A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results (2009)

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Appendix I Title X– and OPA-Funded Research Section 1004 of the Title X Act authorizes the Secretary of Health and Human Services to award grants and enter into contracts for research projects in the biomedical, contraceptive development, behavioral, and program implementation fields related to family planning and population. Research funded by the program includes Title X Service Delivery Improve- ment research—applied research aimed at generating knowledge that will enable the program to improve the delivery of reproductive health services to women and men who need them. Research is also conducted through cooperative agreements. The purpose of these agreements is to analyze data on family planning needs and services over time, develop tools for assessing and improving the quality of care in clinics, and analyze national survey data to better understand the determinants of unintended pregnancy and childbearing (www.hhs.gov/opa/ore/research/index.html [accessed August 19, 2008]). In addition to these grants, the Office of Population Affairs uses 1 percent funds from the Department of Health and Human Services (HHS) to contribute to the National Survey of Family Growth (NSFG) and Adolescent Health Surveys. service delivery grants and cooperative agreements The awards listed below are categorized by fiscal year (FY). These include grants made under the Service Delivery Improvement research standing announcement and through cooperative agreements (three were awarded in FY 2004). Note that grants were not awarded in FY 2002 and FY 2003. 301 

302 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Fiscal Year 2008 Integration of Family Planning Services into an STD Clinic Setting Grantee Organization: Denver Health and Hospital Authority Denver Public Health Department Denver, CO Principal Investigator: Judith Shlay, M.D. Project Period: 9/01/2008–8/31/2011 This study will investigate how providing integrated family planning with STD clinical services in an STD clinic affects quality of care, cost of services, staff duties, clinic flow, clients’ family planning needs, satisfaction with services, and incidence rates of STDs and pregnancies. The study will specifically (1) assess the feasibility and replicability of the clinical processes used by clinicians to provide family planning services in an STD clinic set- ting, (2) assess and compare the costs of providing family planning and STD services in separate clinical settings and through separate programs to the costs of an integrated program, (3) establish computerized procedures to identify clients eligible for family planning services in an STD clinic, and (4) assess the need for family planning services among all clients seen for STD clinical services. In addition, the study will evaluate the effectiveness of a reminder system that notifies staff of a person’s eligibility to receive family planning services; and compare rates of STDs and unintended pregnancies among clients seen in the clinic. Sexual and Reproductive Health Outreach for Young Women of Color: A New Approach Grantee Organization: The Trustees of Columbia University Columbia University Health Sciences Center New York, NY Principal Investigator: Debra Kalmuss, Ph.D. Project Period: 9/01/2008–8/31/2011 The study will develop innovative and practical ways to embed sexual and reproductive health (SRH) referrals, as well as promotional informa- tion and messages, into workforce development (WFD) programs; train WFD program staff to interview men about their use of and/or need for SRH care and how to make care referrals; train staff at Title X clinics how to enhance their facilities and services to be gender sensitive to men, based 

APPENDIX I 303 on the results of a male friendliness needs assessment; and implement and evaluate the efficacy and sustainability of the capacity building outreach model in promoting men’s SRH utilization. The proposed research will occur with two WFD programs that serve low-income Hispanic and Afri- can-American males seeking new job training, and two Title X clinics.  Increasing Family Planning Utilization Among Hispanic Teen and Young Adult Women Grantee Organization: Child Trends Washington, DC Principal Investigator: Jennifer Manlove, Ph.D. Project Period: 9/01/2008–8/31/2011 The specific aim for the project is to reduce the high rate of teen and unintended pregnancies among Hispanics in the United States. This will be accomplished by using quantitative, qualitative and applied research methods to better assess who is or is not accessing family planning services and why. The project work will be performed in three stages. In Stage 1, the project will analyze family, individual, and community factors associ- ated with the utilization of family planning services using data from several cycles of the National Survey of Family Growth. For Stage 2, focus groups will be conducted in three target cities with Hispanic female teens and young adults to gather group insights into their decisions to access or not access services. The project will also include three focus groups with clinics and service providers to discuss the challenges of reaching Hispanic clients. In Stage 3, project staff will work with a clinic or provider in each of the target cities to assess how the programs can use the study’s findings; trans- late the findings; and construct implementation guidelines for the broader family planning practitioner community. Fiscal Year 2007 Medicaid Family Planning Waivers: Service Delivery, Use, and Intended Pregnancy Grantee Organization: Emory University Rollins School of Public Health Atlanta, GA 30322 Principal Investigator: Kathleen Adams, Ph.D. Project Period: 9/30/2007–9/29/2010 

304 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Six states will be study sites for examining the effects of changes in the organization and delivery of family planning services through Medicaid section 1115 waivers on three key outcomes—(1) access to services, (2) use of contraceptive/preventive services, and (3) unintended pregnancy. In each state, the aim will be to test whether the state’s waiver reduced barriers and increased use of services and thereby reduced unintended pregnancy. Overall, variation in the impact of waivers across states and across differ- ent subgroups, such as married women, teens and minority women, will be analyzed. Both quantitative analyses (PRAMS and BRFSS data sets avail- able from CDC) and qualitative research (informant interviews and focus groups) will be carried out. A synthesis of states’ concerns, approaches, successes/failures and client perceptions of the waivers will be generated. A key goal of the analyses is to elucidate the pathways whereby sexually active women not desiring to become pregnant are or are not served under the delivery systems each state has in place under its waiver. The six states are Arkansas, Illinois, New York, California, Washington, and Wisconsin; the project will provide a case study for each of these states. Sexual and Reproductive Health Services: Reaching Latino Men in Rural Areas Grantee Organization: Oregon State University Department of Public Health Corvalis, OR 97331 Principal Investigator: S. Marie Harvey, Dr.P.H. Project Period: 9/30/2007–9/29/2010 The objective of this research project is to increase understanding of the sexual and reproductive health needs of heterosexual Latino men who live in rural areas. In this two-part study, the focus is on Latino men in the new settlement areas of rural Oregon. Study 1 will consist of in-depth interviews of a convenience sample of 80 men to assess their attitudes and behavior pertaining to sexual activity and contraception, and their perceptions of their needs and of the barriers to accessing services and to determine how their attitudes and behaviors vary by age, type of sexual partner and acculturation. Study 2 will include in-depth interviews with administra- tors and practitioners from publicly funded family planning agencies who serve Latinos in rural areas. The specific aims of Study 2 are to (a) explore experiences providing family planning and HIV/STI prevention services to Latino males; (b) identify barriers and facilitators to serving male Latinos; (c) explore advantages and disadvantages of integrating men into sexual and reproductive health services for family planning agencies and for male 

APPENDIX I 305 clients; (d) identify preferred context for providing sexual and reproductive health services to men (e.g., couples, male only, traditional family setting or other contexts); and (e) explore how agencies can build their capacity to improve sexual and reproductive health services for Latino males. Couples-Based Family Planning Services: Is There a Need? Grantee Organization: The Guttmacher Institute New York, NY 10038 Principal Investigator: Rachel Jones, Ph.D. Project Period: 9/30/2007–9/29/2010 The project aims to improve contraceptive use and reduce unintended pregnancy among Title X family planning clients by providing information on a new and mostly untested programmatic strategy of fostering joint decision-making around family planning through couples-oriented services. Three interrelated activities are proposed: 1. Provide a national overview of the extent to which Title X female and male clients, 18–44 years of age, as well as the clients’ part- ners, express a desire for programs oriented to couples designed to improve joint decision making around contraceptives and method selection; 2. Explore the issue from the point of view of providers, to determine what strategies clinics have so far adopted in terms of couples- oriented counseling or services, as well as perceived need for and barriers to implementing such programs; and 3. Disseminate findings to relevant audiences to inform public discus- sion about the potential for contraceptive counseling and services targeting couples in order to foster or promote joint decision mak- ing around contraceptive use. The sampling approach is based on 80 randomly drawn clinics from a universe of U.S. clinics. Individual clients will receive and complete sur- veys at the clinic site and be provided survey forms to take to partners; the sample size of clients is expected to be 2,500 women and 125 men. Clients’ openness to a couples approach will be analyzed by relationship type (married, co-habiting, neither married nor co-habiting) and by racial/ ethnic groupings. Staff at sampled clinics will complete a provider survey on couples-oriented services as well. 

