A National Strategy to Prevent Teen Pregnancy: Annual Report 1998-99

Introduction

At the end of the second year of its National Strategy to Prevent Teen Preg- nancy, the U.S. Department of Health and Human Services (HHS) is pleased to report that teen pregnancy rates continue to decline. However, while the on-going decrease in teen pregnancy rates is encouraging and suggests that the Department's Strategy is having a positive impact, we must remember that the rates continue to be too high and we should not relax our efforts to prevent teen pregnancy.

The President and Congress called on HHS to develop a National Strategy to address this serious challenge and to assure that at least 25 percent of communities in this country have teen pregnancy prevention programs in place — as mandated under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The Department responded to this call by releasing a National Strategy to Prevent Teen Pregnancy in January of 1997. This Strategy presented a comprehensive plan to prevent teen pregnancies in the United States by strengthening, integrating, and supporting teen pregnancy prevention and other youth-related activities in communities across the country.

More Good News. Encouraging trends in teen pregnancy rates continue:

• Teen birth rates declined for white, black, American Indian, Asian or Pacific Islander and Hispanic women ages 15-19, from 1991 through 1998.
• The birth rate for black teens reached the lowest rate ever reported for blacks in 1998, and also declined more than any group between 1991 and 1998.
• Teen birth rates have decreased in every state.

Our Charge and the Work Ahead. While these data indicate that concerted efforts to reduce teen pregnancy may be succeeding, we still have a long way to go. The Federal government, the private sector, parents and other caring adults are all helping send the same message: Don't become a parent until you are truly ready to support a child.

Key Principles. The National Strategy is guided by five key principles which shape and guide our prevention efforts. Based on ideas that are essential to all community efforts, as indicated by research and experience, the key principles are the cornerstone of the Department's Strategy.

The Five Principles

1. Parents and other adult mentors must play key roles in encouraging young adults to avoid early pregnancy and to stay in school.
2. Abstinence and personal responsibility must be the primary messages of prevention programs.
3. Young people must be given clear connections and pathways to college or jobs that give them hope and a reason to stay in school and avoid pregnancy.
4. Public and private-sector partners throughout communities — including parents, schools, business, media, health and human service providers, and religious organizations — must work together to develop comprehensive strategies.
5. Real success requires a sustained commitment to the young person over a long period of time.

Reporting Our Progress. We hope that this annual report will provide useful information on the efforts of the Department of Health and Human Services. We also hope to complement the efforts of others, such as those of the non-profit National Campaign to Prevent Teen Pregnancy, individual states and communities, foundations, other non-governmental entities, parents, youth, and other caring adults.

Trends in Teen Births and Pregnancies

The Department is pleased to report that, according to the latest data compiled from HHS' National Center for Health Statistics (NCHS) (through 1998), teen birth rates continue to decline steadily. Notably, these declines cut across ages (younger and older adolescents) and race and Hispanic origin. Further, fewer teenagers are having second children.

The Decline in Teen Birth Rates Has Continued for 7 Consecutive Years. Both national and state-level teenage birth rates have fallen since 1991. The overall rate for teenagers declined by 18 percent from 1991-1998 (62.1 per 1,000 teens aged 15-19 in 1991 to 51.1 in 1998). Data for states through 1997 show that:

• Teen birth rates have fallen in all states (the decline is not statistically significant for Rhode Island).¹
• Rates fell by 20 percent or more in 10 states and the District of Columbia.

Teen Birth Rates by Age. Birth rates for teenagers differ substantially by age. In 1998, 82.0 of every 1,000 older teens had a baby, more than 2.5 times the rate for teens aged 1517, which was 30.4 per 1,000, a record low.^2,3 The decline in the rate since 1991 experienced by older teens largely reverses the 19 percent increase found during the late 1980s.^3,4

• The U.S. birth rate for teenagers declined 2 percent from 1997 (52.3 per 1,000 aged 15-19) to 1998, and 18 percent from 1991 to 1998.^2,3
• The U.S. rate fell more for younger than for older teenagers. Birth rates dropped 29 percent for girls 10-14 years old, 21 percent for 15-17 year olds and 13 percent for 18-19 year olds.^2,3
• The rate for teens aged 15-17 years fell 5 percent between 1997 (32.1 per 1,000) and 1998, and 21 percent between 1991 (38.7 per 1,000) and 1998.
• The rate for older teens aged 18-19 declined 2 percent from 1997 to 1998 and 13 percent since 1991 (94.4 per 1,000).

Trends by Race and Hispanic Origin. Birth rates for black teenagers have dropped steeply in the 1990s. Since 1991, black teenagers have shown the largest declines in teen childbearing.

• The overall rate for black teens fell 26 percent from 1991 to 1998 (115.5 per 1,000 aged 15-19 in 1991 to 85.3 in 1998).
• The rate for young black teenagers dropped 32 percent from 1991 to 1998 (84.1 per 1,000 aged 15-17 in 1991 to 56.8 in 1998).
• The rate for older black teenagers declined 20 percent during 1991-98, from 158.6 to 126.8.

In addition, birth rates have fallen since 1991 for non-Hispanic white teenagers. The overall rate fell 19 percent (43.4 per 1,000 aged 15-19 in 1991 to 35.2 in 1998), but rates declined more for younger than for older teens. Teen birth rates have declined for Hispanic teenagers as well, but the declines began later (just since 1994) and have been smaller (12 percent). Overall, birth rates continue to be substantially higher for Hispanic and black teenagers than for non-Hispanic white teenagers; since 1994, Hispanic teens have had higher rates than any other group.

Fewer Teenage Mothers Have Second Child. One of the key HHS findings has been that the rate of second births to teenagers who have already had one child has declined 21 percent between 1991 to 1997 (221 per 1,000 in 1991 to 174 in 1997).^1,4 In other words, the proportion of teen mothers who gave birth to a second child fell from 22 percent to 17 percent. The first birth rate for teenagers fell by 6 percent from 1991 to 1996 and then declined an additional 4 percent from 1996 to 1997; the first birth rate has thus declined 10 percent since 1991. The decline in the second birth rate for teen mothers is an important trend since a teenager with two or more children is at greater risk for a host of difficulties.⁵

Births to Unmarried Teens. Birth rates for unmarried teenagers declined again in 1997 for the third consecutive year. Despite these declines, out-of-wedlock childbearing for teens remains a serious concern. Since 1994, the rate for teens 15-17 years has fallen 12 percent, and the rate for teens 18-19 dropped 7 percent. Despite these declines in birth rates, the proportion of teen births that were to unmarried teenagers continued to increase in 1997, and in 1998 according to preliminary data.² Eighty-seven percent of births to 15-17-year-olds and 74 percent of births to 18-19-year-olds were non-marital in 1998. ²

Data Collection and Analysis. Accurate and timely reporting of trends and variations in teen birth rates is based on information reported on the birth certificates of all babies born in the United States. This information is provided to the National Center for Health Statistics (NCHS) by the state health departments through the Vital Statistics Cooperative Program. NCHS and the states share the costs for collecting and processing the data. The last four years have seen faster data collection and processing at the state level and by NCHS. Information can now be analyzed and released more quickly.

The preliminary files provided by NCHS' new statistical series contain very large samples; for example, the most recent preliminary file, for 1998 births, was based on over 99 percent of all births. Data from that file were published in October 1999, and the findings from the 1997 preliminary file have recently been validated with publication of the final data for 1997.^1,6

More information on the collection and reporting of teen birth data is presented in Appendix I.

