In 1996, Congress authorized $50 million annually for five years in funding to states for programs that teach abstinence from sexual activity outside of marriage as the expected standard for school-age children. This funding was established through a new formula grant program created under Title V, Section 510 of the Social Security Act, authorized under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. The funds became available to states in 1998 and are administered by the Maternal and Child Health Bureau. Currently, Title V Section 510 abstinence education is in its last funding cycle, and deliberations regarding reauthorization will begin shortly.
Four years into the Section 510 abstinence education funding, the percentage of teens reporting that they have had sex has decreased, continuing a decline that started in 1991. At this time, however, no definitive research has linked the abstinence education legislation with these downward trends. Most people acknowledge that abstinence works. It is certain to prevent unwanted pregnancy, sexually transmitted diseases (STDs), abortions, and out-of-wedlock childbearing. However, an important question is: To what extent are abstinence education programs effective in persuading youth to be sexually abstinent and in changing teen sexual behavior?
Empirical evidence on the effectiveness of abstinence education is limited. Moreover, most studies of abstinence education programs have methodological flaws that prevent them from generating reliable estimates of program impacts. Even the features of abstinence programs implemented, the curricula used, and the experiences of program staff and program participants are not well documented in a readily accessible way. To address this gap in information, Congress authorized a federally funded, independent evaluation of Section 510 abstinence education programs in the Balanced Budget Act of 1997 (Public Law 105-33). Through extensive implementation, process, and impact analyses, the evaluation will strengthen the research base and knowledge about strategies for promoting sexual abstinence among youth and the benefits of various approaches to abstinence education.
This report presents interim findings from the congressionally authorized evaluation. The first in a series of reports from the evaluation, this report draws most heavily on four years of implementation experiences in a selected group of abstinence education programs funded under Title V Section 510. This report also uses information from federal program monitoring reports, efforts by state and local evaluators, and policy and issue statements by various constituent groups and policy organizations. Later reports from the evaluation will present estimates of short- and longer-term program impacts, as well as studies on special topical areas.
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Despite a steady decline in the teen birthrate between 1991 and the present from a high in 1991 of 62 births per 1,000 females age 15 to 19, to 49 such births in 2000 concerns about teen sexual activity persist:
The consequences of teenage sexual activity and out-of-wedlock childbearing are many and serious for teens, their families, their communities, and society. Over three-fifths of teen mothers live in poverty at the time of their childs birth, and over four-fifths eventually live below poverty (Maynard 1996). Children born to teen mothers often fare badly during infancy, early childhood, and their adolescent and adult lives. Compared with children born to mothers who delay childbearing until age 21 or older, children of teen mothers are more likely to grow up in homes that are not emotionally supportive or cognitively stimulating, to suffer from abuse and neglect, to repeat a grade in school, and to drop out of high school (Moore et al. 1997; Goerge and Lee 1997; and Haveman et al. 1997).
In addition to its social and economic consequences, teen sexual activity also brings increased risks of STDs. In fact, teenage females have the highest rates of STDs of any age group. In the United States, more than 65 million people have an STD, and most are incurable viral infections (National Institute of Allergy and Infectious Diseases 2000). STDs may cause such lifelong complications as infertility, ectopic pregnancies, miscarriages, stillbirths, intrauterine growth retardation, and perinatal infections. One STD, human papillomavirus, is the primary cause of cervical cancer. Moreover, because of limitations in study design, the scientific evidence on the effectiveness of condoms in preventing STDs is inconclusive (National Institute of Allergy and Infectious Diseases 2000).
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In this context of high rates of teen sexual activity and their serious public health and socioeconomic consequences, interest in abstinence education has increased over the past decade. As a result, in 1998 the federal government provided $50 million annually for five years for block grants to states to support abstinence education programs. States must provide $3 in matching funds for every $4 in federal funds, which results in a total of up to $87.5 million available annually for such programs.
These abstinence education grants are allotted to states through a formula based on the proportion of low-income children in the state relative to the total number of low-income children for all the states. States then decide which programs to fund and at what level. Most states have disbursed their funding to numerous local agencies and organizations. However, a few states, such as Massachusetts, have retained their entire funding allocation for a single statewide initiative, such as a media campaign.
Although abstinence education programs have been around for decades, the new investment raised the profile of programs that teach an unambiguous abstinence message to youth. The main factor that distinguishes the Section 510 abstinence education funding from the previous generation of federally funded abstinence education programs is the A-H definition (Title V Section 510 (b)(2)(A-H) of the Social Security Act), which specifies that an abstinence education program funded under the block grant must:
The Maternal and Child Health Bureau guidelines for these abstinence education programs offer the following interpretation of the A-H definition: It is not necessary to place equal emphasis on each element of the definition. However, a project may not be inconsistent with any aspect of the abstinence education definition (Maternal and Child Health Bureau 1997; Haskins and Bevan 1997). Providing instruction in or promoting the use of birth control would be inconsistent with the A-H definition.