306 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM The Fort Peck Sexual Health Project: A Contextual Analysis of American Indian Men Grantee Organization: Montana State University Department of Health and Human Development Bozeman, MT 59717 Principal Investigator: Elizabeth Lynne Rink, Ph.D. Project Period: 9/30/2007–09/29/2009 The study will elucidate the individual, social and environmental factors that most greatly influence American Indian men’s sexual and reproductive health. Individual characteristics to be examined include: knowledge of con- traceptive methods and sexually transmitted infections (STIs); perceptions of pregnancy; perceived risk of STIs; perceptions of abstinence, monogamy and contraceptive use. Social dynamics to be examined are: relationships with family; relationships with peers; culture; religion; and relationships with sex- ual partners. The relevant environmental factors will include: characteristics of family planning services, access to family planning services, and utilization of family planning services. The target population for this project is Ameri- can Indian men ages 18–24 years living on the Fort Peck Indian Reservation in northeastern Montana. The research plan includes a Community Based Participatory Research (CBPR) approach and qualitative research methods. CBPR will entail engaging the Fort Peck Indian Reservation as full and equal partners in the research project, by establishing an 8–10 member community advisory board to provide oversight and coordination of the project. Qualita- tive research methods will include (1) 12–15 key informant interviews with health care professionals and (2) 112 in-depth interviews with American Indian men. Research results will be used to design effective, culturally sensi- tive, family planning intervention strategies for American Indian men. Fiscal Year 2006 CONnecting with Teens About Contraceptive Use (CONTAC-U) Grantee Organization: Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe Street Baltimore, MD 21205 Principal Investigator: Kathleen M. Cardona, Dr.P.H., M.P.H. Project Period: 09/01/2006–08/31/2009 Project Description: The objective of this study is to develop and evalu- ate a clinic-based intervention intended to increase contraceptive use and 

APPENDIX I 307 consistency of use, and reduce 1‑year pregnancy rates among adolescents. Specifically, the plan is to design an easily replicable, technology-based and adolescent-friendly means of continuing contact to enhance contraceptive protection, while encouraging parental involvement. This will involve all female clients under age 20 who present to the youth center in Baltimore City over an 18 month period. Individualized methods counseling sessions will be provided to clients who will be contacted at regular intervals begin- ning 2 weeks post-enrollment and then at least monthly to discuss issues related to method use, and appointment reminders. One technological innovation is clients’ use of text-messaging, e-mail, or phone as a means of clinic contact. A second innovation is the use of a new web-based database to be designed for this project, which will permit contacts to be scheduled, initiated, and recorded, and which will enable the clinic to provide regular, longitudinal follow-up. Clients will also be encouraged to identify a parent or key adult to participate in order to learn about contraceptive options and how to communicate with the teen to reinforce appropriate use of contraception. Chlamydia and Race/Ethnicity in Title X Region X Female Clients Age 15–24 Years Grantee Organization: Center for Health Training 1809 7th Avenue, Suite 400 Seattle, WA 98101 Principal Investigator: David Fine, Ph.D. Project Period: 9/01/2006–08/31/2007 Project Description: The research goal for this project is to explore, assess, and begin to address possible racial/ethnic disparities in chlamydia (CT) screening, prevalence and prevention services in Title X family plan- ning clinics using existing data sets. Specific aims are to (1) assess racial and ethnic disparities in chlamydia screening coverage among Title X Region X family planning (FP) clinic female clients aged 15–24, from 2004–2005; (2) assess racial and ethnic disparities in chlamydia positivity among Region X FP clinic female clients aged 15–24 from 1997–2005; and (3) assess an enhanced array of behavioral, demographic, and socio­economic status mea- sures in relation to race/ethnicity and chlamydia positivity in a sample of FP clinic female clients age 15–24. Data sources to be used for specific aims #1 and #2 include (1) a two-year (2004–2005) data set from the Region X Title X FP client information system that captures patient characteristics and service provision for all Title X encounters; and (2) data from the Infertility Prevention Project (IPP) for the assessment of racial and ethnic disparities 

308 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM in chlamydia positivity. Data for specific aim #3 will come from recruiting female FP clients (375 CT+/375 CT-) age 15–24 from clinics where race/eth- nic disparities were found based on results from specific aim #2. Disparities in Reproductive Health Care Access Among Vulnerable Populations Grantee Organization: Research Triangle Institute 3040 Cornwallis Road Research Triangle Park, NC 27709 Principal Investigator: Christina Fowler, Ph.D., M.P.H. Project Period: 09/01/2006–08/31/2008 Project Description: This study proposes a comprehensive and system- atic examination of disparities in reproductive health service access across multiple vulnerable populations. The objective of this project is to examine whether disparities in access to family planning and other reproductive health services exist for vulnerable groups of women and men, specifically non-His- panic black and Hispanic, relative to non-Hispanic white; poor (<100% of federal poverty level [FPL]) and near-poor or low income (100%–199% of FPL), relative to nonpoor (>200% of FPL); teens (aged 15–19) and young adults (aged 20–24), relative to older adults (aged 25–44); and residents of nonmetropolitan counties and metropolitan suburban counties, relative to residents of metropolitan urban counties. Data from the 1995 (women) and 2002 (women and men) National Survey of Family Growth (NSFG), will be used to analyze whether group differences exist in service utilization, quality, and contraceptive use and to assess the role of Title X clinics in reducing dif- ferences. The IOM’s 1993 Model of Access to Personal Health Care Services, adapted to reproductive health care, will guide the study. Impact of Pack Supply on Contraceptive Continuation Grantee Organization: Columbia University Medical Center 630 West 168th Street New York, NY 10032 Principal Investigator: Katherine J. O’Connell, M.D., M.P.H. Project Period: 09/30/2006–09/29/2009 Project Description: The objective of this project is to determine whether providing an enhanced, seven-month supply of oral contraception (OC) versus the standard 7-month supply of OC results in less contraceptive dis- 

APPENDIX I 309 continuation. It is believed that an extended initial supply of contraception requires fewer visits to obtain refills and may remove a common obstacle to method continuation. The proposed strategy is a randomized trial to compare two approaches to the initial supply of hormonal contraception in women aged 29 and under who receive family planning care at a publicly funded clinic (n = 750). The approaches are (1) a standard 3-month supply of OC, versus (2) an enhanced 7-month supply of OC. Interviews will be conducted at a 6-month follow-up to determine OC continuation rates and adverse events. The researchers believe that the approach of extending the initial supply of contraception has the potential to improve rates of OC, particularly among adolescents who are at the highest risk of early dis- continuation, and by removing a obstacle to method continuation, would ultimately help to reduce the rate of unintended pregnancy. Fiscal Year 2005 How Well Do Family Planning Providers Link Their Low-Income Clients to Primary and/or Specialty Care? Grantee Organization: University of Alabama-Birmingham 1530 3rd Avenue South Birmingham, AL 35294 Principal Investigator: Janet M. Bronstein, Ph.D. Project Period: 09/30/2005–09/29/2007 Project Description: The specific aims of this project are (1) to exam- ine the range of referral facilitation activities provided in family planning settings serving low-income women; (2) to explore the factors associated with family planning clients’ decisions to seek and ability to receive care for other medical conditions, including the role played by referral facilitation and discussions of the problem at the family planning visits; and (3) to com- pare the level of concern about the ability to refer family planning clients for needed primary and specialty care between clinicians who do and do not provide family planning care to clients with Medicaid coverage for these services. Family planning providers who participate in and clients who are enrolled in Medicaid family planning demonstration programs in Alabama and Arkansas are the populations under study. Data for this project will be collected through three surveys: (1) a survey of family planning clinicians to assess referral practices; (2) a survey of these clinicians’ family planning clients, to examine their care-seeking behavior for general health problems and the role played by their family planning providers; and (3) a survey of 

310 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM office physicians who are authorized as Medicaid family planning providers but are seeing few or no Medicaid clients. Men’s Reproductive and Sexual Health Practices, Attitudes and Service Utilization Grantee Organization: Columbia University Medical Center 60 Haven Avenue, Suite B-2 New York, NY 10032 Principal Investigator: Debra S. Kalmuss, Ph.D. Project Period: 09/30/2005–09/29/2008 Project Description: The objective of the proposed study is to examine men’s reproductive and sexual health (RSH) practices, attitudes, and service utilization in order to inform the development of programs for adolescent and older men. The research plan is to employ both quantitative and quali- tative methods to examine men’s RSH status, attitudes and practices and how they vary across race/ethnic, socioeconomic, age, and marital/relation- ship status in order to increase the utilization of RSH services for men. The quantitative approach would use national data from Cycle 6 of the National Survey of Family Growth (NSFG) supplemented by two data sets target- ing high-risk groups of males aged 18–30 from northern ­Manhattan and the Bronx. The qualitative component—use of focus groups—is intended to obtain a more in-depth understanding of men’s perceptions regarding utilization, such as barriers to men’s use of RSH and possible strategies to increase men’s utilization of such services. The final step in the proposed study will involve the translation of research findings into suggestions for program development and/or enhancement. Improving Services for Latina Women and Their Partners: A CAPACITIES Approach Grantee Organization: Georgetown University, Department of OB/GYN 3900 Reservoir Road, NW Washington, DC 20007 Principal Investigator: Rebecka Lundgren, M.P.H. Project Period: 09/30/2005–09/29/2008 Project Description: This intervention research, which will be conducted collaboratively by the Institute for Reproductive Health, ­Georgetown Uni- versity, and Planned Parenthood of San Diego and Riverside Counties, 

