Best Practices in Adolescent Pregnancy Prevention

CHAPTER TWO: PROGRAM MODELS

Section 1. Reproductive Health Services

The provision of reproductive healthcare services is a crucial component in the teen pregnancy prevention puzzle. About three-quarters of the drop in teen pregnancy rates in the United States between 1988 and 1995 has been due to changes in the behavior of sexually experienced teens. Overall contraceptive usage increased slightly, but perhaps more important, teens were choosing more reliable methods of birth control (Boonstra, 2002). Most of these methods are long-acting hormonal methods (e.g., the injectable and the implant). Such methods can only be obtained through a healthcare provider, which underlies the importance of easily accessible and affordable reproductive health services including contraceptive methods (AGI, 1999). In fact, a sexually active teen who doesn’t use contraception will have a 90 percent chance of getting pregnant within a year (AGI, 1994). There are newer hormonal methods now available including the contraceptive ring, the contraceptive patch, and a progestin-releasing intrauterine system, increasing the number of reliable options for women (Long, 2002).

Many programs offer access to reproductive health services that may include gynecological care (pelvic exams and pap tests), pregnancy testing, HIV counseling and testing, sexually transmissible disease testing and treatment, emergency contraception, and other forms of reproductive health counseling and education. These services may take place at family planning clinics, school-based health centers, school-linked clinics, or private physicians’ offices. Research has consistently shown that condom availability programs in schools do not increase sexual activity and that they may increase condom usage among sexually active students, although findings have been mixed on usage outcomes (Kirby, 2001). Dawson (1986) reviewed the literature and concluded that the most successful programs for influencing contraceptive behavior were based in a clinic setting.

A set of common characteristics for the provision of reproductive health services that have been shown to be effective in increasing condom or other contraceptive use among teens has been identified. These programs focused primarily or solely on reproductive health; provided youth with a combination of educational materials and opportunities for one-on-one counseling or discussions; gave a clear message about abstinence, as well as condom or contraceptive use; and provided condoms or other contraceptives (Kirby, 2001).

Research Demonstrates

The following are important components of reproductive health services:

Teens should be able to get an appointment within 24–48 hours (National Campaign to Prevent Teen Pregnancy, 1999). Adolescents tend to focus on the present and are less likely to keep appointments set days or weeks in advance. Successful programs often have drop-in appointment times.
Make services accessible by offering after-school, evening, and weekend appointments (National Campaign to Prevent Teen Pregnancy, 1999). Services provided at non-traditional times may increase teen utilization of clinic services.
Offer sexuality education within provision of clinical services. Most successful adolescent pregnancy prevention programs combine sexuality education with direct access to contraceptive services and have increased contraceptive use by up to 22 percent (Frost & Forrest, 1995).
Ensure confidentiality (National Campaign to Prevent Teen Pregnancy, 1999). Teens often have strong concerns about their privacy. Confidential access to family planning services has been found to help prevent unintended adolescent pregnancy (Kahn, Brindis, & Glei, 1999). Many teens may not know about
confidentiality laws and procedures so it is important to create awareness about confidentiality policies among teens.
Offer counseling at negative pregnancy tests. Zabin, Emerson, Ringer, and Sedivy (1996) found adolescents who receive negative pregnancy test results from healthcare providers to be an accessible and high-risk pregnancy group because they are sexually active, likely to be exposed to ongoing risk for pregnancy, and available for intervention. In their study of adolescents 17 years of age and younger who received a negative pregnancy test, 58 percent were pregnant within 18 months of that pregnancy test. More research is needed to determine whether or not counseling at a negative pregnancy test would show a reduction in adolescent pregnancy in teens who access that service.
Offer assertiveness counseling to young women when they test positive for an STI (Rickert, Sanghvi, & Wiemann, 2002). Clinic staff can seize this important window of opportunity to counsel and use role-play to help girls feel comfortable discussing condom and other contraceptive use with partners, set sexual limits, or refuse sexual intercourse. Often times, teen girls may need permission to set their own limits, to know that they have sexual rights, and to practice skills needed to assert themselves.
Support and encourage parent-child communication about sexuality (Rickert et al., 2002). Clinicians can educate parents who visit the clinic about the importance of talking with their daughters about sex-related topics, offer them resources, and teach parenting skills. Adolescent girls can be asked about comfort levels in discussing sexuality with parents and encouraged to do so. Strong parent-child communication may have positive effects on adolescent females being able to have better communication with their partners (Shoop & Davidson, 1994).
Include males in reproductive health care services. Traditionally, males have been left out of reproductive health care and their own needs have been largely ignored (AGI, 2002). It is not only important to acknowledge the role males play in reproductive health outcomes of females, but also to address the specific needs of males themselves. See Section 5, Male Involvement (page 23), for other ways to meet the needs of males and create a clinic atmosphere that welcomes them.
Promote a clear message about consistent and correct use of effective methods of contraception. The Alan Guttmacher Institute (1999) has analyzed the factors reducing the number of teen pregnancies and found that since 1991, sexually experienced youth have become more successful at avoiding pregnancy through effective contraception. In addition, more teens are reporting using methods the first time they have intercourse.
Utilize a teen advisory board (National Campaign to Prevent Teen Pregnancy, 1999). Inclusion of teens in the planning and delivery of services ensures that such services are truly youth-centered and reflect their needs. Teens listen to what other teens say. The success of social marketing campaigns, websites, brochures, and other educational media may hinge on teen input. Involving teens every step of the way, although challenging, is critical for effective provision of services that meet the needs of adolescents.