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¹ Ventura SJ, Martin JA, Curtin SC, Matthew s TJ. Births: Final Data for 1997. National Vital Statistics Reports; Vol. 47, No. 18. Hyattsville, Maryland: National Center for Health Statistics. 1999.
² Martin JA, Smith BL, Mathews TJ, Ventura SJ. Births and deaths: Preliminary data for 1998. National Vital Statistics Reports; Vol. 47, No. 25. Hyattsville, Maryland: National Center for Health Statistics. 1999.
³ Ventura SJ, Mathews TJ, Curtin SC. Declines in Teenage Birth Rates, 1991-98: Update of National and State Trends. National Vital Statistics Reports, Vol. 47, No. 26. Hyattsville, Maryland: National Center for Health Statistics. 1999.
⁴ Ventura SJ, Mathews TJ, Curtin SC. Declines in Teenage Birth Rates, 1991-97: National and State Patterns. National Vital Statistics Reports, Vol. 47, No. 12. Hyattsville, Maryland: National Center for Health Statistics. 1998.
⁵ Maynard RA, ed. Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing. New York, New York: The Robin Hood Foundation. 1996.
⁶ Ventura SJ, Anderson RN, Martin JA, Smith BL. Births and Deaths: Preliminary Data for 1997. National Vital Statistics Reports, Vol. 47, No. 4. Hyattsville, Maryland: National Center for Health Statistics. 1998.

Building Partnerships

Building partnerships remains a critical aspect of the Department's National Strategy to Prevent Teen Pregnancy. HHS is committed to sustaining current partnerships and creating opportunities for new partnerships to grow. Because HHS recognizes that each group and individual can make valuable contributions to prevention efforts, the Department is committed to involving a wide-range of partners in its work. HHS partnerships involve national, state, and local organizations; schools; health and social service organizations; business; religious institutions; tribes and tribal organizations; federal, state, and local governments; parents and other family members; and teens themselves. HHS seeks to develop partnerships among all groups and individuals concerned about teen pregnancy.

While valuing the potential of partnerships to increase cooperation, reduce duplication, pool resources, integrate services and ultimately, build communities, it is also important to recognize the challenges of developing and sustaining them. Partnerships, particularly at the communitylevel, take a long time to establish and require considerable energy to maintain. Reaching true community consensus on controversial issues is a difficult and timeintensive process. Collaboration is particularly challenging when partners come from different racial, ethnic, linguistic, religious, class and/or educational backgrounds yet it is exactly this crosssectional involvement that is the most valuable product of collaboration.

Community Partnerships

HHS is involved in several projects and programs that promote partnerships in communities interested in preventing teen pregnancy. Following are highlights and updates of HHS efforts to build and strengthen partnerships in communities across the country.

Get Organized: A Guide to Preventing Teen Pregnancy. The Department, in partnership with the National Campaign to Prevent Teen Pregnancy, developed a three volume guide for states and communities to use in their fight against teen pregnancy. The guide includes chapters on important topics such as: "Promising Approaches", "Involving Teen Boys and Young Men", "Involving Parents", "Involving the Faith Community", "Involving Health Care Professionals", and "Involving the Business Community." Other chapters address issues that often challenge community leaders in their efforts to prevent teen pregnancy such as how to conduct a community needs assessment, how to raise funds for prevention programs, how to create an effective teen pregnancy prevention message, and how to move forward in the face of conflict. The Guide is available through the National Campaign to Prevent Teen Pregnancy. The Campaign web site is http://www. teenpregnancy.org.

The Indian Health Service. The Indian Health Service (IHS) is a direct care organization with most efforts concerning teen pregnancy concentrated on providing appropriate prenatal and neonatal care. There is, however, a growing effort to work with various organizations — federal, state, and local — to develop and implement strategies that deal with all issues surrounding teen parenthood, including prevention.

Working with IHS, the Center for American Indian and Alaskan Native Health at Johns Hopkins University is currently providing outreach workers to tribal members of three Navajo units and the White Mountain Apache. The workers conduct a curriculum-based outreach program on healthy pregnancies and well-child care, which includes family planning on an individual basis. With partnerships and funding from the C.S. Mott Foundation and the Ford Foundation, they are now in the planning phase of a program expansion to include fathers and male outreach workers.

Girl Neighborhood Power! — Building Bright Futures for Success (GNP). This five year national demonstration program, begun in 1997, centers on involving communities as active partners in helping girls (9-14 years old) successfully navigate adolescence and reach their maximum potential. Currently, the program consists of four community partners (Girls Inc. of Memphis, TN; Crispus Attucks of York, PA; City of Madison, WI; and Youth & Family Services Inc. of Rapid City, SD) and a national leadership consortium (Healthy Mothers, Health Babies Coalition, Inc. of Alexandria, VA).

GNP encourages and supports partnerships at both the local and federal levels. To be eligible for funding, communities were required to demonstrate local commitment through a broad-based coalition of community agencies and parental involvement. In addition, GNP is supported by several HHS agencies, including the Centers for Disease Control and Prevention, the National Institutes of Health, the Public Health Service's Office of Women's Health, the Administration for Children and Families, and the Health Resources and Services Administration.

This year, the community partners focused on strengthening local coalitions and neighborhood site development. Many valuable partnerships formed at the community level, for example, partnerships with the Association of Retarded Citizens, local churches, community centers, mental health providers, and local justice agencies.

To reach its goal of promoting the well-being of girls, GNP will continue to build strong partnerships among a network of organizations and individuals in order to communicate positive messages and provide meaningful opportunities for girls. Additional information on the promising approaches being used by GNP can be found in the next section.

The Centers for Disease Control and Prevention (CDC) Community Coalition Partnership Programs for the Prevention of Teen Pregnancy. The CDC supports and works closely in partnership with thirteen communities with high rates of teen pregnancy. These demonstration projects, begun in 1995, are currently in their second phase. In this phase coalitions of local public and private agencies and community organizations are working together to implement their action plans, test promising interventions, build financial and programmatic sustainability, and conduct site-specific evaluations. CDC will continue to work with these innovative communities for the next several years. Further details about the promising approaches and evaluation efforts of this program will be discussed later in this report.

Building and Sustaining Partnerships Report. To better understand the potential of partnerships to enhance teen pregnancy prevention efforts, HHS published "Building and Sustaining Community Partnerships for Teen Pregnancy Prevention." This report, issued by the Assistant Secretary for Planning and Evaluation in July 1998, is based on an extensive literature review of various partnership relationships focusing on teenage pregnancy and other risk-taking behaviors. Research in the fields of violence prevention, substance abuse prevention, teen pregnancy prevention, youth development, community development, environmental protection, and general business enterprises were explored and reviewed. In addition, the report discusses the process of partnership development, including how to mobilize a community, organize, implement, and sustain a partnership, and provides models of community development and detailed case studies. By providing this publication, HHS hopes to assist in the development of teen pregnancy prevention partnerships across the country. Copies of this report are available at http://aspe.hhs.gov.

Preventing Pregnancy through Youth Development. Published by the Family and Youth Services Bureau (FYSB), "Preventing Adolescent Pregnancy: A Youth Development Approach", provides useful information and background on using a youth development approach with teen pregnancy prevention efforts. Topics discussed include: "Ideas for Getting Started" and "Building on Lessons Learned." This year, FYSB's National Clearinghouse on Families and Youth (NCFY) distributed over 5,000 copies of the guide to a diverse audience, including: federal, state, and local lawmakers, school representatives, private industry, non-profit organizations, and the academic community. In addition, NCFY produced an article based on this guide that was included in the December 1998 edition of the Preventing Pregnancy for Youth: An Interdisciplinary Newsletter (funded by the C.S. Mott Foundation). Copies of the book are available through the National Clearinghouse on Families and Youth at http://www.ncfy.com.

HHS Partnerships

In addition to working directly with communities to form partnerships, HHS frequently works on broader collaborative efforts to improve teen pregnancy prevention efforts. The following are highlights and updates of major partnership efforts by HHS over the past year.

The National Campaign to Prevent Teen Pregnancy, a private nonprofit organization, was formed in response to the President's 1995 State of the Union challenge to parents and leaders all across this country to join together in a national campaign against teen pregnancy. Since its founding, the Campaign has worked in a nonpartisan, broad-based manner with all the sectors of society that play a role in reducing teen pregnancy including states and communities, faith-based groups, the media, researchers, parents, and teens themselves.

