Adolescent Pregnancy Prevention Programs: Interventions and Evaluations Kristin A. Moore, PhD Barbara W. Sugland, MPH, ScD Connie Blumenthal, BA Dana Glei, MA Nancy Snyder, MA June 1995 4301 Connecticut Ave., NW Suite 100 Washington, DC 20008 202-362-5580 Fax 202-362-5533 www.childtrends.org ACKNOWLEDGMENTS This report was prepared for and funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Senices, under Contract No. HHS-I 00-92-00 15, DO-08. We wish to thank the many researchers who shared their work, published and unpublished, with us. We also wish to express our appreciation to the anonymous persons who reviewed an earlier draft, and to our colleagues who helped to produce this report, Deanna Cooke, Fanette Jones, Carla Butler, Mary Jo Coiro, and Cheryl Oakes. In addition, the helpful comments provided by our Project Officers, Elisa Koff and Amy Nevel, and their colleagues, Barbara Broman and Ann Segal, and other anonymous reviewers were much appreciated. TABLE OF CONTENTS EXECUTIVE SUMMARY ................................................... vii Introduction ........................................................ vii... Summary of Review Findings ............................................ vnt Conclusions ........................................................... ix I . ADOLESCENT PREGNANCY PREVENTION PROGRAMS: INTERVENTIONS AND EVALUATIONS ................................. 1 Introduction ............................................................ 1 II . ALTERNATIVE APPROACHES TO ADOLESCENT PREGNANCY PREVENTION PROGRAMS AND THEIR MEASURED IMPACTS ......................... 7 Introduction ............................................................ 7 Evaluation Strategies ..................................................... 9 Family Life or Sex Education Programs .....................................12 Abstinence and Delayed Sexual Initiation .............................. 13 Service-Based Approaches to Pregnancy Prevention and Pregnancy Resolution ......24 Family Planning Services ..........................................25 Pregnancy Resolution Services ...................................... 31 School-Based and School-Linked Clinic Services ............................. 34 Mentoring and Role Modeling Programs .................................... 38 Initiatives to Promote Self-Esteem .........................................40 Culturally-Based Initiatives ............................................... 41 Community-Based Pregnancy Prevention Initiatives ........................... 43 Life Options and Opportunity Development Programs ..........................47 Comprehensive, Multi-Faceted Programs .................................... 53 SummaryandConclusions ............................................... 54 I11 . ALTERNATIVE APPROACKES TO EVALUATING ADOLESCENT PREGNANCY PREVENTION PROGRAMS .............................. 59 Introduction ........................................................... 59 Theoretical Approaches and Intervention Models .............................. 61 EvaluationApproaches .................................................. 71 Necessary Steps in Every Evaluation ........................................ 72 Experimental Studies .................................................... 76 Possible Studies Involving Random Assignment of Individuals ............. 77 Studies Involving Random Assignment of Families .......................81 PowerAnalyses ........................................................ 86 Quasi-Experimental Designs .............................................. 87 Comparison Sites ................................................. 88 Comparison Created Groupsfrom Existing Survey Data Bases ............. 89 Comparison Individuals Matched with Treatment Individuals .............. 90 Comparisons Using Before/Afier Data ............................... .91 Possible Quasi-Experimental Studies of Schools ....................... .92 Possible Quasi-Experimental Studies ofAFDC ODces ................... 94 Possible Quasi-Experimental Studies Involving Clinics .................. .95 Possible Quasi-Experimental Studies Involving Communities ..............96 Natural Experiments ................................................... .99 Analyses of Individual-Level Micro Data ................................... 10 1 Analyses of Macro-Level Data ........................................... 105 Case Studies and Qualitative Studies .......................................I03 Conclusions .......................................................... 107 BIBLIOGRAPHY .......................................................... 121 Figure 1 Figure 2 APPENDIX A: Programsllnterventions by Evaluation Approach ............. A-1 APPENDIX B: Power Analyses ........................................... B-1 APPENDIX C: Pregnancy Prevention Programs And Evaluations: Detailed Descriptions ..................................... C-1 ADOLESCENT PREGNANCY PREVENTION PROGRAMS: INTERVENTIONS AND EVALUATIONS EXECUTIVE SUMMARY Introduction Widespread concern about the incidence of teenage childbearing led to the establishment of numerous intervention programs throughout the United States during the 1980s. Despite the varied initiatives and ofien quite creative interventions that were implemented during this decade, the teen birth rate (births per 1,000 females aged 15-19) rose between the mid-1980s and the eady 1990s in every state. The magnitude of the increase in the birtb rate varied across states; but overall the birth rate rose by one-quarter between 1986 and 1991. Between 1991 and 1992, this increase was arrested and a tiny decline occurred; however, the teen bid rate was still 22 percent higher in 1992 than it was in 1986. Moreover, the teen birth rate in the United States continues to range between two and seven times higher than the teen biirate in comparable Western industrialized nations. Policy makers, program providers and tax payers all seek to identify strategies to lower the rate of teenage childbearing in the United States. It is generally recognized that most families address the needs of their developing adolescents without requiring assistance from formal or organized programs. However, some families want or need assistance from programs. Such programs seek to prevent or delay sexual initiation, to increase the consistent use of effective contraception, and less often, to affect pregnancy resolution decisions among adolescents who experience pregnancy. Some programs seek more generally to enhance the educational or vii occupational prospects of adolescents, to provide particularly disadvantaged teens a reason to postpone sexual activity, pregnancy, and parenthood. There is, of course, strong interest in immediately identifying interventions that have large and sustained effects in reducing adolescent childbearing. Unfortunately, no remarkably successfd programs stand out. Only a handful of well- designed and well-evaluated programs have been implemented. Although they do not provide evidence of substantial impacts, these flagship projects provide the basis on which further initiatives can be built. Regrettably, aside from a few well-designed, well-implemented, and well-evaluated studies, most of the programs that have been implemented to affect teenage childbearing have been small, ad hoc, and poorly designed short-term projects lacking a useful evaluation strategy. There is a need for a new generation of interventions that are implemented with careful theoretical and conceptual planning and with rigorous evaluations. Summary of Review Findings What we do know fiom adolescent pregnancy prevention programs to date can be succinctly summarized. Numerous programs have been implemented, ranging hmabstinence education to comprehensive, multi-faceted interventions that offer education, counseling, and a variety of support services. Studies have concluded that the provision of sex education to adolescents does not increase the likelihood of initiating sexual activity. However, abstinence-only prevention programs have not been shown to reduce sexual activity either. Studies indicate that sex education, as generally offered in schools, increases knowledge in the short-term, but has minimal effects on whether teens initiate sex or use contraception. On the other hand, theory-based sex education combined with skill- building activities demonstrates somewhat stronger and more sustained impacts. Specifically, the ... Vlll sex education programs with measurable impacts are those that include the following: a specific and focussed message to delay sexual activity; the provision of contraceptive information; and activities concerned with peer and media influences, modeling, communication, and negotiation. Program that include theses components have been found to result in a slight delay in sexual initiation and have moderate effects in improving contraceptive behavior. Family planning services also have been found to reduce unwanted births, primarily because contraceptive services help sexually active persons prevent pregnancy, but perhaps also due to increased access to abortion. Services that reduce bamers to obtaining reproductive care among adolescents are more likely to affect contraceptive use than traditional service delivery approaches. School-based clinics are a source of health care, but have not been found to consistently reduce sexual activity or pregnancy among teens, with the exception of the Self Center clinic in Baltimore. The Selfcenter used a