalitions and task forces in actually preventing early pregnancy and childbearing. However, they high visibility suggests that they have been successful at raising public and professional consciousness about the issues of adoles- cent pregnancy and childbeanug and the need to address them at the state and local level. MEASURING THE COSIS AND BENEFITS OF PREVENTION PR~ Polipy makers, program administrators, and advocates frequently caD for ~fo:~ation ore the costs and benefits of alternative programs, espe- aally those aimed at pregnancy prevention. Such 3mforrnation is often
184 ADOLESCENT SEXUALITY; PREGNANCY; A.hiD CHILDBEARING unavailable because adequate measures of costs (i.e., the dollar value of a program's " input " ~ an] effectiveness (i . e., the amount of " output " that results from each unit of "input") are missing. For this reason, traditional cost-benefit analyses of adolescent pregnancy programs are often problematic. Burt and Leery (Vol. Il:Ch. 10) suggest that one coherent measure of a program's output is the savings in public costs, for example, welfare COStS, medical COStS, food stamp, social service, and housing costs. They farther suggest that these COStS should be aggregated and discounted over the first 20 years of life for a child born to an adolescent mother. Discounting fixture costs in this way recognizes that, because of positive interest rates, predictable future costs can be reduced if they are antia- pate] and necessary funds are allocated at the time of birth In order to take advantage of investment earning. Thus, for example, with a ~ percent interest rate, a $~.00 cost next year requires setting aside $4.67 today. Using this framework, an intervention generates positive savings, even if it Only postpones a pregnancy for a year. Based on their cal=la- tions, Burt and Levy project that the current discounted value of future public costs associated with a first birth to a teenager in 1985 are as follows: Age of teenager at first birth 5 6 7 8 9 20-year discounted public expenditures 518,130 i7,851 7,464 2,214 10,671 These costs incite assumptions about subsequent births, the likelihood of the young mother's receiving Aid to Families With Dependent Children (AFDC), the likelihood of high school completion, employ- ment, and medical risk as discussed in Chapter S. The costs are reduced with each year that a first birth is postponed because of reduced probabil- ities of receiving welfare, smaller completed family size, and fewer medical complications for later childbearers. From these estimates it is apparent that there is a potential savings of public costs for every year that a first birth to a teenager can be postponed. However, the greatest savings would be associated with postponing a first birth until age 18 or 19, assuming that a teenage girl continues and completes high school.
PREVENTIVE IbiTER MENTIONS 18: While a delay from age 16 to age 17, for example, will save an estimated S1,530 (discounted over one year), a delay by the same air! to age 18 will save $7,~82 (discounted over two years) savings of an additional 5;,652 for a second year of delay. The clear implication of this analysis is that program efforts will have the greatest payoff in terms of cost- effectiveness if they are aimed at helping teenagers delay childbearing until they are at least 18 years old and have completed high school (Burt ant] Levy, Vol. Il:Ch. 10~. This type of cost-benefit analysis assumes specific knowledge of a program's effectiveness in postponing pregnancies that would not oth- erwise have been delayed. If, as is often the case, however, such informa- tion is unavailable, a complete estimation of the net benefits (i.e., the dollar value of benefits less program COStS) of an intervention is not possible. Burt and Levy (Vol. Il:Ch. 10) suggest as an alternative a simpler break-even analysis. Using this latter approach, the benefit of a program is measured by the number or proportion of program partici- pants who must postpone pregnancy (i.e., the amount of OUtpUt) tO offset the costs of the intervention (i.e., the amount of input). In such analysis, the evaluator calculates the value of the output, for example, the savings in public costs, and compares it with the input, for example, the unit costs of providing services. Thus, if a program costs $500 per participant per year, and the Prague of postponing an unintended preg- nancy for one year for a 17-year-old girl is $6,049, then the program must result in postponements for ~ out of every 12 17-year-old partici- paDrs in order to be cost-effective. Using this type of break-even analysis, one can assess whether anticipated program effects are within the range of feasibility for being cost-effective. In many situations, in which an administrator may riot know a program's precise effectiveness in pOSt- poning pregnancies that would not otherwise have been delayed, such analysis can be helpful in predicting whether possible likely outcomes wiD make the intervention worth implementing. The clear message from such analyses is that the effectiveness of prevention programs need not be assumed to be very high in order to Justin investment. Although the COStS of operating programs to reduce the incidence of pregnancy cover a wide range-from an estimated $~0 per participant per year for sex education courses to an estimate] $125 per participant per year for comprehensive school-based adolescent health clinics in general these costs are significantly less than the costs to taxpayers that result from nonmantal adolescent childbearing. Most