APPENDIX I 311 will determine whether including the Standard Days Method (SDM) as an option for clients results in an increased focus on the couple in counseling for all methods of contraception; whether incorporating a couple perspec- tive into services results in improved satisfaction with and use of services; whether it increases couple communication and participation in family planning use and decision-making; and whether it results in improved used of and satisfaction with family planning methods. SDM is a simple, effec- tive fertility awareness-based method that is being offered in programs around the world, including a growing number in the United States. The importance of addressing couples may be particularly relevant for Latinos, given cultural considerations. Couples and Contraceptive Practice Grantee Organization: Family Planning Council 260 S. Broad Street, Suite 1000 Philadelphia, PA 19102-5076 Principal Investigator: Paul Whittaker, Ph.D. Project Period: 09/30/2005–09/29/2008 Project Description: The Family Planning Council proposes to conduct a mixed methods investigation to study the feasibility and effectiveness of couples-focused contraceptive services, which will use an integrated com- plement of ethnographic and quantitative methods to attain three aims. The first is to compare the attitudes, subjective norms, and behavioral beliefs of young adult men and women regarding the involvement of intimate part- ners in contraception decisions and the influence of these partners on con- traceptive use. The second is to identify the attitudes, subjective norms, and behavioral beliefs of Title X providers regarding the current and potential provision of couples-focused contraception services. The third is to develop and field-test the potential utility of a culturally relevant couples-focused intervention that promotes informed contraception decisions and effective contraception use. 

312 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Fiscal Year 2004 (Cooperative Agreements) Family Planning Needs and Services in the United States Grantee Organization: The Alan Guttmacher Institute 120 Wall Street New York, NY 10005 Principal Investigator: Jennifer Frost, Dr.P.H. Project Period: 09/30/2004–09/29/2009 Project Description: The goal of the proposed project is to provide core information and analyses that program planners and providers can use to improve the delivery of quality family planning services, and through this, to increase the success with which U.S. women and their partners prevent unplanned pregnancies. This project will use existing national-, state-, and county-level data, and collect new data when necessary, to answer the follow­ing questions: How many women in the United States are in need of subsidized family planning services? To what extent is this need being met? How well are these women being served? What challenges are posed by an increasingly diverse population base? How is financing for family planning changing? What return do we get for our investment in publicly funded family planning services? These data will allow programs to be monitored and services to be adjusted to ensure that those who need and want subsi- dized family planning and related preventive reproductive health services are able to obtain them. Child Trends/OPA Cooperative Agreement for Family Planning Research Grantee Organization: Child Trends 4301 Connecticut Ave., N.W., Suite 100 Washington, DC 20008 Principal Investigator: Jennifer Manlove, Ph.D. Project Period: 09/30/2004–09/29/2009 Project Description: The aim of this project is to examine family, indi- vidual, peer, partner, and community factors to better understand sexual experience and activity, contraceptive use and effectiveness, unintended childbearing and unmet family planning service needs. In addition, studies are planned of nonvoluntary sexual experiences, the male role in reproduc- tive health decisions, and parental involvement on important reproductive health matters. These analyses will help clinic staff identify those most in 

APPENDIX I 313 need of services and provide insights into how to implement challenging family planning policy initiatives. The project will comprehensively analyze relevant data from several national data sources (National Vital Statistics System; Youth Risk Behavior Survey; National Survey of Family Growth; National Longitudinal Study of Adolescent Health or Add Health; National Survey of Adolescent Males; and National Longitudinal Survey of Youth 1997). Research products in the form of Research Briefs and Fact Sheets will be made available. Strengthening the Capacity of Family Planning Agencies to Improve the Quality of Family Planning Services: Cooperative Agreement for Research to Improve the Delivery of Family Planning Services Grantee Organization: Johns Hopkins University School of Hygiene and Public Health 2007 E. Monument Street Baltimore, MD 21205 Principal Investigator: Freya Sonenstein, Ph.D. Project Period: 09/30/2004–09/29/2009 Project Description: The proposed project, which addresses a sig- nificant gap in our knowledge about quality of family planning services in this country, will be conducted by a team of researchers from Johns H ­ opkins University in collaboration with a small network of Title X grantees. The project has the following aims: to develop approaches that assess the ­quality of service delivery; to develop a toolbox of approaches to improve quality of services; and to test interventions aimed at quality improvement. The emphasis is on developing (1) feasible and practical approaches to measuring quality of care in Title X clinics with attention to client–­provider interactions; (2) a demonstration network that could help develop a research infrastructure among Title X grantees; and (3) dis- semination processes that promote science-based practices. Serving a mix of clients, including individuals with limited English proficiency, varying ethnic and racial identities, and men as well as women, the network of agencies will make it possible to test approaches to measure and improve services for diverse populations with varying needs. 

314 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Fiscal Year 2001 Enhanced Family Planning in an STD Clinic Grantee Organization: Johns Hopkins University, School of Medicine 720 Rutland Avenue Baltimore, MD 21305 Principal Investigator: Emily Erbelding, M.D., M.P.H. Project Period: 9/2001–9/2003 Project Description: This project will evaluate the impact of enhanced STD outreach worker services on the reproductive health outcomes in a cohort of women receiving STD care and contraceptive care in inner city STD clinics. Outcomes will be compared to those of a control cohort of women who are enrolled for a similar range of contraceptive services but do not receive the outreach intervention. The study will measure rates of u ­ nintended pregnancy and new STDs among female STD patients in a sys- tem with contraceptive public health outreach compared to standard care. Women Leaving Prison: Two Models of Family Planning Service Delivery Grantee Organization: Rhode Island Hospital 593 Eddy Street Providence, RI 02903 Principal Investigator: Jennifer Clarke, M.D. Project Period: 9/2001–9/2003 Project Description: The researchers will evaluate a current Title X- funded family planning program for incarcerated women in Rhode Island who are soon to be released from prison. Clients will be surveyed to determine factors associated with and barriers to seeking family planning services. The study will compare two modes of delivering family planning services to women being released from prison. The first model will evaluate an innovative program that involves initiating family planning education for incarcerated women and then arranging post-release connection to a clinic for family planning services. The second model will examine a model in which education and contraceptive methods are offered to women prior to their release from prison and then arranging a post-release connection to a clinic for family planning and reproductive health care. Behavioral and biological outcomes will be assessed when testing both these models. 

APPENDIX I 315 Improvement in Northern Manhattan to Two Underserved Populations: Males and Recent Immigrants Grantee Organization: New York Presbyterian Hospital 60 Haven Avenue, B-3 New York, NY 10032 Co-Principal Investigators: Roger Vaughan, Ph.D., and Lorraine Tiezzi, M.S. Project Period: 10/2001–9/2003 Project Description: This project will identify and explore the enabling factors for, and barriers to, health care seeking behavior among a recent immigrant Hispanic population and among Hispanic males in New York City. The project will conduct several case-control studies at different health care access points (including reproductive health care) available to recent immigrants and males. Structured interviews will be conducted among a sample of older adolescents, young adults and older adults who have demonstrated health care needs and who accessed health care, and among a control group who did not access health care. Structured interviews will also be conducted with parents, as well as with the health care providers in the school-based clinics and the community-based family planning clinics. Barriers to Family Planning Services Among Mexican Immigrants in California: Gender, Power and Culture Grantee Organization: University of California, San Francisco Department of Obstetrics, Gynecology and Reproductive Sciences 3333 California Street, #315 San Francisco, CA 94118 Principal Investigator: Catherine Maternowska, Ph.D., M.P.H. Project Period: 1/2001–12/2002 Project Description: This project focuses on understanding the com- plex sociocultural factors that influence reproduction and the use of f­amily planning services in Mexican immigrant communities. The research ­project has three broad aims: (1) to uncover factors that influence the use of family planning services among male and female Mexican immigrants in ­ California; (2) to discern if these factors differ among rural (largely migrant) and urban populations; and (3) to understand providers’ behav- ior and their perceptions of Mexican immigrants in an effort to determine how services can be made more accessible. A sample of Mexican men and women of childbearing age will be recruited for interviews from two 

