The Best Practices in Adolescent Pregnancy Prevention (BPAPP) program began in 1999 with the formation of an advisory group of Title X family planning grantees from Federal Region II (New York, New Jersey, Puerto Rico, and the U.S. Virgin Islands). With input and direction from this group, a Best Practices in Adolescent Pregnancy Prevention Retreat was designed and implemented.

The Best Practices Retreat took place on June 7 and 8, 2000 in Newark, New Jersey, and was attended by over 60 participants. Experts in adolescent pregnancy prevention, program managers, and Title X family planning providers from across the region participated in workgroups that examined current research in adolescent pregnancy prevention. Participants also discussed aspects of programming that were reported to be effective in reducing adolescent pregnancy and worked to apply the research and the current practice to specific populations, topics, or program types.

From the retreat, program types were identified and workgroups were formed to continue the collection and application of best practices research. These workgroups identified trends in adolescent pregnancy, research outcomes, some practical implementation tips and program assessment questions. The assessment questions would assist prevention practitioners in identifying components of their current programming that were supported by the research, as well as ways that they could augment their programming to include additional best practices.

This Research to Practice User’s Guide was originally created from the following sources: the Best Practices in Adolescent Pregnancy Prevention Retreat workgroups, the National Campaign to Prevent Teen Pregnancy’s Get Organized: Guide to Preventing Teen Pregnancy (1999), Douglas Kirby’s Emerging Answers (2001), and empirical other research in adolescent pregnancy prevention. Since the first printing of the User’s Guide, Cicatelli Associates Inc. (CAI) has updated the content of this manual as new information and research have become available.

Overview

The overall goal of the Best Practices in Adolescent Pregnancy Prevention program is to decrease the incidence of adolescent pregnancy. To achieve this goal, CAI seeks to identify best practices guidelines, based on research, and disseminate the information to Title X family planning providers in order to implement or enhance adolescent pregnancy prevention services.

Project Plan

The original Best Practices in Adolescent Pregnancy Prevention: A Research to Practice User’s Guide has been disseminated to all family planning providers in Region II and evaluated for its usefulness and effectiveness in creating practical connections between existing research and everyday practice. We have incorporated suggestions and updated this user’s guide based on the evaluations and feedback received.

From the components of best practices identified, training programs have been developed and delivered to Title X organizations. These trainings focus on the specific elements identified within the User’s Guide and concentrate on the practical integration of best practices into existing adolescent pregnancy prevention programming. In addition, the trainings incorporate planning and implementation skills for creating programming that is informed by research.

Cicatelli Associates Inc. has also developed an interactive website based on the User’s Guide (http://www.cicatelli.org/BPAPP). This technology allows internet users to log on to the web program and generate best practices guidelines that can assist in the design of new programming, assess existing programming, or make suggestions for additional program elements that are research-informed and demonstrated to be effective.

Cicatelli Associates Inc. believes that the integration and application of cutting-edge research into everyday practice are key elements in creating lasting change in the reduction of adolescent pregnancy rates.

What Is a Research to Practice User’s Guide?

Numerous research studies have been conducted on adolescent pregnancy and its prevention. We now know a great deal about the antecedents and outcomes associated with early pregnancies. We also know a great deal about what is effective in helping adolescents reduce their risk of unintended pregnancy, making healthy choices about their bodies and their futures, and supporting those choices within the context of their lives.

The challenge begins when those of us working as direct service providers to youth are presented with new research and literature that are not, in some practical way, connected to the everyday world in which we are working. Articles in journals, research reports, and outcomes data are all tools that help to inform practice. Unfortunately, given the reality of program planning and implementation, perusing such sources for valuable tidbits of information is not always an option.

The Research to Practice User’s Guide is a practical, easy-to-use document that:

Cicatelli Associates Inc. recommend that a variety of initiatives be developed, implemented, and evaluated to address issues of adolescent development and sexuality and reduce the adolescent pregnancy rate. In each case, programs should be designed that incorporate the existing research into best practices that “fit” culturally within your specific communities.

How Can I Use this Guide?