In late April, Secretary Shalala participated in a White House event with the First Lady to honor individuals and groups selected by the Campaign for their outstanding contribution to reducing teen pregnancy. In addition, the National Campaign to Prevent Teen Pregnancy released several publications highlighting the important role that peer influence plays in teen pregnancy including recent research findings and practical advice from teens to their parents and to other teens. These events, along with the Vice President's release of the new teen birth data on April 29th at a round table discussion highlighting promising teen pregnancy prevention strategies, helped kick off Teen Pregnancy Prevention month in May.

The Girl Power! Campaign. Since its formation in November 1996, the Girl Power! Campaign has successfully used multiple and varied partnerships to accomplish its goal of helping girls between the ages of 9 and 14 make the most of their lives. Because studies show that girls at this age have a tendency to neglect their own aspirations and interests, in addition to becoming less physically active, Girl Power! uses a comprehensive approach that addresses both health issues and the topics of self-worth, motivation, and opportunity. Given young girls' increased vulnerability at this stage to negative influences and mixed messages regarding health risk behaviors, the Girl Power! Campaign focuses on increasing their skills and competence in academics, arts, sports, and other beneficial activities. By encouraging girls to develop their skills and sense of self, Girl Power! hopes to decrease the likelihood that they will participate in risky and unhealthy behavior.

As a multi-issue, national public education campaign, Girl Power!, led by the Center for Substance Abuse Prevention in the Substance Abuse and Mental Health Services Administration, has partnered with many national non-profit organizations, including over sixty national endorsing organizations and 300 state and local affiliations, to develop and implement unique Campaign promotional materials, public service announcements, and an award-winning web site (http://www.health.org/gpower). The success of working together is evidenced by the thousands of Girl Power! community programs throughout the country.

This year, the Girl Power! Campaign has formed many exciting partnerships to help promote its message. In cooperation with Girl Power!, the Girl Scouts of the USA developed an official Girl Power! Girl Scout patch and accompanying guides to be used as resources for earning the patch. Through a unique partnership with the Women's World Cup 1999, the campaign promoted and distributed Girl Power! products at selected matches through the 22-day soccer tournament held in the United States this summer. Other partnerships include the National Family Partnership, Avon Running, the WNBA's Washington Mystics basketball team, and the American Association of University Women.

Future products of the Girl Power! Campaign include a Community Education Kit featuring resources for Girl Power! programs. The Girl Power! Campaign plans to continue working with various national, state, and local organizations to improve the future for all young girls.

Joint Work Group on School-Based Teen Pregnancy Prevention. With support from the Centers for Disease Control and Prevention's Division of Adolescent and School Health, nine national non-governmental organizations (NGOs) are working together to help state and local education and health policy makers, school administrators, maternal and child health professionals, school health professionals, and other school personnel prevent unintended teen pregnancies. These organizations include the American Association of Maternal and Child Health Programs (AMCHP), American Association of School Administrators (AASA), American School Health Association (ASHA), Association of State and Territorial Health Officials (ASTHO), Council of Chief State School Officers (CCSSO), National Association of State Boards of Education (NASBE), National Conference of State Legislatures (NCSL), National Education Association (NEA), and the National School Boards Association (NSBA).

Through the Work Group, the NGOs and HHS learned about what their respective constituents needed to help schools implement effective teen pregnancy prevention programs. In its second year, the Work Group has been focusing on helping its constituents implement specific strategies to improve the effectiveness of programs such as collecting, interpreting, and disseminating epidemiological data about teen pregnancy; identifying effective school policies and programs; conducting outreach activities to parents, educators, and the public; helping schools engage parents in pregnancy prevention; helping schools work with community organizations in a shared effort; and helping schools implement youth development activities.

Supporting Promising Approaches

In 1999, HHS provided support to efforts ongoing since the first year of the Strat egy. The Department of Health and Human Services has continued to ensure that at least 25 percent of communities had teen pregnancy prevention programs in place-as mandated by section 905 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

In FY 1998, 34% of communities had teen pregnancy prevention programs in place. This is a conservative estimate because it represents only HHSfunded programs that flow directly to communities. HHS also supports other teen pregnancy prevention efforts through its various state block grant programs. In addition, there are numerous activities supported by funding sources outside of HHS. For example, two of the purposes of TANF are to prevent out-of-wedlock pregnancies and to encourage the formation and maintenance of two-parent families. In support of these goals, states may use TANF funds for a wide variety of teen pregnancy prevention programs, serving both welfare recipients and the general population.

Highlights of HHS Activities. The National Strategy is built on the belief that successful teen pregnancy prevention efforts are specifically tailored to the unique needs, interests, and challenges of diverse individuals and communities. Although the National Strategy sends the strongest possible message to all teens that postponing sexual activity, staying in school, and preparing to work are the right things to do, the research has shown that girls and boys, for example, experience adolescence in different ways. Therefore, different approaches are required to meet the unique needs of different adolescent populations. This year the Department has continued to fund a broad spectrum of programs that actively involve family and community members, as well as young people themselves. In particular, HHS has promoted the involvement of boys and young men in teen pregnancy prevention.

Abstinence Education

The Department funds abstinence education through two programs. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) created a new program entitled the Abstinence Education Grant Program which is funded under Section 510 of Title V of the Social Security Act. The grants funded under this program must meet specific criteria defined in the legislation. In addition, the Department has been funding abstinence education through its Adolescent Family Life Program (AFL) since 1981. New AFL programs, initiated since 1997, now also conform to the PRWORA definition of abstinence.

Abstinence Education Grant Program. The Department's Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) is responsible for the administration of the Abstinence Education Grant Program. The law provides for a mandatory annual appropriation of $50 million for each fiscal year (FY) 1998 through 2002. Fifty-two states and territories applied for and received FY 1999 funding (one less than in FY 1998).

In March 1999, MCHB completed an annual program summary based on the states and territories' FY 1998 annual reports and FY 1999 grant applications. Multiple activities and contracts are being funded in the majority of states and territories. Thus, the following totals exceed the total number of states and territories (54) that received an FY 1998 and/or FY 1999 Abstinence Education Grant. While states and territories differed in their approaches, there were some general consistencies.

• The most frequently funded state/territory activities are communitybased projects (45¹), program evaluations (41), state media campaigns (37), and technical assistance and training (36).
• The most frequently funded local program activities are adult mentoring, counseling and supervision (32), social skills instruction, characterbased education, and assets building (31), curriculum development and implementation (31), schoolbased programs (26), public awareness campaigns (24), parent education groups (21), peer mentoring and education (20), and before and afterschool programs (18).
• The two age groups most frequently served by the states and territories are 1314 year olds (51) and 912 year olds (50). Other frequently served age groups are 1517 year olds (37) and 1819 year olds (26).
• Special population groups frequently targeted by the states/territories are parents (39), atrisk populations, such as youth of color, outofschool youths, and youths in areas with high rates of outofwedlock pregnancies (26), males (25), and teachers and youth serving professionals (20).

Adolescent Family Life Program (AFL). As mentioned earlier, the AFL program's prevention approach, as required by statute, has always been abstinence-based; promoting the postponement of sexual activity as the most effective way for adolescents to prevent pregnancy and STD/HIV infection. In FY 1998, $9.0 million of the total $16.7 million AFL appropriation was spent to support 57 prevention projects using the abstinence-only definition under PRWORA. An additional $3.6 million was spent to continue support for 17 prevention and care projects originally funded in FY 1995 and $1.0 million to support seven research projects. Many address self-esteem and decision-making, life, social, and negotiation skills. Specific components for parent involvement and education are incorporated by most and all are required to include an independent evaluation.

Family Planning

The Department, through the Title X National Family Planning Program, is a primary provider of subsidized family planning services, serving nearly 4.5 million persons annually. The Title X program has always played an important role in adolescent pregnancy prevention; approximately 30 percent of those receiving services are under 20 years of age. In addition to clinical services, outreach and education — including counseling to encourage continued postponement of sexual activity for adolescent clients who are not yet sexually active — are also important components of Title X services for adolescents. The program has also been expanding adolescent pregnancy prevention through special initiatives sponsored regionally.