316 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM groups—clients in the California Family Planning, Access, Care and Treat- ment Program (Family PACT) and non–Family PACT clients. Interviews will address respondents’ fertility histories, contraceptive knowledge and attitudes, financial, time, and health care resources, access to medical care, as well as social and legal networks. The project will also study family planning provider attitudes regarding the Mexican immigrant population and perceptions of their needs. Project to Assess the Impact of Increasing Costs on the Delivery of Family Planning and Reproductive Health Services Grantee Organization: Cicatelli Associates, Inc. 505 Eighth Avenue, Suite 2001 New York, NY 10018-6505 Principal Investigator: Susan Gadon Project Period: 9/2001–9/2002 Project Description: Cicatelli Associates, Inc. (CAI) will conduct a case study approach to explore the impact of increasing costs and other factors on the delivery of family planning and reproductive health services over a 5–10-year period. The project will work with a sample of Title X family planning grantees and provider agencies to conduct an in-depth review and analysis of purchasing records, clinic operations, and other records to extract information required to determine the effect that changing costs have had on the delivery of family planning services. A relative value cost methodology will be utilized for each participant agency to determine the unit cost of service by CPT codes. CAI will develop cost of service reports providing in-depth information on the impact of changing costs, as well as other contributing factors, affecting the delivery of family planning services. Fiscal year 1983–2000 Awards Service Delivery Improvement grants for FY 1983–2000 are listed below, organized according to the following topic areas: increasing cost of family planning services, family planning client behavior, adolescent family planning clients, male family planning clients, targeting of family plan- ning services, organization/management of family planning services, role of private physician, natural family planning, infertility services, counseling services, and cross-national studies. 

APPENDIX I 317 Increasing Cost of Family Planning Services Project to Assess the Impact of Increasing Costs on the Delivery of Family Planning and Reproductive Health Services Grantee Organization: Cicatelli Associates, Inc. 505 Eighth Avenue, Suite 2001 New York, NY 10018-6505 Principal Investigator: Susan Gadon Project Period: 9/2001–9/2002 Project Description: Cicatelli Associates, Inc. (CAI) will conduct a case study approach to explore the impact of increasing costs and other factors on the delivery of family planning and reproductive health services over a 5–10-year period. The project will work with a sample of Title X family planning grantees and provider agencies to conduct an in-depth review and analysis of purchasing records, clinic operations, and other records to extract information required to determine the effect that changing costs have had on the delivery of family planning services. A relative value cost methodology will be utilized for each participant agency to determine the unit cost of service by CPT codes. CAI will develop cost of service reports providing in-depth information on the impact of changing costs, as well as other contributing factors, affecting the delivery of family planning services. Family Planning Client Behavior Assessing Family Planning and Reproductive Health Needs and Services in the United States Grantee Organization: The Alan Guttmacher Institute 120 Wall Street New York, NY 10005 Principal Investigator: Jacqueline E. Darroch, Ph.D. Project Period: 7/01/1999–6/30/2004 Project Description: The objectives of this project include the following: (1) to document the nation’s need for publicly funded reproductive health and family planning services, service providers’ capability and success in meeting those needs with attention to the demographic and socioeconomic characteristics of those in need; (2) to investigate emerging issues and 

318 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM significant trends in publicly funded reproductive health and family plan- ning service delivery, with special attention to the Title X family planning program; (3) to monitor federal and state funding and policies that affect reproductive health family planning service delivery, including funding provided under Medicaid and other major sources and through managed care mechanisms; and (4) to disseminate information and analyses that will enable policy makers, providers and other individuals and organizations to improve the quality and reach of reproductive health and family planning services in the United States. Improving Condom Use for STD Prevention by Clinic Patients Grantee Organization: Family Health Council of Central PA 1017 Mumma Road P.O. Box 360 Camp Hill, PA 17001-0360 Principal Investigator: Laraine Winter, Ph.D. Project Period: 1/1998–12/2000 Project Description: The aim of this study was to evaluate an inter- vention to increase condom use among partners of family planning clinic patients. Using a prospective cohort design, the study was conducted in three family planning clinics in Pennsylvania and Maryland. A sample of 2,100 female family planning patients under age 30 received one of three counseling strategies—the skill training condition, a control condition with standardized condom education, and a second control condition in which a list of suggestions was added to the standard condom education. The intervention, which was designed to enhance the subjects’ negotiation skills in getting partners to use condoms, consisted of a counseling based social skill training exercise which targeted social barriers to condom use. Patients were first required to identify obstacles to their condom use, and with the help of a counselor devised plans to overcome each obstacle. At the end of their clinic visit, patients were invited to take as many free condoms from a basket of 50 as they wished and complete a questionnaire which assessed intention to use condoms, attitudes, knowledge, number of condoms taken, and frequency of sexual intercourse. Demographic information and STD infection status were gathered from the clinic’s Patient Input and Clinic Report Forms. Twelve months later, at the annual clinic visit, patients answered questions about their condom use since the intervention. Also, patient medical charts were examined for evidence of new STD infections since the intervention. 

APPENDIX I 319 Norplant, Depo Provera, the Pill: Influences and Outcomes Grantee Organization: Family Planning Council of Southeastern Pennsylvania 260 South Broad Street, Suite 1900 Philadelphia, PA 19102-3865 Investigator: Kay A. Armstrong Project Period: 10/1993–9/1996 Project Description: This study involved clinicians and clients at five Title X funded family planning clinics in Southeastern Pennsylvania and focused on the three major methods of hormonal contraception: Norplant, Depo-Provera, and oral contraceptives. It examined two issues: (1) clinician influences on clients’ contraceptive decision making with a particular focus on the choice of the three hormonal methods, and (2) behavioral compli- ance outcomes associated with the use of each of the three methods. Family Planning in Clinic Discontinuation Grantee Organization: Family Planning Council of Southeastern Pennsylvania 260 South Broad Street, Suite 1900 Philadelphia, PA 19102-3865 Investigator: Roberta Herceg-Baron, M.A. Project Period: 10/1983–3/1985 Project Description: This project examined the complete clinic histo- ries of over 13,000 women in Pennsylvania and follow-up interviews were conducted with a subsample to obtain answers to the following questions: (1) What are the rates and patterns of clinic discontinuance among family planning clients? (2) To what extent are personal, clinic, and community attributes associated with the rate of discontinuance? (3) What are the rea- sons for clinic discontinuation and what sources are used subsequently by women still desiring family planning care? Family Planning Performance: Acceptance and Drop-Out Grantee Organization: Johns Hopkins University School of Hygiene and Public Health Department of Population Dynamics 615 North Wolfe Street Baltimore, MD 21205 Principal Investigator: Dr. Lien P. Chow, M.D. 

320 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Project Period: 10/1983–9/1985 Project Description: Two major data sources were utilized to study family planning services in Maryland, with emphasis on the study of clinic acceptors and dropouts. First, computerized data files on all new accep- tors in Maryland (except Baltimore) for the past 5 years were assessed to ascertain if the program was increasing its numbers of those it is designed to serve and to analyze the characteristics of dropouts. Second, follow-up interviews of 1,500 women were conducted to determine subsequent contra­ ceptive behavior and fertility and to obtain additional data not available on medical records. Choice of Family Planning Services Among Poor Women Grantee Organization: University of Florida Department of Psychology Gainesville, FL 32611 Principal Investigator: Lawrence J. Severy, Ph.D. Project Period: 10/1983–9/1986 Project Description: This project surveyed 1,000 low-income women in need of family planning services in north central Florida to examine the utility of the expectancy-value model in predicting both choice of provider (private physicians, family planning clinics, or other) and change in providers over an 18-month period. The results can alert providers as to whether there are misperceptions about their service delivery systems which can be addressed. Family Planning Needs of Underserved Women: Contraception, Patient Education, and Reproductive Health Grantee Organization: University of Southern California School of Medicine Department of Medical Education KAM Room 200 1975 Zonal Avenue Los Angeles, CA 90033 Principal Investigator: Robert C. Mendenhall, Ph.D. Project Period: 9/1985–6/1987 Project Description: The study identified low-income women who, while at the risk of unintended pregnancy, were not receiving clinic or 

