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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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.,

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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

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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)

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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

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~ 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

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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

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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

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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

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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.

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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

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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

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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.

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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.