For example:

• Region IV (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) has been funding community-based organizations to implement adolescent pregnancy prevention initiatives. Interventions include sexuality education, parent involvement, mentoring, peer counseling, tutoring, job skills training, career planning and recreational activities in various combinations.
• Region VI (Arkansas, Louisiana, New Mexico, Oklahoma, Texas) has funded a number of programs to coordinate the linkage of family planning providers with community-based organizations that serve hard to reach populations, including adolescents, in providing appropriate services and activities related to family planning and reproductive health.
• All ten regions have been supporting projects in Title X clinics designed to increase male responsibility with respect to reproductive health and family planning and to enhance young men's futures through training and employment. Selected clinics employ adolescent males, as well as provide them with on the job training in various aspects of clinic operation, family planning, and reproductive health education.

Community Collaboratives

The Community Coalitions Partnership Program and Girl Neighborhood Power! are two of the Department's cornerstone programs aimed at reducing teen pregnancy. Over the course of this year, the communities involved in these two programs progressed in their efforts to develop and maintain multi-sectoral collaborations responsible for planning, implementing and evaluating prevention strategies.

Since 1995, the CDC, through the Community Coalition Partnership Program for the Prevention of Teen Pregnancy, has supported demonstration projects in thirteen communities with high rates of teen pregnancy (Boston, Chicago, Jacksonville, Kansas City, Milwaukee, Oklahoma City, Orlando, Philadelphia, Pittsburgh, Rochester, San Antonio, San Bernardino, and Yakima). Moreover, eleven of the thirteen communities are actively working with Latino youth and Latino neighborhoods as part of their overall plan to prevent teen pregnancy. In Phase II of the demonstration, which began in 1997 and continues for five years, coalitions of local public and private agencies and organizations in communities are working on implementing their action plans, field testing promising interventions, building toward financial and programmatic sustainability of their programs, conducting site-specific evaluations, and participating in cross-site evaluations.

This year, each of the thirteen demonstration communities continued their efforts to develop and strengthen communitywide coalitions. They have continued to mobilize and organize community resources in support of comprehensive, riskspecific, effective and sustainable programs for the prevention of initial and repeat teen pregnancies. The communities are pursuing a wide variety of strategies to provide health, education, employment, recreation and other youth development services, programs and opportunities for youth and their families. Ongoing activities include: training for community leaders and neighborhood residents on community engagement and empowerment; the selection of intervention programs and components that address the documented needs and assets of specific neighborhoods; field testing of promising approaches; parentchild communication workshops; the development of youth councils; the use of health communications to enhance the planning and delivery of programs; the involvement of the faith community in planning efforts, and fund development to sustain programs.

Girl Neighborhood Power! — Building Bright Futures for Success (GNP), a
five-year national demonstration program that started October 1997, fits under the umbrella of the Department's Girl Power! campaign. Its several purposes include: (1) promoting the health and well-being of girls and young female adolescents between the ages of nine and fourteen; (2) preventing the onset of health risk behaviors among girls during their adolescence; (3) connecting girls and the communities in which they live and supporting the growth of girls' citizenship; (4) developing leadership skills in girls and young female adolescents; and (5) fostering communities' and neighborhoods' investments in their youth.

The first year of this project included efforts to invest in neighborhood site development, to strengthen coalitions, and to develop a common process to monitor activities across sites. On average, the four neighborhood sites of each community partner enrolled about 50 girls (at least 200 girls per community partner) during the first project year. The racial and ethnic composition of participating girls varied by community site.

Although each community partner's programming is unique, several common themes have emerged across sites in this past year. Each community partner has:

• Developed mechanisms to help girls and their families identify physical and mental health needs, to enroll in Medicaid and the Children's Health Insurance Programs, and to access appropriate health care services;
• Convened an advisory council composed of girls;
• Worked to help girls with their schoolwork and to feel connected to their schools (school success is protective against engagement in health risk behaviors and helps young people to thrive as adolescents and as adults);
• Developed creative community service programs to enhance girls' connectedness to community, pride in citizenship, and leadership skills (examples include transforming a vacant lot into a community garden, gathering canned goods at Halloween ("trick or treat for others to eat"), developing public service announcements, and advocating for a Neighborhood Watch program); and
• Incorporated field trips, which broaden girls' horizons, into its regular programming activities and developed sports programming activities to improve girls' opportunities for and attitudes toward physical activity.

In addition to these two programs that target teen pregnancy, in 1998 the Family and Youth Services Bureau announced the award of more that $1 million in State Youth Development Collaboration Projects. FYSB awarded funding to nine states to develop and support innovative youth development strategies. Each of the following states received a grant of $120,000: Arizona, Colorado, Connecticut, Iowa, Maryland, Massachusetts, Nebraska, New York, and Oregon.

The grants will support efforts that focus on all youth, including vulnerable youth in at-risk situations. Youth development programs have been shown to promote youth self-efficacy, build competencies and encourage young people to delay child- bearing. Each state has designed a unique plan for implementing the project on the basis of identified youth needs and prior state activities with regard to youth development.

Programs for Boys and Young Men

Traditionally, adolescent pregnancy prevention research and programs have focused on adolescent girls. It has become increasingly clear, however, that adolescent boys and young men must share that focus. The National Strategy along with the Administration's Fatherhood Initiative have continued to work on ways to expand the Department's efforts to target boys and young men. In 1998, the Office of Population Affairs funded several research grants aimed at improving the knowledge of what works in male involvement by developing new program models. This year, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) funded a project to identify abstinence programs for males, and also supported several meetings to synthesize what is known thus far about male involvement programs.

Title X Male Involvement Grants. In FY 1998, the Office of Population Affairs funded ten research grants, through the Title X Family Planning Program, to support communitybased organizations in developing, implementing, and testing approaches for involving young men in family planning education and reproductive health services programs. Research has shown that young men recognize unintended pregnancy as a serious problem and its prevention as a joint responsibility; nevertheless, drawing them into family planning/reproductive health information and service programs continues to be difficult. This year, the grantees completed their program development and began implementing new approaches to bringing family planning services and education components into programs where young males were already receiving other health, education, and social services.

While each program reflects the specific needs of its community, several themes predominate the interventions. Because most of the programs place significant emphasis on the role of adult men as guides, teachers or examples for younger men in their transition to adulthood, nearly every program is anchored on a strong mentoring component. This component is then often paired with community, cultural and recreational activities, as well as life skills instruction. (Several sites are using the nationally-known Wise Guys curriculum, while others have developed their own curricula for life skills and reproductive health education.) In addition, these programs have seen both the benefit and the appeal of youth development activities. Components such as academic tutoring, sports, and talent shows are used as incentives to draw young men into the project. Finally, some of the grant programs are targeting specific populations such as the Latino community by using culturally appropriate services and language.

Abstinence Based Teen Pregnancy Prevention Programs Focusing on Males. Consistent with the Department's focus on abstinence education, ASPE commissioned a paper, written by the South Carolina State University Policy Analysis Consortium, to identify and describe existing abstinence programs targeting boys and young men. The study will identify 66 programs that provide either abstinencebased (40%) or abstinence only (60%) programming to boys and girls or to boys only. The authors found that the majority of abstinence programs serve 9 to 14 year old boys. The most frequently used service approaches were teen support groups and mentoring types of activities as well as parent/teen classes. The matrix of existing programs will be published and will be regularly updated with new and promising strategies for reaching boys and young men with an abstinence message. A final report will be available in Winter, 1999.

Federal, State, and Local Strategies for Promoting Male Involvement in Teen Pregnancy Prevention. The Department sponsored several meetings to identify innovative male involvement strategies that might be disseminated to a larger audience. The meeting results are being summarized in a report that outlines multipronged strategies for reaching a much wider population. The report draws upon the experiences of numerous local and one statewide (California) male involvement initiatives.

The report will first identify "stakeholder" audiences whose activities stand to benefit from male involvement and who have resources, networks and capacities to help promote and strengthen it. These audiences include: (1) regional, state and local public officials administering family planning, maternal and child health, education and family/social service programs; (2) teen pregnancy prevention programs; (3) responsible fatherhood programs; (4) communitybased reproductive health programs; and (5) male serving programs in the armed services, juvenile justice, prison systems, and youth development and recreation programs.