The Research to Practice User’s Guide can be used to support and inform:

What We Know about Adolescent Pregnancy

After twenty years of increasing teen pregnancy and birth rates in the United States, adolescent pregnancy, abortion, and birth rates have declined steadily since 1991. These trends have been seen in teens across all age and racial/ethnic groups (Kirby, 2001; Boonstra, 2002). Although the rate of adolescent pregnancy and birth in the United States is declining, the rate remains the highest among comparable industrialized nations. Yet, among those developed nations, there are similar levels of teen sexual activity and age at which teens become sexually active (Kirby, 2001; Darroch, Singh, & Frost, 2001; Boonstra, 2002).

At least three-quarters of young women have sexual intercourse and four out of ten young women in America get pregnant at least once before they turn 20. In 1999, there were over 9,000 births to girls under the age of 14 (Finer & Henshaw, 2003). Half of teen males have had sexual intercourse by their 17th birthday, rising to over 80 percent by age 19 (Sonenstein, Stewart, Lindberg, Pernas, & Williams, 1997). In the United States, there are nearly one million teen pregnancies per year, and in 1997 there were approximately 93 pregnancies per 1,000 girls aged 15–19. Seventy-eight percent of these pregnancies are unintended (Henshaw, 1998; Alan Guttmacher Institute [AGI], 2002).

It is generally agreed that adolescent pregnancy, and particularly childbearing, is a medical concern with compelling social antecedents—or precursors—and consequences. The individual, social, and economic conditions of adolescents who become pregnant, and particularly those who become mothers, are strikingly different from those who do not become pregnant (Kirby, 1997). Maynard (ed.) reports that 40 percent of girls who begin families before age 20 will not complete high school or receive a GED by age 30 (1996). Many teen mothers will raise their children alone and in poverty. Children born to teen mothers are at risk of premature birth, low birth weight, lower academic achievement, more behavioral and emotional problems, and greater likelihood of becoming teen parents themselves (AGI, 2003). Declines in adolescent pregnancy rates should fuel optimism but not complacency, because the number of pregnancies in females younger than 20 years continues to approach one million per year.

Why Are Rates Declining?

The percentage of all high school students who report ever having had sexual intercourse has declined over the last decade. The decline in teen pregnancy rates is partially due to increased abstinence among American teens (Henry J. Kaiser Family Foundation, 1998). Among teens who are sexually active, rates of contraceptive use, including condom use, have increased only slightly. However, teens are choosing more effective, long-lasting birth control methods like injectable contraceptives and hormonal implants and, more recently, new highly effective methods that are now on the market (e.g., contraceptive ring or contraceptive patch). Teens have been more successful in avoiding pregnancy in recent years because of this shift in contraceptive use. However, sexually transmitted infection rates remain high—approximately four million per year (AGI, 2002; Long, 2002).

Future Trends

In the near future, we may see an increase in adolescent pregnancy and childbearing. It is estimated that from 1995–2005, the number of 15 to 17 year-olds in the United States will increase by 15 percent. According to the Annie E. Casey Foundation (2003), if the current fertility rate remains the same, the absolute number of babies born to teenagers is likely to increase. In fact, using the 1996 rate to project the number of births to women ages 15 to 19 in the year 2005 suggests a 14 percent increase in the number of babies born to teen mothers.

Adolescent pregnancy is still a problem with economic, social, and personal costs for teens, their children, and society, and is likely to remain high on the nation’s health agenda.

What Do We Know About the Causes of Teen Pregnancy?

No single approach will work to prevent pregnancy in all teens, largely because there are many factors that contribute to early teen intercourse, poor contraceptive use, pregnancy, and childbearing. Douglas Kirby with the National Campaign to Prevent Teen Pregnancy (2001) reviewed at least 250 studies to create Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. This informative report discusses over 100 antecedents (or risk factors) found to increase the chances of adolescent sexual risk-taking and pregnancy.

According to the research findings, there are sexual as well as non-sexual antecedents. Sexual antecedents may include negative attitudes towards contraception as well as lack of sexual negotiation skills. Non-sexual antecedents include living in communities where adults have low levels of education, high unemploymentrates or higher rates of crime—conditions that are largely beyond the control of young people. At the same time, there are antecedents that act as protective factors, reducing those same risks, such as a close connectedness to one’s parent or a strong affinity for school.