Implementation Tips

Set specific after school or weekend “drop-in” hours for teen clients.
Post “confidential services” signs in waiting and exam rooms.
Inform every teen client about the rules and exceptions to confidentiality.
Follow-up negative pregnancy tests with risk assessment counseling including specific discussion of, or practice with, birth control methods.
Ask teens who make appointments if they have a partner or friend they would like to accompany them to their appointment.
Find out what teens know about your clinic and their opinion of the services and staff. Word travels fast among teens and it is important to find out what your reputation is in the community you serve.
Begin to assemble a youth advisory board. Some ideas include accessing existing community youth leaders, doing outreach to youth through volunteer activities, or partnering with a youth-service organization in your area.

Reproductive Health Services Program Assessment .pdf

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Section 2. Sexuality Education

Comprehensive sexuality and HIV education programs that directly address sexual antecedents have shown great promise in preventing adolescent pregnancy and childbearing (Kirby, 2001). A number of curricular programs have been rigorously evaluated and shown to be successful in prevention efforts. In fact, 44 percent of youth ages 13–18 identify sex education courses as an important resource for sexual health issues (Henry J. Kaiser Family Foundation, 2000). When comprehensive sexuality education is included in a broader youth development program there is greater potential for success.

Recent data tell us that most young people are getting some kind of education relating to sexuality, but the content of programs varies widely (Henry J. Kaiser Family Foundation, 2000; Kirby, 2001). Decisions of which components to include in an adolescent pregnancy program need to be made by each agency with consideration to the specific population in which it serves. In this section, the focus will be on comprehensive approaches and what can be learned from successful programs. Recently, some people have referred to comprehensive sexuality programs as “Abstinence-Plus” programs, in order to emphasize that abstinence is also an important component of comprehensive programs.

Sexuality education has been widely debated in the United States for the last few decades. One argument against it is that providing comprehensive sexuality education “will encourage young people to have sex.” On the contrary, research shows that these programs do not increase sexual activity, the number of partners, the frequency of sex, or hasten the onset of sexual activity in teens (Kirby, 2001). In fact, some programs delay onset of sexual activity and reduce frequency, as well as the number of sexual partners among teenagers. Some programs also found increases in use of condoms and other contraceptives among groups of sexually active youth (Kirby, 2001).

Douglas Kirby, Ph.D., has rigorously evaluated and critiqued existing research on sexuality education and HIV education programs, and has determined that there are ten characteristics that were found to be consistent in all of the successful curricular programs. These characteristics are discussed later in this document (page 13). He has identified five programs that have shown strong evidence of success and the Centers for Disease Control and Prevention (CDC) has identified these same five sex and HIV education programs as effective.

Sexuality and HIV education programs might address an array of topics, such as anatomy and the body; reproduction: puberty and sexual development; sexual decision-making and limit setting; peer and partner pressure; abstinence; information about condoms and other contraceptive methods; gender; sexual orientation; sexually transmitted infections (STIs) including HIV; risk reduction; healthy relationships; reproductive health and rights; healthy sexuality over the lifespan; and other topics. Information about pregnancy prevention and the development of necessary skills is put in the larger context of healthy sexuality. Many programs offer opportunities for young people to ask embarrassing or difficult questions anonymously.

Research Demonstrates

The following are important components of comprehensive sexuality and peer education programs based on the work of Dr. Douglas Kirby and the National Campaign to Prevent Teen Pregnancy. While many types of programs may be able to show an increase in knowledge, the following characteristics are important in order to actually reduce sexual risk-taking, which is far more challenging. Interestingly, these characteristics are similar to those of educational programs that have been found to reduce substance abuse (Dusenbury & Falco, 1995).