Specific strategies designed to inform and collaborate with these stakeholder audiences and other communitybased partners include creative use of the media and social marketing, regional and state forums and summits, peertopeer networking opportunities and technical assistance. The goal is to promote and support a view of boys and men wherever they live, learn, work or play as responsible members of familiessons, fathers, spouses, grandfathers.

The report (available in Winter, 1999) will outline some inherent tensions and barriers to promoting male involvement and discusses the most critical challenge to be faced—identifying state and national leaders and vehicles to coordinate and steer the wide ranging efforts needed to effectively promote male involvement.

Welfare Reform

Welfare reform included an incentive for states to reduce the incidence of out-of-wedlock childbearing and encourage the development of new approaches to pregnancy prevention. Awards for the first year of the Bonus to Reward Decrease in Illegitimacy Ratio were announced in September 1999. Alabama, the District of Columbia, California, Massachusetts and Michigan all received awards of $20 million each. The decrease in the ratio of out-of-wedlock to total births ranged from 5.7% in California to 1.5% in Massachusetts. This provision is targeted toward all women, not just teenage mothers; however, in measuring state decreases in out-of-wedlock births, this measure would also include births among unmarried teens. Although the bonus is part of the TANF grant, the funds can be used to support a wide variety of programs extending beyond the TANF population.

The Administration for Children and Families has developed a guide for states entitled Helping Families Achieve Self-Sufficiency. This guide offers suggestions on how best to use TANF funds for services to children and families (including teen pregnancy prevention efforts). The guide can be found at http://www.acf.dhhs.gov/programs/ofa/funds2.htm .

In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) is supporting an initiative on teen parents and welfare reform that generates knowledge on the effects of welfare reform on parenting teens, and measures the effects of preventive interventions on teen parents and their children. The four objectives in support of this goal are: (1) prevention or reduction of alcohol, tobacco, and drug use; (2) improvement in academic performance; (3) reduction of subsequent pregnancies; and (4) improvement in life skills and general well-being. SAMHSA has awarded ten cooperative agreements which are in the process of collecting baseline data for the evaluation of the initiative.

Research and Evaluation Activities

Research Activities-From Data Collection to Findings

In the past year, the Department has continued its commitment to support research related to teen pregnancy. This commitment includes investment in long- term research to follow trends in important areas. With such a commitment, many of the Department's activities reported here are continuations of research initially highlighted in last year's report. Areas of research include:

• Adolescent sexual activity
• Timing of first intercourse
• Use of contraceptives
• Intent to become pregnant
• Adolescent decision making
• Male Involvement

Data Collection. The data sets used to conduct research in the area of teen pregnancy are vital to the Department's mission to prevent teen pregnancy. To conduct quality research, the Department has invested resources to gather and maintain high-quality, comprehensive data. These data serve as a critical foundation for the information we now have with regard to teen pregnancy and for the information we will need in the future. A brief description of each data set is in Appendix IV.

Research Activities. The Department's research activities cover a wide spectrum of topics. Continuing research on the sexual activity of adolescents allows for an understanding of the patterns of sexual behavior. Examinations of whether and which adolescents intend to become pregnant or cause a young woman to become pregnant clarify how adolescents feel about becoming pregnant and have important implications for the decisions they make, their physical and emotional well-being, and potentially for the well-being of their children. Research funding is also spent in designing, implementing and evaluating pregnancy prevention programs, so that resources may be used to replicate programs that are demonstrably effective.

Adolescent decision making impacts on many risk-behaviors, including sexual activity and contraceptive use, and is a vital factor in understanding how and why teens become or make someone pregnant. Knowledge of how adolescents make decisions also enhances the ability to create effective prevention and intervention programs. Research on male involvement in teen pregnancy highlights the role, often ignored, that men have in sexual, romantic, marital and parenting relationships. The couple relationship, as well as peer relationships, have important influences on sexual risk behaviors.

Adolescent Sexual Activity. Research supported by the National Institute of Child Health and Human Development (NICHD) indicates that, between 1988 and 1995, a decrease has occurred in the proportion of teenagers aged 15-19 who had ever had sexual intercourse¹. This decline occurred primarily among young men.^2-3 Research conducted by the NCHS revealed that the levels for young women remained stable.^2-3 These trends are departures from trends since the early 1970s, which had been toward increasing percents of sexually experienced teens.

Young Women's First Intercourse. NCHS and other researchers have found that many teenage girls are ambivalent about their first intercourse. More complete knowledge about adolescents' feelings about their first intercourse may help understand its timing, and clarify relationships between sexual initiation, contraceptive use, and teenage pregnancy.⁴ Among women who had their first intercourse at age 13 or younger, 24 percent report the experience to have been non-voluntary, compared with 10 percent of those who were between 19-24 at first premarital intercourse. Yet, women's experiences are not simply voluntary or non-voluntary. Women were asked to rate, on a scale of 1-10, how much they wanted their first intercourse to occur. About one-quarter of respondents who reported their first intercourse as voluntary also rated it as more unwanted than wanted.

Contraceptive Use. Research supported by NCHS indicates that the principal trend in contraceptive method choice in 1988-1995 was an increase in condom use, especially among black, Hispanic, or unmarried women under the age of 25. The increase in condom use at first intercourse, which dramatically increased in the 1980s and 1990s, was accompanied by a decrease in use of other methods that do not prevent HIV and STDs.⁵

Twenty-four percent of all black teens using contraception were using injectable or implant contraception, methods which are very effective against pregnancy.⁵ The use of injectable and implant contraception may help to explain the decline in the second and higher order birth rates for teen mothers — teens who already had a child. This adoption of injectable and implant contraception and the increase in condom use at first intercourse and afterward may have been important factors in the sharp decline in black teen birth rates.^3,6For white teens, declines in current sexual activity as well as the increases in condom use may be significant factors in declines in birth rates.^2-5 For further information, please see Appendix I.

Unintended Pregnancies. Research conducted by the NCHS indicates that a large proportion of recent pregnancies to women of all ages in the United States — over 50 percent — are unintended even though contraceptives are widely available and widely used.⁷ Unintended pregnancies that were wanted, but came too soon, or that were not wanted at all, are associated with a woman's attitudes about her pregnancy at the time it was conceived.

The National Survey of Family Growth (NSFG) (see Appendix IV), which has long been the principal national source of information on intended and unintended pregnancy in the United States, traditionally classifies women's pregnancies as intended, mistimed, or unwanted. To study whether young women were having inconsistent feelings about pregnancy, researchers developed a set of scales to measure these feelings.⁸ The scales were used to show a woman's positive, negative, or conflicting (ambivalent) feelings about her pregnancy and were compared with the traditional measures of unintended pregnancies. Though she may not have actively wanted to get pregnant at the time she did, the young woman may have felt some attraction to what being pregnant would add to her life, for example, looking forward to the new experiences that having a baby would bring. These results affirm the impressions of many service providers that the strength of the motivation to prevent pregnancy, or ambivalence about preventing it, is a prime determinant of both the likelihood of getting pregnant and how effectively contraceptives are used among young and teenaged unmarried women. By measuring ambivalent feelings, service providers may be able to better address teen's feelings and concerns about pregnancy and contraception.

Many unintended pregnancies are pregnancies toward which the mother's attitude was not entirely negative — as measured in a new series of questions asked of teens and young women under age 25 in the 1995 wave of the NSFG.⁹ In 1995, as in 1988 and 1982, teenaged women had high levels of unintended pregnancy (about 78 percent of recent pregnancies in 1994).¹⁰ Teens 15-19 years of age were also more likely to have lower values on a "happiness to be pregnant" scale, which suggests that they had stronger negative or ambivalent feelings about their pregnancies than young women ages 20-24. Overall, the greatest amount of ambivalence was shown by teen women 15-19 years old.

Adolescent Decision Making. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) funded a workshop in January, 1998 which was convened by the Board on Children, Youth, and Families (a joint activity of the National Research Council and the Institute of Medicine) to explore the role that decision making plays in adolescents' involvement in high-risk behaviors.