The A-H definition of abstinence education has generated controversy. Some abstinence educators and policymakers are critical of Section 510 abstinence education programs that do not emphasize all elements of the A-H definition. These criticisms have been especially strong for some preexisting health and teenage risk reduction programs that are perceived to have simply added limited abstinence education modules to their services specifically to gain access to Section 510 funding. On the other hand, some policymakers and health educators object to the Section 510 abstinence education programs primarily because of their restrictive definition of abstinence education.
Still, since the inception of the Section 510 abstinence education funding, the number of abstinence education providers has increased dramatically. The funding has stimulated considerable discussion at the state and local level on the problem of teen sexual activity and raised local awareness and consideration of the role of abstinence education in local programs and policies. Supporters of abstinence education contend that such programs are effective because they are consistent with the developmental needs of adolescents for clear, consistent messages and boundaries. Their concern with sex education programs that teach about sexuality, contraceptives, and abstinence is that they send the mixed message that (1) teens should be abstinent, but (2), if they are going to have sex, they need information about and access to contraceptives.
On the other side, proponents of comprehensive sex education programs contend that, while abstinence is preferred, broader sex education is essential because most teens are sexually active by the time they finish high school. Comprehensive sex educators contend that teens need to be taught about and provided access to contraceptives to reduce their risk of pregnancies and STDs.
Despite these different perspectives on how best to address high rates of teen sexual activity, a common thread in the ongoing policy debate is an underlying interest in learning about effective program strategies that help youth make good choices that avoid risk-taking behaviors and promote healthy future lives. The evaluation of Section 510 abstinence education programs is designed to contribute much-needed knowledge on approaches to, and the effectiveness of, selected abstinence education programs.
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In fall 1998, the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, awarded a competitive contract to Mathematica Policy Research to conduct an independent evaluation of Section 510 abstinence education programs. The evaluation addresses three important questions:
To address these questions, the evaluation includes an extensive implementation and process analysis, focused on 11 abstinence education programs, as well as rigorously designed impact studies of 5 of these programs. The implementation and process analysis uses program documents; program observations; focus groups with program participants, parents, and other area youth; and interviews with program staff and community leaders to document and understand important features of the range of programs that have been implemented. The impact study uses longitudinal survey data for groups of youth randomly assigned to the abstinence program in the community or to a control group.
The evaluation design was developed and implemented with guidance from a technical workgroup composed of individuals with demonstrated expertise in the myriad critical aspects of this complex research agenda (see Appendix A). In addition, the evaluation team held meetings with numerous interest groups to solicit their input regarding the evaluation questions, site selection criteria, and data collection strategies.
The first step of the evaluation entailed selecting abstinence programs for study. The evaluation team first called and met with numerous state officials and experts across the country to identify promising programs for inclusion in the evaluation. Grant applications and program documents then provided additional detail on program goals, target population, activities, size, and curricula. The evaluation team visited and observed 28 abstinence education programs across the nation. After extensive communication with abstinence experts and DHHS staff, 11 programs were invited and agreed to participate in the evaluation (Table 1). Although not a representative set of Section 510 abstinence education programs, these 11 programs are judged to offer a rich range of program strategies and implementation settings for study.
Five of the programs included in the evaluation are referred to as targeted programs, as they target their services to specific, identifiable groups of youth. In addition to providing valuable information about program implementation, each of these programs offers the potential to provide rigorous evidence on the effectiveness of abstinence education program strategies in reducing teen sexual activity and other risk behavior. The other six programs represent a range of multifaceted, community-wide initiatives that aim to alter youth behavior through stimulating systemic change. These programs are using their abstinence education funding in a variety of ways to increase public awareness of the problems of teen sexual activity, to change community norms and attitudes, to engage parents and encourage stronger parent-child communications, and to engage youth in abstinence education and support services. Including these community-wide initiatives in the evaluation adds breadth to an understanding of strategies for changing youth behavior.
For several reasons, though, rigorous impact studies of these community-wide abstinence program initiatives are not possible. First, these programs often use their abstinence funding to form or become part of a larger network of services for teens, making it impossible to separate the effects of the abstinence program from those of other programs or providers. Second, the target population often is not easily identifiable, since, by intent, these programs aim to change the norms and behavior of an entire community. Finally, systemic change is a long-range goal, and the time frame for the impact analysis and federally funded evaluation is too short to allow such change to be measured.
In selecting programs for the evaluation, the goal was to maximize the overall knowledge that would be generated, including providing operational lessons and impact estimates based on a range of program approaches and implementation settings. Moreover, all 11 programs met two additional criteria: (1) each conformed to, and in some cases was based on, a theoretical framework that links its services to changes in youth knowledge, attitudes, intentions, and behavior; and (2) each appeared to be reasonably well implemented, which included having its core services operational, committed staff in place, and key partnerships established.
