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OCR for page 141
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.
Representative terms from entire chapter:
sex education