The changes associated with adolescence, including physical, cognitive, social, and emotional growth, impact decision making. Cognitive changes create an increased capacity for more complex and abstract reasoning. Social cognition—the way one thinks about one's social world, the people with whom one interacts, and the groups in which one participates—may change from adolescence to adulthood. External factors, such as the media—television, radio, movies, music videos—may influence decision making by helping to set both positive and negative social norms.

Research examined at this workshop can assist those involved in the development of programs designed to prevent health risk behaviors. Research on drug use prevention programs, for example, has found that promising programs: (1) are long term, (2) are designed to counter social influences, (3) begin in elementary or middle school, and (4) are supplemented by booster sessions throughout the high school years. Programs may not explicitly use a decision-making model, yet may incorporate decision-making skills such as providing information that teenagers need for effective decision making in a clear and personalized way; encouraging teenagers to take responsibility for their actions and to analyze their options; and showing adolescents how to discuss decisions in a group setting. The report is available on the web at http://aspe.hhs.gov

Male Involvement. Research on male involvement is another important piece of the Department's research focus on teen pregnancy. Examples of programs in this area are highlighted in the section "Supporting Promising Approaches." Including males in the examination of teen pregnancy means investigating how men feel about their sexuality and sexual relationships, attitudes of males regarding what it means to be a man, and attitudes towards and use of contraceptives. Further, male involvement can incorporate issues not directly involving sexuality such as family relationships and parenting, career and educational goals and opportunities among a host of other issues that directly affect young men in the United States.

One area of research in this area is the expansion of the NSFG (see Appendix IV for details on the current NSFG). The 6^th cycle of the NSFG, due to be conducted in 2001 will include, for the first time, a national sample of men 15-49 years of age. It is anticipated that the expanded survey will be done every 3-4 years instead of every 6-7 years to more accurately monitor trends. Future improvements under consideration are to include populations of men who are often excluded from national surveys: the military and prisoners. These improved data can be expected to yield reliable national estimates of male sexual behavior and contraceptive use, attitudes toward marriage, cohabitation and fatherhood, extent to which births are wanted by males, and father-child contact and the father's role in raising his children. Further, these data are expected to allow for examinations of similarities and differences in attitudes and behaviors between men and women and subgroups of men and women.

Attitudes Towards Sexual Activity. Small research projects funded at the NIH are addressing adolescents' attitudes toward sexuality. Data collected under the AddHEALTH project (see Appendix IV) are demonstrating, among other things, that a young person's public profession of an intention to remain virgin does have a strong effect upon that person's abstaining from sex for the next year, even when controlling for other influences such as family structure, religiosity, and school success. Other researchers are able to examine how the strength of young people's sense of connection to school and family protect against initiating health risk behaviors, including early and unprotected sex.

Evaluation-Assessing Promising Approaches

The Department continues to be committed to learning what approaches have an effect on teen pregnancy and its related antecedents so that better interventions can be effectively designed. HHS continues to support ongoing evaluations and seeks to incorporate evaluation in HHS funded demonstration projects and programs. To expand knowledge in this area, the Department supports a number of efforts.

Abstinence-Only Education Programs-National Evaluation. The Department, through the Office of the Assistant Secretary for Planning and Evaluation (ASPE), is responsible for conducting an evaluation of the state abstinence-only education grants described in the Promising Approaches section of this report. The Balanced Budget Act of 1997 set aside funding to evaluate a select number of sites receiving funding from this program. In August, 1998, a contract was awarded for a three-year multi-site effort to improve knowledge about programs aimed at preventing teen sexual activity and its negative consequences. The process of site selection is well underway and is expected to be completed by the fall of 1999. Data collection will begin in the fall of 1999. The evaluation will focus on approximately twelve sites: eight sites will involve random assignment experiments of particular programs and four sites will involve a rigorous evaluation of a comprehensive community
approach to abstinence-only education. Outcomes of interest will include—but will not be limited to—the four performance measures identified in the Department's program guidance. These four measures are:

• The rate of pregnancy to teenagers aged 15 to 17
• The proportion of adolescents aged 17 years and younger who engage in sexual intercourse
• The incidence of sexually transmitted diseases among youths aged 15-19
• The rate of births to teenagers aged 15-17

Teenage Pregnancy Prevention Program Evaluation. There continues to be more to learn about what works to prevent teen pregnancy. Current knowledge about pregnancy prevention programs needs to be expanded to delineate which strategies are the most promising, which aspects of which programs demonstrate the strongest impact, and which programs are successful in affecting behavior across various
communities and population characteristics, such as ethnicity and socioeconomic status. To contribute to the expansion of this knowledge base, ASPE provided grants to enhance three existing evaluations of teen pregnancy prevention interventions that were rigorous in design and already had funding. Results from these three evaluations are expected in the Winter of 1999. The following are brief descriptions of the evaluations.

• California Adolescent Sibling Pregnancy Prevention Program (UCSD)

Researchers from the University of California, San Diego are evaluating the California Adolescent Sibling Pregnancy Prevention Program (CASSP) which targets the siblings of pregnant and parenting teens. The evaluation is providing important information about a significant subpopulation of girls who have been shown to be at elevated risk for teen pregnancy. There are two goals to the enhanced evaluation: (1) to analyze the differential impact of specific services and (2) to analyze community level factors that may be contributing to the risk of pregnancy for this population. The research around these two questions should add meaningfully to the knowledge base about solid teen pregnancy prevention practices. Basic knowledge about the high risk of the siblings of pregnant and parenting teens was funded under an earlier NIH grant.

• Inwood House

Inwood House is a wellestablished agency in New York City that has long-standing pregnancy prevention programs as well as an array of services for pregnant and parenting adolescents in middle through senior high school. The research team is currently comparing three differing levels of intervention (and no intervention) with respect to outcomes for students transitioning into high school. One of the interventions is an "abstinence plus" program funded by the AFL program. Abstinence plus programs promote abstinence as the most desirable method of preventing teen pregnancy, but these programs also provide other types of prevention information to sexually active teens.

The researchers are using ASPE funds to improve the quality of the abstinence program's comparison group while establishing comparison groups for the other two levels of intervention. This enhanced study will provide an important comparison of interventions provided by the same agency, and undergirded by the same philosophical approach toward working with adolescents. The interventions differ in their emphasis on abstinence and in the breadth and intensity of services they provide.

• Institute for Health Policy Studies (UCSF)

The Center for Reproductive Health Policy Research, at the Institute for Health Policy Studies (UCSF), is conducting a large scale evaluation of the California Community Challenge Grant Program. This program funds 112 sites in the state to provide services to pregnant and parenting teens and teen pregnancy prevention programs. Each site has implemented its own program and is given a choice of a variety of modules to complete process, outcome or impact evaluations. This has allowed the Center to provide an alternative to the "one size fits all" evaluation approach which would be less appropriate for these community-driven programs. The enhancement of the evaluation is developing comparison groups for these communities.

Community Coalition Partnerships Program. CDC's 13 community demonstration projects, described previously, are conducting sitespecific evaluations, and participating in crosssite evaluations. These evaluations include process and progress evaluation, and additionally, in six of the communities, enhanced evaluations of the impact of the program, or of specific program components.

• Process and Progress Indicators

Each of the demonstration sites is engaged in efforts to monitor its process and progress. In partnership with CDC and the Academy for Educational Development, the demonstration sites have collectively defined Cross Site Process Indicators for Adolescent Pregnancy Prevention in the following areas: (1) needs and assets
assessment; (2) health outcomes; (3) defining the program; (4) project administration; (5) positioning for financial sustainability. The analysis of the crosssite indicators over the life of the project will enhance the communities' capacity to evaluate and strengthen their programs. Furthermore, the documentation of these aspects of program development may also benefit other communities seeking to address teen pregnancy.