Focus on reducing one or more sexual behaviors that lead to unintended pregnancy (Kirby, 2001). It is critical to have a singular focus when addressing the reduction of sexual behaviors. If a program takes on too much by utilizing a broad prevention message aimed at reducing numerous sexual behaviors, the take home message becomes too large and is therefore less likely to be digested by the target audience.
Provide basic, accurate information about the risks of teen sexual activity and methods of avoiding unprotected intercourse (Kirby, 2001). Youth need to have information presented in a simple way in order to help them assess risks and avoid risky behaviors like unprotected sex. The importance of providing honest answers to young people’s questions based on factual evidence cannot be overemphasized.
Convey and repeatedly reinforce a clear message about abstinence and/or condom use or other forms of contraception. Effective programs give a clear and consistent message about behavior, such as delaying sexual intercourse or messages about condom and contraceptive use and continually reinforce that message through activities and discussion (Kirby, 2001). Educators should present a clear value towards abstinence, and proper and consistent condom and contraceptive use as the most beneficial choices young people can make. Programs that try to affect the group norms of young people through group activities show the most promising success (Kirby, 2001).
Build skills through modeling and practice. Research suggests that skills training greatly increases the effectiveness of sexuality education (Kirby, 2001). Effective programs provide information about skills, demonstrate effective use of those skills, and then provide some sort of skill rehearsal and practice (Kirby, 2001). Reinforcing the messages of the program with skills building exercises that model communication, negotiation, and refusal skills, will assist young people in putting their beliefs into practice. In one national survey, students who had any type of sexuality education said they wanted more time spent on practical skills, such as how to talk to a partner about STIs or other sexual health issues, where to get tested for HIV or other STIs, or where to get birth control and how to use it (Henry J. Kaiser Family Foundation, 2000). It is important to provide as many opportunities as possible for young people to actively work on their skills.
Address social pressures related to sexual behavior. A survey by the Henry J. Kaiser Family Foundation and YM Magazine (1998) showed that 36 percent of teens felt pressure to do something sexual or had actually done something sexual that they were not ready to do. More often, girls had these experiences. This underlines the importance of proactively addressing very real and complex pressures young people experience. Youth feel pressure from peers, partners, media and other sources; and boys and girls may experience different kinds of pressures, or attach different meaning to the social pressures they receive. Effective programs include activities that discuss situations that might lead to sex, address peer norms about having sex or using condoms, and address ubiquitous media influences and messages that are often unrealistic (Kirby, 2001).
Use a variety of teaching methods that involve the participants and help them personalize information (Kirby, 2001; National Campaign to Prevent Teen Pregnancy, 1999). Engage students in the learning process by asking them what they want to learn and involving them in the planning and evaluating of the program. View the curriculum as flexible, depending on emerging student needs and current events. Avoid using a purely didactic approach to teaching by using experiential exercises, small group activities, discussions, and role-play. Have the staff serve as a facilitator, guide, resource, and co-learner (Hedgepeth & Helmich, 1996).
Incorporate behavior goals, teaching methods, and materials that are appropriate to the age, sexual experience, and culture of the participants. Postrado and Nicholson (1992) suggest designing programs for different age groups. They indicate that younger, non-sexually active youth may be more easily influenced by abstinence approaches than adolescents who are sexually active. Similarly, programs must differ to reflect the differences in youth in regards to sexuality, that is, their gender, sexual orientation, sexual values and attitudes, sexual health, sexual experience, and relationships. It is important to remember that such differences not only appear within groups but within individuals themselves (Hedgepath & Helmich, 1996). A great deal of cultural diversity exists in our society. When designing prevention programs, staff must consider the fact that our communities consist of individuals from many racial, religious, and cultural backgrounds, with diverse beliefs, values, and practices and create programs accordingly (Hedgepath & Helmich, 1996).
Programs should be based on theoretical approaches that have been demonstrated to be effective in influencing other health-related risk behaviors (Kirby, 2001). There should be a theoretical background for sexuality education programs in order to go beyond a cognitive level and affect social norms, behavior, and individual values, and to build personal skills. Programs might use social learning theories or theories of behavior change in order to reach youth in meaningful ways.
Provide ongoing education that lasts long enough to allow participants to complete important activities. It takes time to fully process activities and information, and to have a behavioral impact on youth. One or two sessions are not sufficient to address the myriad issues and questions adolescents have about sexuality. It is important to provide enough structured time to meet program objectives. Kirby (2001) found that programs with effective outcomes fell into two categories in terms of duration. The first were those that lasted 14 or more hours and the second were those that lasted a smaller number of hours, but worked with youth in small group settings who had voluntarily joined the program. The second type also had the benefit of smaller, more intensive group experiences, which could have a greater impact in some respects.
Use teachers or peers who believe in the approach and have been trained to deliver the program (Kirby, 2001; National Campaign to Prevent Teen Pregnancy, 1999). Careful selection of teachers and peer leaders is essential. Not everyone is cut out for teaching about sexuality and pregnancy, and it is important to identify those who are comfortable with sexuality in general, and with your program objectives and messages, in particular. Leading effective role-plays is tricky and it requires a great deal of skill to successfully process activities. It is vitally important that all teachers and peer leaders receive training, which may range from a few hours to a few days, and which should include multiple opportunities to practice leading exercises and discussing sensitive topics.