APPENDIX I 321 private family planning care; determined what are the barriers to service utilization for them; and assessed deficits of clinic providers in their efforts to reach such clients. Approximately 600 low income Los Angeles women from different ethnic groups and poverty levels were surveyed, and those survey data were linked with information from providers located in the same “district” as the surveyed women. Rural Family Planning Services: An Interactionist View Grantee Organization: Cornell Institute for Social and Economic Research Cornell University 123 Day Hall Ithaca, NY 14853 Principal Investigator: Burton Mindick, Ph.D. Project Period: 1/1985–12/1986 Project Description: This project will look at how person and clinic situation interrelate to influence family planning effectiveness in a rural setting. A three-county area in Central New York State is the ­geographical location of the study; data will be obtained from approximately 900 sub- jects: women of childbearing age attending family planning clinics, a com- parable group of women receiving noncontraceptive services, and provider personnel serving the two groups of women. Over-time measures will be taken on both clients and clinics. Qualitative, as well as quantitative, data will be sought. A theoretical model of adaptive coping behavior will guide the analysis, which will employ multivariate techniques. Adolescent Family Planning Clients Adolescents’ Motivation to Prevent Pregnancy Grantee Organization: Child Trends 4301 Connecticut Avenue, N.W., #100 Washington, DC 20008 Principal Investigator: Barbara W. Sugland, Sc.D. Project Period: 6/1995–5/1998 Project Description: The goal of this study was to develop a concep- tual framework for explaining the determinants of pregnancy risk-taking behavior among youth. To fulfill this aim, the investigators conducted focus groups among a sample of European-American, African-American, 

322 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM and Hispanic-American youth aged 16–19 to determine youth percep- tions about the decision-making process concerning pregnancy risk-taking behavior; and held concept mapping groups to provide insights into how youth conceptualize the decision-making process for pregnancy risk-taking behavior. Tailoring Family Planning Services to the Needs of Teens Grantee Organization: Family Health Council of Central PA 1017 Mumma Road P.O. Box 360 Camp Hill, PA 17001-0360 Principal Investigator: Laraine Winter, Ph.D. Project Period: 7/1994–3/1998 Project Description: This study followed approximately 2,000 teen (under 18) female clients of two inner-city Pennsylvania clinic sites and evaluated an intervention strategy designed to improve clinic outcomes for these young women in the areas of contraceptive use, contraceptive knowledge, continued clinic attendance, and pregnancy prevention. Using an intervention strategy referred to as the New Adolescent Approach, the experimental protocols emphasized extended counseling, addressed clients fears and worries, and provided more clinic supervision. Its ultimate goal was to improve the delivery of services to young women who visit family planning clinics. Abuse Dimensions of Teen Contraception and STD Prevention Grantee Organization: The Center for Health Training 400 Tower Building 1809 Seventh Avenue Seattle, WA 98101 Principal Investigator: David N. Fine, Ph.D. Project Period: 3/1992–2/1995 Project Description: Using a sample of 400 subjects (200 abused and 200 nonabused) drawn from Title X clinics in Region X, this project inves- tigated the prevalence of sexual abuse (nonvoluntary sexual experience) among the family planning clinics and examined the relationship between sexual abuse and contraceptive compliance and sexually transmitted disease prevention. Another aim of the project was to determine the most effective 

APPENDIX I 323 approach for obtaining client abuse histories and to develop strategies for improving services to sexually active adolescents who are at risk for contra­ ceptive noncompliance. Influencing Adolescent Male Contraceptive Behavior and Attitudes Grantee Organization: Children’s Hospital National Medical Center Department of Adolescent Medicine Washington, DC 20010 Principal Investigator: Lawrence J. D’Angelo, M.D. Project Period: 7/1/1988–6/30/1992 Project Description: The purpose of this longitudinal study was to investigate the attitudes and behaviors of adolescent males towards con- traception. The specific aim of this project, which involved a sample of 500 sexually-active adolescent males aged 11–21 from Title X clinics, was to provide answers to the following questions: (1) Can the attitudes and behaviors of sexually active males be changed either through an educational program or the availability of free condoms? (2) How do the attitudes of non-sexually active adolescent males compare with those of their sexually active peers? (3) What psychosocial variables affect attitudes and behav- iors? (4) Has AIDS influenced contraceptive attitudes and behavior? Effects of Psychosocial Factors on Teen Contraception Grantee Organization: University of Texas Health Science Center at Dallas Southwestern Medical School 5323 Harry Hines Blvd. Dallas, TX 75235 Principal Investigator: Judith B. Keith, Ph.D. Project Period: 10/1986–9/1988 Project Description: The goal of this project was to obtain a more comprehensive understanding of adolescent contraceptive behavior by uti- lizing a multivariable framework that included psychosocial and cognitive determinants of contraceptive use. Several kinds of data were collected over a 6-month period on 200 unmarried, nulliparous adolescent women attending a clinic serving lower-income black and Hispanic adolescents. The data were analyzed with regard to differences between contracepting and 

324 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM noncontracepting adolescents and between those behaving consistently and inconsistently in the contraceptive area. Male Family Planning Clients Reproductive Health Screening of Male Adolescents Grantee Organization: Kaiser Foundation Hospitals Center for Health Research 4610 S.E. Belmont Portland, OR 97215 Principal Investigator: Ross Danielson, Ph.D. Project Period: 10/1984–9/1987 Project Description: This project tested the impact on adolescent males’ subsequent sexual and contraceptive activity of providing reproductive health information and counseling in combination with the delivery of routine medical care in a HMO setting. Approximately 1,000 males, who were 15–17 years of age and who scheduled routine HMO appointments, were recruited for the study. The Male Role in Adolescent Contraception Grantee Organization: Children’s Hospital National Medical Center Department of Adolescent Medicine 111 Michigan Avenue, N.W. Washington, DC 20010 Principal Investigator: Lawrence D’Angelo, M.D. Project Period: 9/1985–8/1986 Project Description: This study sought to determine factors affecting use or nonuse of contraceptives, particularly condoms, through interviews of 500 males, aged 11–19, attending a general medical clinic in an urban hospital setting. Other Research: A second grant was awarded to Dr. D’Angelo in June 1988 to evaluate the impact of an educational strategy on both sexually active and non-sexually-active adolescent males, as well as the impact of a free condom distribution arrangement on the former. 

APPENDIX I 325 Males’ Use of Public Health Contractive Services Grantee Organization: University of Illinois College of Medicine at Rockford Department of Community Medicine 1601 Parkview Avenue Rockford, IL 61107 Principal Investigator: Michael Glasser, Ph.D. Project Period: 4/1987–3/1988 Project Description: The purpose of this research was to obtain a ­better understanding of the male experience in using public family planning ser- vices, as a basis for designing a program to better serve the needs of male clients. Data were obtained from all men utilizing the family planning ser- vices of the Winnebago County Public Health Clinic in Rockford, Illinois, during a 6-month period. The project sought answers to basic questions such as “Who are male clinic users, why do they use the clinic, and how satisfied are they?” Specific comparisons were made between males who visit the health department primarily to receive condoms and males who attend the scheduled family planning visits of their female partners. Targeting of Family Planning Services Improving Family Planning and Reproductive Health Services for Individuals with Limited English Proficiency Grantee Organization: Center for Health Training 1809 7th Ave., Suite 400 Seattle, WA 98101-1341 Principal Investigator: David Fine, Ph.D. Project Period: 9/01/2002–8/31/2004 Project Description: The aim of this research project is to increase understanding as to how to effectively meet the specific and unique family planning and reproductive health service needs of individuals with limited English proficiency (LEP). The research will consist of a descriptive and exploratory study of the individual, family, clinic and community factors that affect access to family planning and other health services by indi- viduals with LEP. The objectives will also include developing and testing outreach and communication strategies at selected clinics. The research will be conducted at Title X family planning clinics and community-based 