|Principal Program Components||Target
|Targeted Programs (Impact, Implementation, and Process Analysis)|
Youth service agency
|Elective class offered daily, all year to girls in middle schools. Urban setting; diverse student population. Curriculum: ReCapturing the Vision and Vessels of Honor||Grades 68|
Community health agency
|Mandatory weekly year-long curriculum. Rural community; extremely poor population. Curriculum: Revised Postponing Sexual Involvement and Sex Can Wait||Grades 56|
Youth service agency
|Five-session mandatory curriculum with voluntary enrollment in weekly or biweekly character clubs. Middle-income community. Curriculum: Heritage Keepers||Grades 69|
County health department
|36-session mandatory curriculum. Middle-income community. Curriculum: Reasonable Reasons to Wait; The Art of Loving Well; and Choosing the Best||Grades 8 and 10, with 9th and 11th grade boosters|
Social service agency
|Voluntary after-school program; two hours daily all year for multiple years. Seven-week summer program. Poor, inner-city community. Curriculum: Families United to Prevent Teen Pregnancy||Grades 38|
Community-Wide Initiatives (Implementation and Process Analysis)
|IA (Cedar Rapids)
|Abstinence curriculum; community resource library; classroom presentations; workshops for parents and educators; Baby Think It Over dolls; speakers; mentoring program; teen panels||Emphasis on middle school youth|
|NY (Monroe County)
County health department
|Not Me Not Now media campaign; abstinence curriculum; parent outreach program; interactive web site; mentoring program||Emphasis on 914 year olds|
Youth service agency
|Abstinence curriculum; character clubs; school assemblies; training/information for medical providers, faith workers, parents, and media personnel; numerous collaborations and partnerships||Middle and high school youth|
|TX (Fort Bend County)
|Abstinence curriculum; separate youth development programs for girls and boys; peer education program; school assemblies; community training; parent education programs; parent resource center; community events; medical provider involvement||917 year olds, with a heavy focus on middle school youth|
|TX (McLennan County)
|Abstinence curriculum; school assemblies; character education in elementary schools; mentors; media spots; medical provider training; faith-based partners; resource library||Emphasis on 1014 year olds|
|UT (Tooele County)
County health department
|Abstinence curriculum; parenting class; self-esteem days for 5th8th graders; self-esteem classes for high-risk youth; Baby Think It Over dolls; peer educators; school fairs; billboards and newsletters; merchant involvement; faith-based linkages||914 year olds|
For the five programs targeting services on particular groups of youth, three additional site selection criteria were applied in order to ensure the feasibility of conducting a rigorous impact analysis of each program:
While the abstinence education programs selected are considered interesting and well-implemented programs, they are not necessarily better than or representative of the more than 700 abstinence education programs funded under Section 510 and operating nationwide. Many of the other Section 510 abstinence education programs are being examined in evaluations that states and localities have funded themselves, and these other studies will provide rich and important detail on the range of abstinence strategies and their effects (Mathematica Policy Research, Inc. 2001).
The implementation and process analysis documents the experience of organizations and communities applying for and receiving abstinence education funding in both the targeted and community-wide program sites. It describes the abstinence interventions implemented the program goals, the underlying theoretical framework, and the specific curriculum elements covered by the program. It examines the target population and community context, and reports the participants experiences with the program. It also details the organizational structure of the abstinence education program models, identifying those models that have been used and the factors associated with successful implementation.
The implementation and process analysis uses three primary data sources: (1) review of program documents and records; (2) interviews and focus groups with program staff, school staff, community leaders, parents, and program participants; and (3) on-site program observations. Program documents and records provide important background information on the programs objectives and message, as well as data on youth served. Most programs selected for the evaluation have promotional materials that are distributed to youth and, in some cases, to the community at large. Some have web sites or use the media to deliver the abstinence message and to identify community resources available for youth. Program documents also often describe staff qualifications and background, present staff training materials, and include written communications among abstinence providers. Program records provide valuable information on youth served, resource requirements, and costs.
Interviews with program and school staff also convey important information on program goals and implementation, as well as on the more intangible aspects of commitment to the program message and the importance of helping youth. Interviews and focus groups with program participants provide insights into the experiences of youth, their perceptions of the program, and the intangible factors that lead to program success. Focus groups with parents yield additional insights on the needs of youth and how programs can best engage parents in helping their children make good choices. Finally, firsthand program observations are invaluable for assessing how the program messages and services are delivered and received.
The data collection efforts to support the implementation and process analysis were extensive. Evaluation team members made multiple rounds of site visits to all programs included in the evaluation, as well as to many others ultimately not included in it. During these site visits, the evaluators conducted executive interviews with numerous staff members, facilitated the focus groups, and observed program delivery. In addition, phone calls and ongoing review of program records provided further detail on program implementation. Finally, an extensive communications effort and outreach to constituent groups and policy organizations yielded rich information on the context of abstinence funding and the types of programs supported.
To date, the evaluation team has successfully implemented a scientifically rigorous impact study design in the five targeted program sites. Study enrollment is completed, and longitudinal tracking of youth is ongoing. Because of the importance of having large sample sizes and sufficient followup of program and control youth, no impact estimates are available for inclusion in this report. This report does, however, provide detail on the key features of the study design, the characteristics of the youth served by these programs, and plans for the impact analysis and reporting.
As discussed in greater detail later, critical features of the impact analysis study design are:
The first report on short-term program impacts will be released early in 2003, once the second wave of survey data is available for the full study sample. The final impact analysis report will be released in summer 2005.
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Human Services Policy
Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services