Implementation Tips

Identify a specific behavior that you would like your youth to adopt or avoid (e.g., using condoms, avoiding risky situations, not making sexual
decisions while using drugs or alcohol) and target your messages specifically to that behavior.
Include lots of opportunities for participants to practice the skills associated
with the topics discussed. This may include role-plays, condom relays,
research activities, or homework.
Have students fill out anonymous cards that ask for real-life sexual situations that they or their friends have faced. Use these cards for practice exercises and role-plays.
Ask students regularly, “Would this happen this way in real life?” If not, ask them what would work or how the situation might turn out better.
Provide ongoing training and support to the people delivering the program.

Sexuality Education Program Assessment .pdf

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Section 3. Youth Development

In designing youth development programs to address adolescent pregnancy outcomes, the hope is that the programs will build on the strengths of young people in positive, life-affirming ways, and that as their resiliency and life skills become greater, they will avoid behaviors that may have detrimental effects on their futures. The youth development approach is not designed to “fix the problem of youth,” but to create stronger, more resilient, highly capable, goal-oriented young people.

A report entitled, Understanding Youth Development: Promoting Positive Pathways of Growth (1997) published on the U.S. Department of Health and Human Services’ Family and Youth Services Bureau website, outlines four key areas of development that should be fostered in young people to help them avoid risk-taking behaviors and assist them to lead healthy and happy lives. Research shows that we can assist youth on positive developmental pathways when we help them develop the following:

A sense of industry and competency;
A feeling of connectedness to others and to society;
A belief in their control over their fate in life; and
A stable identity (U.S. Department of Health and Human Services, 1997).

Each of these characteristics is complex and there are myriad ways to foster each one. Youth development programs need to address the specific needs of the youth population they serve and work to build these four characteristics while assisting youth with the transition from childhood to adulthood. Some youth development programs have been shown to be effective in addressing non-sexual antecedents or a combination of both sexual and non-sexual risk factors (Kirby, 2001; Philliber, Kaye, Herrling, & West, 2002).

The most promising youth development programs that do not specifically address sexuality are based on service-learning, in which youth participate in a form of volunteer or unpaid community service and have structured opportunities to prepare for and reflect on the service. Other vocational education programs have not been shown to significantly reduce teen pregnancies (Kirby, 2001). To assist young people as they work through the many difficult changes and challenges of adolescence, youth development programs need to incorporate adults who are consistent, caring and supportive. Such adults must help to instill in youth a belief in the variety of life opportunities that exist and to assist youth in developing the necessary skills to make the best of their current and future opportunities (Lezin, 2002).

Research Demonstrates

At this point, it is not clear why some youth development programs are effective in reducing adolescent pregnancy and others with similar characteristics are not. This is an important area for further research (Kirby, 2001). To date, promising protocols of youth development programs do the following:

Develop the capacity of teens to set goals, organize resources, and take positive action. Strong programs build on strengths and develop life skills (National Campaign to Prevent Teen Pregnancy, 1999; Lezin, 2002). Teens who have established concrete educational and career goals are less likely to have or cause an unplanned pregnancy.
Build critical thinking skills (National Campaign to Prevent Teen Pregnancy, 1999). It is important for teens to have the skills necessary to examine situations, identify options, make critical judgments, and take actions that will ensure their health and safety. Teens often say they were unprepared for sexual situations or that “It just happened.” (Henry J. Kaiser Family Foundation, 1998). Linking critical thinking to health and sexual decision-making can help youth make healthy decisions and approach sexual behavior consciously so that nothing “just happens.”
Enhance teens’ sense of self-reliance and confidence (National Campaign to Prevent Teen Pregnancy, 1999). When teens have a sense of confidence in the skills required to perform assertive actions such as negotiating with a partner about using a condom they are more likely to be able to have control in sexual situations. If confidence or self-reliance is lacking, they will be less likely to feel comfortable negotiating situations, even if they are aware of the benefits of that negotiation.
Provide opportunities for teens to contribute and get involved and place youth in supported leadership positions (Lezin, 2002). Brooks (1992) stresses adolescents’ need for opportunities to make a contribution, make choices, solve problems, and assume responsibility. As youth assume more responsibility and take on leadership roles, they have increasing capacity to be more responsible for themselves.
Engage teens in productive activities and provide opportunities for recognition of good work (U.S. Department of Health and Human Services, 1997). Recognizing youth for positive achievements develops their sense of competency and nurtures their belief in their own abilities. Such recognition also helps youth to develop their own sense of identity and see themselves as potentially productive members of society. This can involve any number of extracurricular activities including sports, clubs, art, community service or part-time jobs. As teens feel valuable in other areas, they may see more benefits to postponing sexual activity and/or parenthood.
Provide a sense of belonging by creating positive social networks for teens within their community (National Campaign to Prevent Teen Pregnancy, 1999). Programs that promote community responsibility in addition to personal responsibility help decrease risk-taking activities in youth. Adolescents need to build a sense of connectedness to others and to society (U.S. Department of Health and Human Services, 1997).
Encourage teens to have meaningful, supportive, positive interactions with caring adults. Teens need help from adults to identify the things they do well and to assist in the development of the skills or qualities they need for identity building (Brooks, 1992). Scales (1991) discusses the significance of “at least one warm relationship with a caring adult” (page 15) in developing skills and competence in youth.
Help youth believe that they have the ability to control their fate in life (U.S. Department of Health and Human Services, 1997). It is important that youth believe they have some control over their life paths. This can be fostered when youth experience consequences that match their behaviors, be they positive or negative. Adults should provide positive outcomes or recognition for prosocial behaviors and negative consequences for misbehavior. This helps youth make connections between their own actions and their future fate. If youth have hope for their futures and believe that the choices they make will impact their lives, they may have better coping skills and make healthier decisions.
Treat each young person as “pure potential” (Philliber et al., 2002). This is one of the main tenets of the empirically successful Children’s Aid Society-Carrera Program. The positive approach and attitude of the adults in the program is crucial for the success of the youth. Many adults get frustrated with behaviors that are typical of adolescents and are part of their development. While staff may be frustrated by what they perceive as teen behavior, it is important that staff respond to each young person based on that teen’s own actions, rather than any preconceived notions or assumptions about that teen. Build on each teen’s strengths and focus on what he/she does well and is capable of achieving. Work actively with staff to shift their thinking about youth from a “deficit-based” to an “attribute-based” approach.

Implementation Tips

Work with your whole staff to outline a clear vision for implementing your youth development program. Examine your philosophical approach and the messages you wish to convey as a staff member to the young people you serve. Be sure your environment as well as the staff conveys that message.
Incorporate community members with careers and educational experience in your programs as mentors or advisors.
Recruit mentors for your programs, especially volunteers, who will maintain consistent connections with the teens you are serving.
Create ways for parents to be actively involved in the program.
Provide activities that require teens to evaluate situations and make critical judgments (i.e., debates, pro/con discussions, etc.).
Include activities and experiences that instill a sense of success. Be sure that goals are achievable and that success is acknowledged through awards or certificates.
Connect your program to other organizations that are doing community service in your immediate area.
Sponsor a neighborhood clean-up day or volunteer days at local hospitals or assisted living communities and encourage youth involvement.

Youth Development Program Assessment .pdf

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Section 4. Gender-Specific for Young Women

Young women need information and skills that address their specific concerns and needs, and opportunities to participate in effective programs in order to avoid unintended pregnancy. Indeed, gender expectations and roles are a strong force in American culture, and boys and girls often receive very different messages about sexuality, sex, and pregnancy. There are many unique antecedents that put females at risk of early intercourse or teen pregnancy (Kirby, 2001). Girls may experience peer or partner pressure to engage in sexual activity including intercourse. According to the Henry J. Kaiser Family Foundation (2000), 40 percent of teen girls say they have experienced personal pressure about sex and relationships. Also, girls are much more likely than boys to identify pressure from a partner or the need to be loved as reasons for having sexual intercourse. A survey by the Henry J. Kaiser Family Foundation (1998) showed that 36 percent of teens felt pressure to do something sexual or had actually done something sexual that they were not ready to do. More often, girls had these experiences. Adherence to gender roles or scripts that do not empower teen girls to make decisions or assert their personal sexual limits puts girls at greater risk of succumbing to such pressure (Rickert et al., 2002).