326 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM organizations that represent urban and rural communities in Washington state, particularly in areas with high concentrations of Hispanics and Asian Pacific Islanders. Meeting the Needs of Substance Abusers: A Title X Service Delivery Model Grantee Organization: Family Planning Council, Inc. 260 South Broad Street, Suite 1000 Philadelphia, PA 19102-5076 Principal Investigator: Linda Hock-Long, Ph.D. Project Period: 9/01/2002–8/31/2004 Project Description: The goal of this project is to implement and evalu- ate the delivery of Title X funded reproductive health services to an under- served population of substance abusers who are not currently in treatment. The study will examine the changes required of service providers as they expand from one intervention approach (i.e., substance abuse services) to a more comprehensive package of services that include reproductive health services. The investigators will collaborate with two substance abuse orga- nizations, one which provides services to men and women over 18 years of age, and another which provides health promotion programs for hard- to-reach youth ages of 13 to 25. The objective is to build upon the harm reduction outreach model these two substance abuse programs already have in place and integrate the delivery of reproductive health services. Through street outreach, clients will be recruited at mobile van services that are already provided and at centralized service centers where comprehensive clinical and support services are provided. This research will provide insight into how difficult it is to address multiple problems. Enhanced Family Planning in an STD Clinic to Improve STD Services Grantee Organization: Johns Hopkins University, School of Medicine 720 Rutland Avenue Baltimore, MD 21305 Principal Investigator: Emily Erbelding, M.D., M.P.H. Project Period: 9/2001–9/2003 Project Description: This project will evaluate the impact of enhanced STD outreach worker services on the reproductive health outcomes in a cohort of women receiving STD care and contraceptive care in inner city STD clinics. Outcomes will be compared to those of a control cohort of 

APPENDIX I 327 women who are enrolled for a similar range of contraceptive services but do not receive the outreach intervention. The study will measure rates of u ­ nintended pregnancy and new STDs among female STD patients in a system with contraceptive public health outreach compared to standard care. Women Leaving Prison: Two Models of Family Planning Service Delivery Grantee Organization: Rhode Island Hospital 593 Eddy Street Providence, RI 02903 Principal Investigator: Jennifer Clarke, M.D. Project Period: 9/2001–9/2003 Project Description: The researchers will evaluate a current Title X– funded family planning program for incarcerated women in Rhode Island who are soon to be released from prison. Clients will be surveyed to determine factors associated with and barriers to seeking family planning services. The study will compare two modes of delivering family planning services to women being released from prison. The first model will evaluate an innovative program that involves initiating family planning education for incarcerated women and then arranging post release connection to a clinic for family planning services. The second model will examine a model in which education and contraceptive methods are offered to women prior to their release from prison and then arranging a post release connection to a clinic for family planning and reproductive health care. Behavioral and biological outcomes will be assessed when testing both these models. Improvement in Northern Manhattan to Two Underserved Populations: Males and Recent Immigrants Grantee Organization: New York Presbyterian Hospital 60 Haven Avenue, B-3 New York, NY 10032 Co-Principal Investigators: Roger Vaughan, Ph.D., and Lorraine Tiezzi, M.S. Project Period: 10/2001–9/2003 Project Description: This project will identify and explore the enabling factors for, and barriers to, health care seeking behavior among a recent immigrant Hispanic population and among Hispanic males in New York City. The project will conduct several case-control studies at different 

328 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM health care access points (including reproductive health care) available to recent immigrants and males. Structured interviews will be conducted among a sample of older adolescents, young adults and older adults who have demonstrated health care needs and who accessed health care, and among a control group who did not access health care. Structured inter- views will also be conducted with parents, as well as with the health care providers in the school-based clinics and the community-based family planning clinics. Barriers to Family Planning Services Among Mexican Immigrants in California: Gender, Power, and Culture Grantee Organization: University of California, San Francisco Department of Obstetrics, Gynecology and Reproductive Sciences 3333 California Street, #315 San Francisco, CA 94118 Principal Investigator: Catherine Maternowska, Ph.D., M.P.H. Project Period: 1/2001–12/2002 Project Description: This project focuses on understanding the com- plex sociocultural factors that influence reproduction and the use of fam- ily planning services in Mexican immigrant communities. The research project has three broad aims: (1) to uncover factors that influence the use of family planning services among male and female Mexican immigrants in California; (2) to discern if these factors differ among rural (largely migrant) and urban populations; and (3) to understand providers’ behav- ior and their perceptions of Mexican immigrants in an effort to determine how services can be made more accessible. A sample of Mexican men and women of childbearing age will be recruited for interviews from two groups—clients in the California Family Planning, Access, Care and Treat- ment Program (Family PACT) and non–Family PACT clients. Interviews will address respondents’ fertility histories, contraceptive knowledge and attitudes, financial, time, and health care resources, access to medical care, as well as social and legal networks. The project will also study family planning provider attitudes regarding the Mexican immigrant population and perceptions of their needs. 

APPENDIX I 329 Improving Family Planning to Southeast Asian Refugees: A Study of Their Knowledge, Attitudes, and Practices Grantee Organization: University of Californian-SF School of Medicine 126 Medical Sciences Bldg. San Francisco, CA 94143 Principal Investigator: Donald H. Minkler, M.D. Project Period: 10/1983–3/1985 Project Description: The focus of this study was an assessment of the family planning needs of Indochinese refugees presently in California who are seeking self-sufficiency in the United States. Data from official records and interviews of refugees were used to describe fertility patterns, family planning attitudes, and service utilization. Cross-cultural barriers to utiliza- tion of family planning services were analyzed, and a cost-benefit analysis was conducted to identify cost-efficient models for the delivery of family planning services to monolingual, cost-cultural groups. Child Care Adequacy and Family Planning Practices: A Study of the Fertility Patterns and Contracepting Behaviors of Low-Income Child Housing and Child Neglecting Mothers Grantee Organization: The Baltimore City Department of Social Services Division of Policy and Resource Development 1510 Guilford Avenue Baltimore, MD 21202 Principal Investigator: Susan J. Zuravin, Ph.D. Project Period: 12/1983–5/1985 Project Description: This project examined the relationship of child abuse and neglect and contraceptive use and childbearing patterns. Among the project objectives was the development of recommendations about family planning strategies that could address problem areas identified in this study. 

330 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Family Planning Needs of the Child Welfare Population Grantee Organization: Humanalysis, Inc. 74 Henry Street Suite 139 Saratoga Springs, NY 12866 Principal Investigator: Denise F. Polit, Ph.D. Project Period: 10/1985–3/1987 Project Description: Information to inform strategies for meeting the family planning needs of female adolescents in the child welfare population were obtained from several sources: (1) a national survey of state policies and practices regarding family planning and sexuality counseling in this population; (2) interviews of 150 girls, aged 13–18, who were child welfare clients in metropolitan areas of Missouri; and (3) interviews of the girls’ caseworkers and parents/guardians or foster parents. Organization/Management of Family Planning Services Reassessing United States Family Planning and Reproductive Needs Grantee Organization: The Alan Guttmacher Institute 120 Wall Street New York, NY 10005 Principal Investigator: Jacqueline E. Darroch, Ph.D. Project Period: 5/1/1994–4/30/1999 Project Description: The objective of this project was to provide infor- mation intended to help assess the current family planning system by (a) analyzing the current status of the nation’s public family planning pro- viders, including numbers and locations of service sites, staffing, ­ services offered and fees charged; (b) estimating the need for publicly funded ­family planning services; (c) documenting the numbers of clinics and clients served according to county, state and region; (d) describing the characteristics of family planning clients; (e) documenting the public funds spent on ­family planning services; (f) analyzing private physician contraceptive service deliv- ery; and (g) describing linkages between family planning clinics and STD clinics and school-linked health services. The information was expected to be useful in the development of services and policies aimed at reducing the level of unintended pregnancy, as well as suggesting means to improve other areas of reproductive health. 

APPENDIX I 331 Integration of Contraceptive Services into an STD Clinic Grantee Organization: Johns Hopkins Hospital Infectious Diseases Division 600 N. Wolfe Street Baltimore, MD 21205 Principal Investigator: Edward W. Hook, M.D. Project Period: 4/1/1987–3/31/1990 Project Description: The primary goal of this study was to investigate the benefits of integrating contraceptive services in inner-city STD clinics. It involved a prospective study of the benefits of offering free on-site contra- ceptive counseling and services at STD clinics in terms of (1) contraceptive acceptance and continuation rates, (2) detection of STDs among contracep- tive acceptors returning for follow-up visits, and (3) the cost-effectiveness of adding contraceptive services in this manner. An Assessment of Family Planning Service Delivery in South Carolina Grantee Organization: South Carolina Department of Health and Environmental Control 2600 Bull Street Columbia, SC 29201 Principal Investigator: Harold D. Gabel, M.D. Project Period: 10/1983–9/1984 Project Description: This project developed indicators of family plan- ning service effectiveness, which were then related to cost, productivity, and characteristics of service delivery organizations. Resulting analyses were used as a basis for developing model interventions in clinic-level delivery organizations to improve efficiency and effectiveness. A Mathematical Model for Family Planning Clinic Staffing Grantee Organization: University of South Carolina College of Business Administration Columbia, SC 29208 Principal Investigator: Lori Sharp Franz, Ph.D. Project Period: 1/1984–12/1984 