• Enhanced Evaluation Activities

Six of the 13 communities receive supplemental funding to support evaluations of the impact and outcome the demonstration projects have had in their communities. The studies underway include the following:

• Longitudinal study measuring the timing and frequency with which youth use the activities and services supported by the coalitions.
• An examination of changes in birth and STD rates in school populations based on whether the schools are in an intervention or comparison area.
• Annual surveys of adult knowledge, attitudes and behaviors with regards to youth development activities and issues in the intervention and comparison communities.
• Longitudinal study of parents and their children who participate in parentchild communication programs to assess changes in communication and connectedness.
• Survey of households in intervention and comparison communities assessing community and neighborhood resources, family and youth assets, and adolescent risk behaviors to assess changes in interorganizational relationships among key community agencies in intervention and comparison communities.

Girl Neighborhood Power! (GNP) Evaluation. The GNP initiative, described
earlier in this report, has also stressed the importance of evaluation. Each project is responsible for developing and implementing its own evaluation for determining how successfully it has achieved its goals and objectives. In addition, the sites have together developed and agreed on the use of a common form to document and monitor project activities. Supplemental funding is being provided by the Office on Women's Health so that community partners will be able to use a common set of variables to explore how they influenced participating girls and their families, to measure the degree of community investment in programming for girls, and to explore how their projects' activities have affected participating neighborhoods.

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¹ Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ. Fertility, Family Planning, and Women's Health: New Data from the 1995 National Survey of Family Growth. National Center for Health Statistics. Vital and Health Statistics, Series 23, No. 19. 1997.
² Abma JC, Sonenstein FL. Teenage Sexual Behavior and Contraceptive Use: An Update. Paper presented at Conference: "Teenage Sexual Activity and Contraceptive Use: An Update," at the American Enterprise Institute Welfare Reform Academy, May 1, 1998.
³ Sonenstein FL, Ku L, Lindberg LD, Turner DF, Pleck JH. Changes in Sexual Behavior and Condom Us Among Teenaged Males: 1988 to 1995. AJPH 88(6):956-959. 1998.
⁴ Abma JC, Driscoll A, Moore K. Young Women's Degree of Control Over First Intercourse: An Exploratory Analysis. Family Planning Perspectives 30(1): 12-18. 1998.
⁵ Piccinino LJ, Mosher WD. Trends in Contraceptive Use in the United States: 1982-1995. Family Planning Perspectives 30(1):4-10, 46. 1998.
⁶ Ventura SJ, Mathews TJ, Curtin SC. Declines in Teenage Birth Rates, 1991-97: National and State Patterns. National Vital Statistics Reports, Vol. 47, No. 12. Hyattsville, Maryland: National Center for Health Statistics. 1998.
⁷ Piccinino, LJ. Unintended Pregnancy and Childbearing. In: Wilcox, LS and Marks, JS, eds. From Data to Action. Atlanta: Centers for Disease Control and Prevention, pp. 73-82. 1994.
⁸ Adler, NE. Unwanted Pregnancy and Abortion — Definition and Research Issues. Journal of Social Issues 48 (3). 1992.
⁹ Piccinino, L, Peterson, LS. Ambivalent Attitudes and Unintended Pregnancy. In: Severy, L and Miller, W, eds. Advances in Population, Vol. 3. London: Jessica Kingsley Publishers Ltd., 227-249. 1999.

¹⁰ Henshert, SK. Unintended Pregnancy in the United States. Family Planning Perspectives 30 (1):24-29,46. 1998.

APPENDIX II: Measuring the Proportion of Communities with Teen Pregnancy Prevention Programs

Recent declines in the teen birth rate, and indications of further declines in the teen pregnancy rate, suggest that the numerous public and privatesector efforts across the country to prevent teen pregnancy are having a positive impact. Measuring all factors that help adolescents postpone premature sexual activity and avoid pregnancy is difficult, however, since individual, family, and community characteristics are all influential. Nevertheless, measuring the proportion of communities that have at least one teen pregnancy prevention program in place (estimated by dividing the number of such communities by the number of communities in the United States) provides a rough sense of how many communities are responding to this problem with specific, targeted prevention efforts. In 1997, at least 31 percent of communities had HHSsupported teen pregnancy prevention and related programs.

To develop a sound, albeit conservative, estimate of this proportion, the estimate includes only those programs supported by HHS. HHSsupported programs which include teen pregnancy prevention services as a component are diverse, ranging from comprehensive health and social services to substance abuse treatment and HIV prevention education. In this report, the number of teen pregnancy prevention programs funded by HHS includes those programs funded in the year FY 1998 (including the latest year for which complete information on grants awarded is available).

To determine the number of communities with at least one program, the location of each program was identified based on the site of the services provided and/or the location of the grant recipient. A community with more than one program was counted only once. The estimate excludes HHS funding provided directly to states (e.g., Medicaid, Maternal and Child Health Block Grant) which states may use to fund activities in multiple communities. Since there is no single standard definition for community in the United States, the estimate uses a definition of community based on areas identified by the Commerce Department's Bureau of the Census. This definition includes all incorporated places with a population of 10,000 individuals or more (2,673) and all counties where, excluding these incorporated places, the remaining population reaches 10,000 or more (2,079), for a total of 4,752 communities. Under this definition, for example, Montgomery County, Maryland would consist of four communities, including three incorporated places of 10,000 or more inhabitants (Gaithersburg, Rockville, and Takoma Park) and one community representing the balance of the county's population, which exceeds 10,000.

Using these calculations, the resulting estimate of the proportion of communities in the United States with HHSsupported teen pregnancy prevention and related programs is at least 34 percent for FY 1998. This proportion represents about 1616 communities across the country.

APPENDIX III: HHS Activities

The Department of Health and Human Services supports a variety of efforts to help communities develop comprehensive teen pregnancy prevention strategies that reflect five principles: parental and adult involvement, abstinence and personal responsibility, clear strategies for the future, community involvement, and a sustained commitment.

HHS Programs

State Children's Health Insurance Program (CHIP) was established by the Balanced Budget Act of 1997 under Title XXI of the Social Security Act. This program, administered by the Health Care Financing Administration (HCFA) and Health Resources and Services Administration (HRSA), enables states to provide health insurance coverage to uninsured targeted lowincome children. States have the opportunity to involve communities as they design and implement their CHIP programs so that the new programs, including teen pregnancy prevention programs, may be an additional avenue to provide services to adolescents at risk. All 54 states, territories, and the District of Columbia have submitted CHIP plans which have been approved.

The Abstinence Only Education Program was part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to enable states to provide abstinence education through activities such as mentoring, counseling, and adult supervision designed to promote abstinence from sexual activity until marriage. The program, administered by the Health Resources and Services Administration (HRSA), has a mandatory appropriation of $50 million for each Fiscal Year from 1998 through 2002.

The Girl Neighborhood Power! Building Bright Futures for Success is challenging America's communities to become active partners in assisting 9 to 14yearold girls to successfully navigate adolescence and achieve maximum potential. The initiative, administered by HRSA, strives to combine several elements including strong "no use" messages about tobacco alcohol, and illicit drugs with an emphasis on physical activity, nutrition, abstinence, mental health, social development, and future careers.

The Center for Disease Control's Community Coalition Partnership Program for the Prevention of Teen Pregnancy has supported demonstration grants for the prevention of teen pregnancies in 13 communities in 11 states since 1995. Coalitions of local and public and private agencies and organizations in communities with high rates of teen pregnancy have been working over the last two years to develop community action plans, coordinate efforts to reduce teen pregnancy, identify gaps in current programs and services, target existing resources, and design evaluation plans. CDC awarded approximately $250,000 per year for two years to 13 communities in 11 states to help these communities mobilize and organize their resources to support effective and sustainable teen pregnancy prevention programs. For FY 1998, a total of $13.7 million was made available to help the 13 community coalition partnerships implement their action plans and evaluate their impact, as well as to support related data collection, evaluation, and dissemination activities.

Reproductive Health and Family Planning Services (under Title X of the Public Health Service Act) are provided to nearly 5 million persons each year, nearly one third of whom are under 20 years of age. Abstinence counseling and education are an important part of the Title X service protocol for adolescent clients. These services are provided by 84 grantees with more than 4,000 clinic locations.