Girls need to know that they have options in life and that they can realize their potential. Gender-specific programming can work to boost the confidence, self-esteem, and skills of girls as they reach adolescence–a time of great risk for plummeting self-esteem (Office of Juvenile Justice and Delinquency Prevention [OJJDP], 1998). A study of young adolescents from seventh to ninth grades found that girls with high self-esteem were more likely to delay intercourse than girls with low self-esteem, although it found the exact opposite effect for boys (Spencer, Zimet, Aalsma, & Orr, 2002). This points to gender role differentials that can be used in developing gender-specific programs for both girls and boys. Girls need positive reinforcement and strong female role models (OJJDP, 1998).

In a study examining patterns of sexual assertiveness in young women ages 14 to 26, almost 20 percent of women “believed that they never have the right to make their own decisions about contraception, regardless of their partner’s wishes; to tell their partner that they do not want to have intercourse without birth control, that they want to make love differently or that their partner is being too rough; and to stop foreplay at any time including at the point of intercourse” (Rickert et al., 2002). In the same study, younger women were less likely to feel they have the right to ask a partner about history of STI testing than older women were.

A number of variables have been linked to risk of adolescent pregnancy in girls. While it may be impossible to address every one of them in a single program, there are many approaches that can help to empower girls, can give them hope and viable options for their futures and help them to actively avoid behaviors that put them at greater risk of early and/or unintended pregnancies.
Research Demonstrates The following are important factors to consider for successful female-only programs:

Create a safe environment where girls can express themselves openly. The Valentine Foundation and Women’s Way (1990) clarified essential elements for successful gender-specific programming for girls. They emphasize the importance of a physical space that is removed from the distraction of male attention; time for girls to talk in an emotionally safe environment where they can build ongoing, nurturing relationships with others; and opportunities for building trust with other girls and women who care about their growth.
Build healthy connections between young women and their families and communities (National Campaign to Prevent Teen Pregnancy, 1999, 2003). Best practices for girls’ programming focus on building a healthy community around young women. Young women need positive female role models and mentors, and people who believe in them. Youth are less likely to engage in unprotected sex if they have strong attachment to their schools, parents (especially their mothers), or faith communities (Kirby, 2001). It is beneficial for programs to help foster these connections.
Help young women see many options for their future (National Campaign to Prevent Teen Pregnancy, 1999, 2003). Helping young women to set future goals has been identified as a motivating factor in postponing adolescent pregnancy. Young women need options, support, and assistance for setting future goals. Academic achievement is associated with avoidance of behaviors that put girls at risk for unintended pregnancy (Rickert et al., 2002). Academic tutoring or assessment is a beneficial component of any program, along with other job- preparation skills, money management, and other skills that teach girls how to be self-sufficient and self-reliant.
Work with the daughters and younger sisters of girls who experienced a teen pregnancy. It has been well documented that a younger sibling will follow in her older sister’s footsteps and have a teen pregnancy of her own. The California Adolescent Sibling Pregnancy Prevention Program (ASPPP) was successful in delaying onset of intercourse and lowering the chances of pregnancy for younger sisters of teen mothers by providing a unique combination of services including training in self-esteem enhancement, decision-making skills, individual case management, academic guidance, job placement, and contraceptive and sexuality education (East, Kiernan & Chavez, 2003). Additionally, daughters of mothers who were teen parents are also at risk (National Campaign to Prevent Teen Pregnancy, 1999). It is necessary to address the potential risk of these daughters and younger sisters through interventions that specifically address their needs.
Work with teen couples to help them maintain responsible behaviors and communicate well (National Campaign to Prevent Teen Pregnancy, 1999). Few programs work with couples as units, even though this approach is likely to have a positive effect because it puts the burden to prevent pregnancy on both partners and allows for both partners to hear the same information. Programs should work with young couples around communication skills and encourage them to make decisions about contraception use if they are becoming sexually active.
Encourage girls to participate in sports. A longitudinal study found a direct relationship between athletic participation and reduced frequency of sexual behavior among girls (Sabo, Miller, Farrell, Melnick, & Barnes, 1999). The same study also found an indirect relationship to reduced risk of pregnancy for girls who play sports. A report from The Women’s Sports Foundation (1998) found that female athletes are less than half as likely to get pregnant as teens than female non- athletes, were more likely to be virgins, had first intercourse later in adolescence, had sex less often and with fewer partners, and were more likely to use contraception when they did have sex. Additionally, the link between sports participation for girls and a higher than average self-esteem is widely documented, helping girls to take pride in their bodies and to feel a greater sense of confidence and pride. There is ample evidence to support athletic programs that aim to reduce the incidence of teen pregnancy and other risk behaviors in girls.
Address sexual assault and/or abuse in a proactive way. Because girls are three times more likely than boys are to experience sexual abuse, sexual assault is a gender issue that requires critical attention. Young females with a history of sexual assault are more likely to have early onset of sexual intercourse and to report not having used birth control at last sexual encounter (Stock, Bell, Boyer, & Connell, 1997). One study showed that 74 percent of girls who had intercourse before age fourteen reported having intercourse involuntarily (AGI, 1994). History of physical or sexual assault has also been linked to beliefs in girls about sexual rights including feeling like they don’t have the right to make sexual decisions or to refuse sexual intercourse with a familiar partner (Rickert et al., 2002). Girls need to know that their bodies belong to them and that they have agency over how they choose to explore their sexuality (OJJDP, 1998).
Discourage teen girls from relationships with older men (National Campaign to Prevent Teen Pregnancy, 1999, 2003). Teenage girls who are partnering with men who are older are a serious concern among youth service providers. In such relationships, there are power differentials that put teen girls at particular risk and need to be addressed in sensitive ways. For instance, young adolescents with significantly older male partners are less likely to use contraception than those whose partners are teens (National Campaign to Prevent Teen Pregnancy, 1999). Their ability to set sexual limits may be compromised and special programs to provide skills and awareness are critical.
Tailor programs for young women who are lesbian, bisexual, or questioning their sexual identity. Girls who are lesbian, bisexual, or questioning (LBQ) their sexual identities may be disenfranchised and need specific support and help in developing a positive self-image. One study found that bisexual and lesbian youth had a pregnancy rate that was twice that of their heterosexual counterparts (Saewyc, Bearinger, Blum, & Resnick, 1999). Additionally, lesbian and bisexual young women were much more likely to have multiple pregnancies and worse pregnancy outcomes, and to have engaged in prostitution. Programming that ignores the reproductive health needs of LBQ youth can fail to recognize the risk of unintended pregnancy among this population.
Address substance use proactively. Teens who engage in one type of risky behavior are more likely to engage in other risky behaviors. Youth who start drinking or experimenting with drugs at an early age are also likely to have early sexual experiences (Kandel, 1990). One study of 14 to 21 year olds who had unplanned pregnancies found that one third of the girls had been drinking when they had sex and that for 91 percent, the sexual encounter was unplanned (Flanigan, Mclean, Hall, & Propp, 1990). The National Center on Addiction and Substance Abuse at Columbia University (1999) reports that nearly one quarter (23 percent) of sexually active teens and young adults ages 15 to 24 report having unprotected sex because of the use of alcohol or drugs at the time. Additionally, 29 percent said they “did more than they had planned” due to alcohol or other substance use. Males are more likely than females to report using alcohol or drugs at their last sexual encounter (CDC, 1999).

Implementation Tips

Get teen girls to help create a safe and nurturing physical space that reflects what is important to them.
Take time often to talk about how decisions affect relationships.
Ask girls, “How would you respond in this situation and still keep the relationship intact?”
Sponsor a mother-daughter event. Dinners or luncheons with brief workshops work well to increase participation from busy parents.
Start a “Sisters” campaign, encouraging each participant to share his or her
experience with a female friend or family member. Invite that “sister” to an event.
Be very careful with the messages you use about teen mothers. Some of your
participants could very well be the children and/or sisters of teen mothers and you do not want to characterize them poorly.
Include teen mothers as much as possible into “everyday” programming rather than making them exceptions or illustrations of “what might happen.”

Gender Specific Programs for Young Women Program Assessment .pdf

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Section 5. Male Involvement

Boys and men are increasingly recognized as an important part of adolescent pregnancy prevention efforts and reproductive health programs in the United States, as well as in many countries around the globe. Male involvement programs are still relatively new and rigorous research evaluating these programs is lacking, but we do have some information about the role male involvement programs can and should play in preventing teen pregnancies.