332 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Project Description: This project developed a mathematical staff plan- ning and resource allocation model to assist decision makers in multiclinic family planning programs or districts. The model, which was tested with actual data from South Carolina Family Planning Districts, may provide planning and allocation methods such as assigning itinerant staff and sched- uling individual clinic operations to meet client demand with minimal cost and staff time. An Integrated Services Model: Family Planning and Pediatrics Grantee Organization: University of Texas Southwestern Medical Center at Dallas Department of Obstetrics and Gynecology Division of Maternal Health/Family Planning 5323 Harry Hines Blvd. Dallas, TX 75235 Principal Investigator: Stephen F. Heartwell, Dr.P.H. Project Period: 10/1984–9/1986 Project Description: The study examined quality of care, recruitment and retention of patients, appointment keeping, clinic costs and efficiency, repeat pregnancies and other factors as they are affected by combining fam- ily planning with post-partum and new infant assessment so that mothers may receive these services at a single clinic appointment. Effects of the Integration Model on Family Planning Programs Grantee Organization: The Center for Health Training 400 Tower Building 1809 7th Avenue Seattle, WA 98101 Principal Investigator: Susan DeLisle, M.P.H. Project Period: 10/1986–11/1987 Project Description: This project studied how integration of family planning services with other services affects the character of family plan- ning service provision. It described and compared DHHS Regions I and X using the quality-assurance guidelines of Dimensions of Care (clinical appropriateness, continuity, efficiency, comprehensiveness, accessibility, and accountability). Regional databases, computerized and archival, were utilized. 

APPENDIX I 333 Role of Private Physician Private Physician Family Planning Services in the United States Grantee Organization: The Alan Guttmacher Institute 111 Fifth Avenue New York, NY 10003 Principal Investigator: Margaret Terry Orr, Ph.D. Project Period: 10/1983–9/1984 Project Description: This project analyzed data previously obtained from a large national sample of private physicians (obstetricians/­gynecologists, general and family practitioners, and general surgeons). The analysis focused on (1) describing the role of private physicians in providing contraceptive and infertility services to poor women and (2) estimating the cost of family planning services obtained by poor women from private physicians. Family Planning Services for Economically Disadvantaged Women: Utilization, Cost, and Patient Satisfaction Grantee Organization: University of Southern California School of Medicine Department of Medical Education KAM Room 200 1975 Zonal Avenue Los Angeles, CA 90033 Principal Investigator: Robert C. Mendenhall, Ph.D. Project Period: 10/1983–3/1985 Project Description: The study involved interviewing low-income Los Angeles–area women concerning source of family planning care and satis- faction with such care. Interview responses were augmented with data sup- plied by identified physicians and clinics, to provide comparative pictures of private and clinic-provided family planning care. The results may enable family planning clinics to initiate improvements to increase clients’ accept- ability of the services offered. 

334 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Natural Family Planning Factors Affecting the Choice of Natural Family Planning Grantee Organization: International Population Center San Diego State University San Diego, CA 92182-3083 Principal Investigator: John R. Weeks, Ph.D. Project Period: 9/1987–8/1988 Project Description: The aim of this study was to identify possible stumbling blocks to wider utilization of NFP, particularly in Title X set- tings. Specifically, it assessed the extent to which knowledge of and attitudes toward NFP on the part of family planning clinic administrators, clinic service providers, and physicians in private settings affect the availability of NFP services, controlling for program characteristics, client characteristics, and the sociodemographic background of respondents. Questionnaires were sent to 1,000 providers in Los Angeles and San Diego counties; the results were analyzed and then translated into a set of policy recommendations for removing existing barriers. Infertility Services Infertility Services in the United States: Need, Accessibility, and Utilization Grantee Organization: The Alan Guttmacher Institute 111 Fifth Avenue New York, NY 10003 Principal Investigator: Jacqueline D. Forrest, Ph.D. Project Period: 10/1984–9/1985 Project Description: This project utilized several data sets to estimate (1) need for infertility services among poor women and (2) their ability to access such services from various sources, including family planning agencies. 

APPENDIX I 335 Counseling Services Computerized Contraceptive Counseling Aid Grantee Organization: University of Wisconsin-Madison 425 North Charter Madison, WI 53706 Principal Investigator: Betty A. Chewning, Ph.D. Project Period: 1/1/1988–6/30/1991 Project Description: The objective of this project was to evaluate the potential of a computerized contraceptive counseling aid to improve Title X family planning services for women under age 20. Specifically, it evaluated (1) the receptivity of Title X clients and staff to the computerized aid; (2) whether the computer aid could strengthen the contraceptive knowl- edge, satisfaction, and confidence of clients in using a method; (3) whether the computer can reduce sexual risk-taking by promoting consistent use of the selected contraception; (4) the computer’s ability to encourage the male partner’s support for the client’s choice; and (5) whether the computer aid can improve contraceptive compliance. The Effectiveness of Contingency Planning Counseling Grantee Organization: Columbia University Center for Population and Family Health 60 Haven Avenue, B-3 New York, NY 10032 Principal Investigator: Pearila B. Namerow, Ph.D. Project Period: 10/1984–3/1987 Project Description: Approximately 1,500 young adult family plan- ning clients were studied in a randomized clinical trial of an innovative counseling approach which involved the use of a written plan to deal with contingencies that may affect birth control use over time. Effects on con- tinued clinic attendance, use of contraception at last coitus, consistency of contraceptive use, and unintended pregnancy were examined at 6- and 12-month intervals. 

336 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Aid for Contraceptive Decision Making Grantee Organization: University of Wisconsin Sonderegger Center School of Pharmacy 425 North Charter Madison, WI 53706 Principal Investigator: Betty A. Chewning, Ph.D. Project Period: 11/1985–12/1986 Project Description: This project developed and assessed the content and software of a computerized counseling aid to be used in conjunction with and prior to seeing a health provider. The counseling aid was designed to help the female client gather accurate information regarding tradeoffs associated with different contraceptives, clarify her priorities and select a method which best fits her preferences and circumstances. Other Research: A second grant was awarded to Dr. Chewning in June 1988 to evaluate the developed computerized counseling aid in clinic settings. Strategies of Counseling and Follow-up in Family Planning Clinics Grantee Organization: Family Planning Council of Southeastern Pennsylvania 260 South Broad Street Suite 1900 Philadelphia, PA 19102-3865 Principal Investigator: Kay A. Armstrong, M.S. Project Period: 11/1985–10/1987 Project Description: This project was conducted to determine which of three counseling approaches—directive, anticipatory, and information (with and without a follow-up component)—is most effective in promoting clinic continuity and contraceptive compliance. Data were obtained from approximately 3,500 clients of six comparable family planning clinics in Southeastern Pennsylvania at the initial visit and 9 months later. 

APPENDIX I 337 Cross-National Studies An International Comparison of Unintended Pregnancy, Contraceptive Practice and Family Planning Services Grantee Organization: The Alan Guttmacher Institute 111 Fifth Avenue New York, NY 10003 Principal Investigator: Jacqueline D. Forrest, Ph.D. Project Period: 10/1985–9/1987 Project Description: This study searched the experiences of other c ­ ountries to learn how family planning can be delivered in the United States more efficiently and effectively. Existing quantitative and qualitative data on 22 developed countries were assembled to provide an overview and frame of reference for in-depth study of four countries—the United States, the United Kingdom (England and Wales), Canada, and the Netherlands. Family Planning Services Delivery: Danish Experience Grantee Organization: Transnational Family Research Institute 8307 Whitman Drive Bethesda, MD 20817 Principal Investigator: Henry P. David, Ph.D. Project Period: 11/1985–10/1987 Project Description: Population subgroups whose family planning needs are underserved in the United States, but better met in Denmark were the focus of this study, with an emphasis on identifying successful service delivery features that are transferable from Denmark to the United States. Focus group discussions with Danish users, providers, and policymakers were conducted. peer-reviewed research from title x–funded research The Office of Research and Evaluation requested from grantees and compiled published peer-reviewed research from the past several years. There were 5 grantees funded in 2001, 4 each year during 2005–2007, and 3 cooperative agreements funded in 2004, totaling 20 grantees. The 5-year Alan Guttmacher Institute (AGI) project funded from 1999 to 2004 was also included in the request sent to current and former grantees (overall 