The approach of some of the program models highlighted in this guide is to address specific sexual antecedents, while others address non-sexual antecedents, and still others address both. In determining what type of program will be most beneficial to your youth, their families, and the community, it is important to be aware of the many risk-factors that may be affecting the population you are working with and to address them in your program design and services. It would be impossible to address every antecedent to early teen intercourse, poor contraceptive use, and teen pregnancy and childbearing, so choosing which ones to focus on in the most effective ways for your particular population of youth is the best strategy (Kirby, 2001). We have some encouraging reports about what approaches can work with specific populations, but more rigorous evaluation is still
needed to identify more successful programs.

A variety of adolescent pregnancy prevention approaches is needed to effectively reach diverse populations of youth. Some approaches work for some groups of youth, while others do not. The most promising approaches address sexual and non-sexual antecedents to teen pregnancy in a variety of ways. For instance, multi-component programs can directly address the reproductive health and sexual behavior of teens, while also helping teens develop as people in more holistic ways. Simplistic solutions will not stem the tide of teen pregnancy. It is important that agencies take a close look at the risk factors, as well as the potential protective factors they can foster in their youth when designing a program and be realistic about which ones can be effectively addressed.

What Are “Best Practices?”

Programs are often expected to solve the “problem” of teen pregnancy, but adolescent pregnancy and childbearing are complex issues connected to larger societal concerns such as poverty and sexual abuse. Community educators, family planning clinic staff, classroom teachers, counselors, and case managers are often called upon to work with adolescents for the purpose of preventing teen pregnancy. At the same time, funding organizations and program directors are driven by outcome-based interventions (i.e., those that demonstrate measurable results). Adolescent pregnancy prevention programs number in the hundreds and it is difficult to know which programs are “best practices.” While no single strategy will work for all teens, there are some model programs which include specific components that help to create and support change.

There are several ways to determine best practices, as there is not a single commonly accepted definition of, or criterion for, best practices. For the purposes of this User’s Guide, “best practices” are determined from the outcomes of research studies that have been conducted on adolescent pregnancy prevention programs. Best practices are not determined by the opinions or judgments of practitioners within pregnancy prevention programs.

The National Campaign to Prevent Teen Pregnancy published the three-volume guide, Get Organized: A Guide to Preventing Teen Pregnancy (1999). Get Organized covers a lot of material, from tips on networking with community partners to practical advice on how to raise money. It offers many program examples of best practices from around the country. The research generated from evaluation of these programs is utilized in this document.

How is Effectiveness Measured?

Outcome studies determine the effectiveness of pregnancy prevention programs through three main outcome objectives or measures: changes in sexual knowledge or attitudes; increase in skills; and changes in sexual behavior. Knowledge tests, standardized measures, or questionnaires are used to measure an increase in knowledge or change in attitudes. An increase in skills is demonstrated by improved decision-making and an increase in communication or other interpersonal skills. Standardized measures and role-play are often used to make these evaluations. Changes in sexual behavior are usually determined by measuring pregnancy rates or self-reports of specific behaviors.

A literature review on pregnancy prevention indicates, despite the limitations of sexual behavior outcome measures, that behavior measures are superior to other measures and are the best indicator of the effectiveness of the prevention programs. In addition, changing knowledge, attitudes, and skills does not necessarily lead to changes in sexual practices or behaviors (Kirby, 2001).

There are numerous programs for adolescent pregnancy prevention, and practitioners are faced with a range of possible program components and curricula. Outcome research offers some guidance on which components and curricula to use. Although there are considerable differences in research findings, there is enough consensus to draw some conclusions for guiding practice. The remainder of this manual will focus on those model programs.

Program Models

Many adolescent pregnancy prevention programs have emphasized education, abstinence, and access to contraception. The definition of what constitutes adolescent pregnancy prevention programming can be expanded to include many different kinds of programs to help teens avoid pregnancy. Several authors recommend ways to categorize programs (Kirby, Waszak, & Ziegler, 1991; Kirby 1992; Plotnick, 1993). Some of those categories include reproductive health services, youth development, sexuality education, multi-component programming, gender-specific programs for young women, and male involvement programs.

Chapter 2 identifies the following six program areas and the elements of best practices associated with each:

It is important to remember that overlaying each of these program types is the essential lens of cultural competency. Programs with sound, research-informed designs can easily falter should they fail to address and include the unique cultural attitudes and beliefs of their target audience. Cultural competency must inform all programming from design to evaluation (Betancourt, Green, & Carrillo, 2002).