186 ADOLESCENT SEXUALITY PREGNANCY AND CHILDBEARING prevention programs need only demonstrate the delay of a relatively few adolescent pregnancies that lead to births in order to be cost-effective, assuming that they do not have any unintended or undesirable side effects that would outweigh their benefits. Measunug the unintended effects of prevention programs is difficult, yet critics of such interventions frequently point to their potentially harmful consequences. In particular, attention has focused on the extent to which such programs reduce the actual or perceived risks (costs) of early nonmantai sexual behavior and therefore lead teenagers to engage in it more freely. Sex education programs and contraceptive sernces are especially vulnerable to charges that they may induce more sexual activ- ity among adolescents than would otherwise occur. Similarly, some critics have expressed concern that more intercourse with contraception may also lead to more intercourse without contraception, which in turn might lead to more unintended and untimely pregnancies than would otherwise occur. Available data suggest that these types of interventions have not inadvertently increased levels of adolescent sexual risk taking, but the available data are admittedly imperfect. In addition to measuring the monetary costs and savings of prevention programs, more attention should be devoted to measuring the unintended and potentially undesir- able effects of such programs as wed. CONCLUSION Among the three general categories of preventive interventions there are some interesting and innovative program models with the potential for preventing uriintended pregnancy. Yet the ability of almost all these programs to demonstrate their impact on teenage fertility is limited. To do this they would need to show the rate of pregnancies prevented as a direct result of intervention; this wood require knowledge of the preg- nancy rates for adolescent clients before and after intervention or com- parative rates for matched control groups. These kinds of outcome measures are difficult to fed. With few exceptions, even programs with the specific objective of preventing pregnancy and childbeanug cannot directly demonstrate that this goal has been achieved ~ - oos, 1983~. Although several evaluations are currently under way that may yield more information in this regard, there were only three programs among aD those the pane] examined that actuary documented reductions in adolescent pregnancy. First are contraceptive services: greater use of
PREVENTIVE INTERVENTIONS 187 contraception by teenagers has been shown to reduce the incidence of pregnancy. To the extent that the availability of family penning services encourages teenagers who would not otherwise be sexually active to initiate intercourse, the positive effects of such programs on pregnancy prevention could be overwhelmed. However, there is no available ev~- dence to indicate that availability and access to contraceptive sentences influences adolescents' decisions to become sexually active, while it does significantly affect their capacity to avoid pregnancy if they are engaging Intercourse. Second, the St. PauT, Minn., school-based clinic had the specific goal of lowering fertility among its clients and succeeded In doing so. So too did the Self Center in Baltimore, Md. As discussed earlier, however, because the St. Paul program did not collect data on pregnancy, we cannot be sure whether lower fertility rates represent a decrease in the incidence of pregnancy or an increase in the use of abortion services to avert childbearing. The Baltimore program, however, provides power- fi~] evidence of reductions in pregnancies as well as some postponement of initiation of sexual activity for those students with longer exposure to the program. Third, the Teen Outreach Project in St. Louis, Mo., suggests a reduc- tion in pregnancy. Given the small scale of this project, replication is needed to confi~ the results. With the exception of programs that pronde family planning services and several of the comprehensive youth service programs, few of the . . . . preventive Interventions we examined save pregnancy prevention as a primary goal Most programs tO provide knowledge and influence atti- tudes and tO enhance life options have other primary (direct) objectives yet may also have the potential for preventing pregnancy. In most cases, these programs have not collected the kmds of data necessary tO demon- strate their eKects on pregnancy or fertility. Several, however, have been successful ire meeting their primary (direct) program objectives: · Sex education programs can effectively pronde inflation con- cern~ng reproduction and contraception. · Family communication programs can help increase the number and frequency of discussions about vaines and sexual behavior between par- ents and their children. · Assertiveness and dec~sion-making training can increase teenagers' problem-soinng and communication skills and even increase diligent . . contraceptive pracnce.
188 ADOLESCENT SFXUALI~ PREGNANCY AND CHILDBEARING · Contraceptive services can increase birth control use and improve contraceptive continuation among adolescents. · Programs to improve school performance can prevent dropping out of school and boost academic achievement. · Youth employment programs can teach job skills and place teenag . . . ers art lo as. Evidence from the available research on the antecedents of early unin- tended pregnancy and childbearing suggests that success in achieving these primary objectives may indirectly have positive secondary effects on fertility reduction among adolescents. Unfortunately, there is little information available on the costs of alternative interventions. While there are data on the unit costs of family planning services (e.g., contraceptive services, school-based clinics, etc.) and some scattered data for other programs (e.g., sex education), we know very little about the costs of other types of preventive interven- tions. Policy makers, program administrators, and advocates frequently call for information on the costs and benefits of alternative programs, especially those aimed at pregnancy prevention. However, in the absence of adequate measures of costs (i.e., the dollar Prague of a program's "output") and effectiveness (i.e., the amount of "output" that results from each unit of "input"), cost-benefit analyses of adolescent preg- nancy programs are problematic. As an alternative to traditional estimations of the net benefits of prevention programs, break-even analysis (as descnbed above, the esti- mation of the number or proportion of program participants who must postpone pregnancy to offset the costs of the intervention) offers an alternative for assessing cost-effectiveness. Cost-effectiveness is typically measured in terms of savings of public COStS, including welfare, medical costs, food stamps and related social senaces, and housing. Estimations of the dollar value of postponing a pregnancy suggest that the greatest savings of public costs will result from postponing a first birth until age 18, if the adolescent girl continues and completes high school. Thus, the greatest payoffin terms of cost-effectiveness of prevention programs can be expected from interventions aimed at helping teenagers delay a first pregnancy and birth until they are past their eighteenth birthday and have received a high school diploma.