338 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM total 21). The list below includes responses from 6 of the 21 individual grantees that have had at least one peer-reviewed publication. 1. Men’s Reproductive and Sexual Health Practices, Attitudes, and Service Utilization Grantee: Columbia University Medical Center Kalmuss, D., and C. Tatum. 2007. Patterns of men’s use of sexual and reproductive health services: Results from cycle 6 of the national sur- vey of family growth. Perspectives on Sexual and Reproductive Health 39(2):74–81. Kalmuss, D., B. Armstrong, M. Franks, G. Hecker, and J. Gonzalez. 2008. Evaluation of a community-based sexual health intervention for young adult Latino and African-American men. Journal of Men’s Health 5(4):318–326. 2. Family Planning Needs and Services in the United States Grantee: Guttmacher Institute Frost, J. J. 2008. Trends in U.S. women’s use of sexual and reproductive health care services, 1995–2002. American Journal of Public Health 98(10). Frost, J. J., L. B. Finer, and A. Tapales. 2008. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. Journal of Health Care for the Poor and Underserved 19(2008):778–796. Lindberg, L. D., J. J. Frost, C. Sten, and C. Dailard. 2006. The provi- sion and funding of contraceptive services at publicly funded family planning agencies: 1995–2003. Perspectives on Sexual and Reproduc- tive Health 38(1):37–45. Lindberg, L. D., J. J. Frost, C. Sten, and C. Dailard. 2006. Provision of contraceptive and related services by publicly funded family plan- ning clinics, 2003. Perspectives on Sexual and Reproductive Health 38(3):139–147. 3. Child Trends/OPA Cooperative Agreement for Family Planning Research Grantee: Child Trends 

APPENDIX I 339 Manlove, J., E. Terry-Humen, and E. Ikramullah. 2006. Young teen- agers and older sexual partners: Correlates and consequences for males and females. Perspectives on Sexual and Reproductive Health 38(4):197–207. Manlove, J., S. Ryan, and K. Franzetta. 2007. Risk and protective fac- tors associated with the transition to a first sexual relationship with an older partner. Journal of Adolescent Health 40:135–143. Manlove, J., E. Terry-Humen, L. Mincielli, and K. Moore. Forthcom- ing. Outcomes among children of teen mothers at kindergarten entry and through adolescence: Analyses of recent data. In Kids having kids updated edition: Economic costs and social consequences of teen preg- nancy. Edited by R. Maynard and S. Hoffman. Washington, DC: Urban Institute Press. Manlove, J., E. Ikramullah, and E. Terry-Humen. Forthcoming. ­Condom use and consistency among U.S. teen males. Journal of Adolescent Health. Ryan, S., K. Franzetta, J. Manlove, and E. Holcombe. 2007. Adoles- cents’ discussions about contraception or STDs with partners before first sex. Perspectives on Sexual and Reproductive Health 39(3):149–157. Ryan, S., K. Franzetta, J. Manlove, and E. Schelar. 2008. Older sexual partners during adolescence: Links to reproductive health outcomes in young adulthood. Perspectives on Sexual and Reproductive Health 40(1):17–26. 4. Strengthening the Capacity of Family Planning Agencies to Improve the Quality of Family Planning Services Grantee: Johns Hopkins University Becker, D., M. A. Koenig, Y. M. Kim, K. Cardona, and F. Sonenstein. 2007. The quality of family planning services in the United States: Find- ings from a literature review. Perspectives on Sexual and Reproductive Health 39(4):206–213. 5. Women Leaving Prison: Two Models of Family Planning Service Delivery Grantee: Rhode Island Hospital Clarke, J. G., C. Rosengard, J. S. Rose, M. R. Herbert, J. Peipert, and M. D. Stein. 2006. Improving birth control service utilization by 

340 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM offering services prerelease vs. postincarceration. American Journal of Public Health 96(5):841–845. Clarke, J. G., M. R. Herbert, C. Rosengard, J. S. Rose, K. M. DaSilva, and M. D. Stein. 2006. Reproductive health care and family planning needs among incarcerated women. American Journal of Public Health 96(5):834–839. 6. Assessing Family Planning and Reproductive Health Needs and Services in the United States Grantee: Alan Guttmacher Institute Donovan, P. 1996. Taking family planning services to hard-to-reach populations. Family Planning Perspectives 28(3):120–126. Finer, L. B., J. E. Darroch, and S. Singh. 1999. Sexual partnership patterns as a behavioral risk factor for sexually transmitted diseases. Family Planning Perspectives 31(5):228–236. Finer, L. B., J. E. Darroch, and J. J. Frost. 2002. U.S. agencies providing publicly funded contraceptive services in 1999. Perspectives on Sexual and Reproductive Health 34(1):15–24. Finer, L. B., J. E. Darroch, and J. J. Frost. 2003. Services for men at publicly funded family planning agencies, 1998–1999. Perspectives on Sexual and Reproductive Health 35(5):202–207. Forrest, J. D., and R. Samara. 1996. Impact of publicly funded contra­ ceptive services on unintended pregnancies and implications for ­Medicaid expenditures. Family Planning Perspectives 28(5):188–195. Frost, J. J. 1996. Family planning clinic services in the United States, 1994. Family Planning Perspectives 28(3):120–126. Frost, J. J. 1998. Clinic provision of contraceptive services to managed care enrollees. Family Planning Perspectives 30(4):156–162. Frost, J. J. 2001. Public or private providers? U.S. women’s use of repro- ductive health services. Family Planning Perspectives 33(1):4–12. Frost, J. J., and M. Bolzan. 1997. The provision of public-sector ­services by family planning agencies in 1995. Family Planning Perspectives 29(1):6–14. 

APPENDIX I 341 Frost, J. J., N. Ranjit, K. Manzella, J. E. Darroch, and S. Audam. 2001. Family planning clinic services in the United States: Patterns and trends in the late 1990s, Family Planning Perspectives 33(3):113–122. Frost, J. J., L. Frohwirth, and A. Purcell. 2004. The availability and use of publicly funded family planning clinics: U.S. trends, 1994–2001. Perspectives on Sexual and Reproductive Health 36(5):206–215. Gold, R. B., and C. Richard. 1998. Lessons learned: The managed care experiences of family planning providers. Journal of Public Health Management and Practice 4(6):1–13. Gold, R. B., and A. Sonfield. 1999. Family planning funding through four federal-state programs, FY 1997. Family Planning Perspectives 31(4):176–181. Landry, D. J., and J. D. Forrest. 1996. Public health departments pro- viding sexually transmitted disease services. Family Planning Perspec- tives 28(6):261–266. Landry, D. J., and J. D. Forrest. 1996. Private physician’s provision of contraceptive services. Family Planning Perspectives 28(5):203–209. Lindberg, L. D., F. L. Sonenstein, L. Ku, and G. Levine. 1997. Young men’s experience with condom breakage. Family Planning Perspectives 29(3):128–131, 140. Murphy, J. J., and S. Boggess. 1998. Increased condom use among teen- age males, 1988–1995. Family Planning Perspectives 30(6):276–280, 303. Sollom, T., R. B. Gold, and R. Saul. 1996. Public funding for con- traceptive, sterilization and abortion services, 1994. Family Planning Perspectives 28(4):166–173. Sonfield, A., R. B. Gold, and J. J. Frost. 2004. U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002. Perspectives on Sexual and Reproductive Health 36(2):72–79. 

342 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM OPA large-scope evaluation efforts Through OPA’s Office of Research and Evaluation, evaluation projects are carried out under contracts funded by HHS 1 percent evaluation funds. The evaluation activities cover a wide range of issues. OPA collaborates with other federal agencies in efforts related to ­family planning and reproductive health. OPA is one of the major funding con- tributors to the NSFG, which is conducted by the National Center for Health Statistics. The NSFG has completed six cycles and currently pro- ceeds on a continuous interviewing basis. OPA also has funded several research initiatives at the National Institute of Child Health and Human Development. It provides support for the National Longitudinal Study of Adolescent Health. A number of comprehensive final 1 percent evaluation reports are relevant to Title X. They include Healthy People 2010 content related to family planning and STDs/HIV, documents outlining Food and Drug Administration approval of the hormonal contraceptive skin patch and hor- monal vaginal contraceptive ring, the Family Planning Annual Report, and reports on parent involvement strategies in programs serving adolescents and on statutory rape. In 2007, OPA and the Administration for Children and Families c ­ osponsored an Abstinence Education Evaluation Conference for the absti- nence education community. In addition, OPA contracted with The Lewin Group to conduct the Developing Theoretical Frameworks for Abstinence Education project. The goal of this project is to develop theoretical frame- works that can help explain primary and secondary abstinence for adoles- cents and provide likely mechanisms for behavior change.