These sites offer reproductive health services including pregnancy prevention, family planning, and diagnosis of sexually transmitted diseases, either on site or by referral. The program has also launched an adolescent male initiative called the "Young Men/Family Planning Partnership Training Program." Under this initiative, Title X clinics employ male high school students as interns while also providing training in clinic operation and peer education; assisting in identifying career paths in allied health and related occupations; and increasing their use of services in a family planning setting.

Healthy Schools, Healthy Communities, a Health Resources and Services Administration program created in 1994, has established schoolbased health centers in 26 communities in 20 states to serve the health and education needs of children and youth at high risk for poor health, teenage pregnancy, and other problems. For the first three years of the program, $1 million each year was provided to fund health education and promotion programs that were coordinated with the health services grants.

The Social Services Block Grant (SSBG) (under Title XX of the Social Security Act) provides funding to prevent, reduce, or eliminate dependency; achieve or maintain selfsufficiency; prevent neglect, abuse, or exploitation of children and adults; prevent or reduce inappropriate institutional care; and provide admission or referral for institutional care when other forms of care are inappropriate. SSBG Grants are made directly to the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands to fund social services tailored to meet the needs of individuals and families residing within each jurisdiction.

The Community Services Block Grant, which operates in all 50 states, the District of Columbia, and the territories, enables local community agencies to provide lowincome populations, including youth at risk, with job counseling, summer youth employment, GED instruction, crisis hotlines, information and referral to health care, and other services.

The Independent Living Program, run by the Administration for Children and Families, provides funds to states to support activities ranging from educational programs to programs that help young people who are making the transition from foster care to independent living to avoid early parenthood. This program supports activities in all 50 states and the District of Columbia.

Youth Programs including Runaway and Homeless Youth Programs, Transitional Living Programs, and the Youth Sports Program, address a wide range of risk factors for teen pregnancy. Together, these programs operate in 500 communities in 50 states and the District of Columbia.

Healthy Start, administered by HRSA, has 62 projects to reduce infant mortality in the highestrisk areas and to improve the health and wellbeing of women, infants, and their families. Among a broad array of services provided (including state prenatal hotlines), thousands of teenagers participate in prevention programs exclusively designed for adolescents. The programs encourage healthy lifestyles, youth empowerment, sexual responsibility, conflict resolution, goal setting, and the enhancement of selfesteem.

Maternal and Child Health Services Block Grant (Title V) funds support a variety of adolescent health programs in 57 states and jurisdictions, including adolescent pregnancy prevention programs, state adolescent health coordinators, family planning, technical assistance, and other prevention services.

The Adolescent Family Life Program (AFL), created in 1981, supports research into the causes and consequences of adolescent pregnancy; demonstration projects that provide health, education, and social services to pregnant and parenting adolescents, their children, male partners, and families; and programs aimed at promoting abstinence among preadolescents and adolescents as the most effective way of preventing adolescent pregnancies, sexually transmitted diseases, and HIV/AIDS. In FY 1997, the AFL program funded 83 projects in 37 states and the District of Columbia. AFL is administered by the Office of Population Affairs.

Empowerment Zones and Enterprise Communities in 105 rural and urban areas in 43 states and the District of Columbia have been awarded grants to stimulate economic and human development and to coordinate and expand support services. As they implement their strategic plans, some sites are including a focus on teenage pregnancy prevention and youth development.

Health Education in Schools supports the efforts of every state and territorial education agency to implement local school health programs to prevent the spread of HIV and sexually transmitted diseases (STDs). Assistance is also provided to 13 states to build an infrastructure for school health programs. Efforts are targeted at preventing early sexual activity, STDs, HIV, drug and alcohol abuse, tobacco use, and injuries.

Community and Migrant Health Centers, including family and neighborhood health centers, operate in 3,032 communitybased sites through 685 center grantees in all 50 states, the District of Columbia, and six territories. The centers provide primary and specialized health and related services to medicallyunderserved adolescents. Some centers include special hours or clinics for adolescent patients.

Indian Health Service (IHS) provides a full range of medical services for American Indians and Alaska Natives. IHS supports projects targeted at preventing teenage pregnancy, and its prevention and treatment programs also have a special emphasis on youth substance abuse, child abuse, and women's health care.

Drug Treatment and Prevention Programs include services to prevent first time and repeat pregnancies among teenagers. One hundred twentytwo residential substance abuse treatment programs for pregnant and postpartum women, as well as for women with dependent children, receive support to provide family planning, education, and counseling services in 39 states, the District of Columbia, and the Virgin Islands. Also, 25 programs to prevent substance use and other adverse life outcomes serve highrisk female teens in 13 states and the District of Columbia.

Health Care and Promotion under Medicaid provides Medicaideligible adolescents under age 21 with access to a comprehensive range of preventive, primary, and specialty services within its Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

The Medicaid program also funds family planning services at an enhanced match rate for states. The federal government pays 90 percent of state expenditures for Medicaid family planning services, while the state funds the remaining 10 percent. The enhanced match encourages states to fund family planning programs which include patient counseling and education concerning pregnancy prevention and reproductive health.

APPENDIX IV: HHS Funded Data Sets

NSFGBNational Survey of Family Growth. The National Survey of Family Growth (NSFG), conducted by the National Center for Health Statistics (NCHS), is based on personal interviews with a national sample of women 15-44 years of age in the United States. Its main function is to collect data on factors affecting pregnancy and child bearing. Please see http://www.cdc.gov/nchswww/about/major/nsfg/nsfg.htm for more information.

 

NSAMBNational Survey of Adolescent Males. The National Survey of
Adolescent Males (NSAM), conducted by the Urban Institute and supported by the National Institute of Child Health and Human Development (NICHD), provides data exclusively on teenage males ages 15-19, specifically their contraceptive and sexual behavior. This data set complements the data on teenage females which is available from the NSFG. Please see http://silk.nih.gov/silk/DBSB/nsam.htm for more information.

Add HealthBNational Longitudinal Study of Adolescent Health. The National Longitudinal Study of Adolescent Health (Add Health), conducted by the Carolina Population Center, University of North Carolina and supported by the NICHD and seventeen other federal agencies, is a school based study of adolescents in grades 7 to12 which provides information on physical, mental, and emotional health status, and health behaviors, including sexual behavior and contraceptive use. It provides the first comprehensive view of the health and health behaviors of adolescents and the antecedents — personal, interpersonal, familial, and environmental — of these outcomes. This study will follow-up with these young people in to their late teens and early 20s. Please see http://www.cpc.unc.edu/addhealth/ for more information.

YRBSSBYouth Risk Behavior Surveillance System. The Youth Risk Behavior Surveillance System (YRBSS), established by the Centers for Disease Control and Prevention (CDC), monitors the prevalence of youth behaviors that most influence health. This national school-based survey focuses on priority healthrisk behaviors established during youth that result in the most significant mortality, morbidity, disability, and social problems during both youth and adulthood. Please see http://www.cdc.gov/nccdphp/dash/yrbs/ov.htm for more information.

NLSYBNational Longitudinal Survey of Youth. The NLSY, supported by the NICHD and the Bureau of Labor Statistics, is a national sample of approximately 12,000 men and women who were aged 1421 in 1979. The sample is oversampled for the black and Hispanic population. Data have been collected annually through 1994 and every other year beginning in 1996 on topics which include employment, fertility, marriage, divorce, child care, and infant health. In 1986, and biannually since then, data were collected from and about the children of the female respondents. Please see http://stats.bls.gov/nlshome.htm for more information.

NVSSB National Vital Statistics System. The National Vital Statistics System (NVSS), operated by the National Center for Health Statistics (NCHS), CDC, is based on the collection of individual record data for every birth registered in the United States. Data are collected by each State and transmitted to NCHS through the Vital Statistics Cooperative Program (VSCP). Under this program, NCHS partially supports State costs of producing vital statistics through a contract with each State. Please see http://www.cdc.gov/nchswww/about/major/natality/natality.htm. for more information.

¹Number of States and Territories.