Adolescent boys tend to initiate sexual behaviors earlier than girls do and have more sexual partners over their lifetimes (Sonenstein et al., 1997; Henry J. Kaiser Family Foundation, 1998). Most males have monogamous sexual relationships and over half of those who are sexually experienced have one or no sexual partners in a year (Sonenstein et al., 1997). Yet young males are much less likely than girls to access health care in general, or reproductive health care specifically (Armstrong et al., 1999). This is in part because there are so few services crafted specifically to meet their needs. More and more efforts are being made to reach boys in effective ways that build on their strengths and develop them more holistically.

Since teenage girls often have sexual relationships with males who are older than they are, more programming is needed for young men in their early 20s, who are more likely to be sexually experienced, more likely to be involved in a teen pregnancy and have higher rates of sexual risk behaviors than teen boys (Bradner, Ku & Lindberg, 2000). Programs that partner with local medical and healthcare clinics should assist providers in using any contact with male clients as opportunities to address reproductive health care and provide prevention information to young men.

Male involvement programs often take more of a youth development approach. One study of a multi-component youth development program that was highly successful for females found that the same program was unsuccessful for the males who participated (Philliber et al., 2002). The recommendations based on this study of the Children’s Aid Society-Carrera Program are that better outcomes may be achieved if programs begin working with males in pre-adolescence. The negative perceptions of providers have also been obstacles in being able to reach men in effective ways. Young males have often been seen as irresponsible or “the problem,” rather than part of the solution and possessing their own valid needs (AGI, 2002). New health care standards need to be developed for the reproductive and sexual health of males.

In order for male involvement programs to have more wide-reaching success, it is vital that they reach out to young men in alternative settings beyond school and health clinics, where they may spend more of their time and where those most disenfranchised can be found. Male involvement programs vary widely in scope and often involve crucial community partnerships and coalitions. In order to fully address the issue of men’s role in pregnancy prevention, it is important to provide a safe, comfortable, and culturally competent space for young men to get information and access to services.

Research Demonstrates

The following are important factors for successful male involvement programs: • Avoid stereotypes and tailor your message carefully to address the specific needs of males (Armstrong et al., 1999). Many young men are open to changing their reproductive health behaviors if given the information and opportunity. Scolding them or assuming they do not want positive outcomes is not helpful for
engaging them. Creating a clear male-positive philosophy and making sure everyone working in the program supports it is crucial so that message comes across in every encounter. A program’s ability to attract and maintain “a critical mass of male participants” may largely depend on the philosophical approach (Sonenstein et al., 1997).

Design programs that are exclusively for teen boys and young men, not simply add-on services in a program designed for females (National Campaign to Prevent Teen Pregnancy, 1999). Tailor programs to the audience; males are different from females developmentally, emotionally, and physically. The Young Adult Clinic in New York City found that the only way to get men and boys in the door was to create the Young Men’s Clinic, a male-only session held once per week (Armstrong et al., 1999). Males need to know that their health needs are a priority in and of themselves.
Offer job training and career services in addition to reproductive health services (National Campaign to Prevent Teen Pregnancy, 1999). Prevention programs that provide job training opportunities for young men increase self-esteem and respect, which helps them avoid teen pregnancy. Additionally, Armstrong et al. (1999) found that young men are more likely to access reproductive health care clinics when the social, economic, cultural, and health needs they consider to be important are addressed as well.
Offer free condoms. There have been huge shifts in condom use among teenage males. In fact, condom use doubled between 1979 and 1988 with further increases in the 1990s (Sonenstein et al., 1997). Boys who participated in a high school condom availability program in Los Angeles reported using condoms every time they engaged in vaginal intercourse during the past year (Schuster, Bell, Berry, & Kanouse, 1997). Armstrong et al. (1999) found in their study of 529 young men who use the Young Men’s Clinic in New York City that repeat clinic visits were associated with increased condom use at the last sexual intercourse and increase partner communication about reproductive health matters. Still, many young men do not know how to properly use a condom (AGI, 2002), so it is important not to assume they do and to include information and practice whenever possible. Indeed, condoms are a primary and direct link between males and pregnancy prevention efforts.
Hire male staff or “male friendly” female staff (National Campaign to Prevent Teen Pregnancy, 1999). It is important for all program staff to examine their attitudes and beliefs about adolescent males and their roles in adolescent pregnancy. Negative attitudes transmitted through nonverbal behaviors can quickly give a program the reputation of being “unfriendly.” Hire male staff to let participants know they are welcome and that they belong. Male staff are important role models for any program aimed at reaching young men.
Assist young men in healthy fatherhood. Men need guidance and space to reflect
on and develop their own positive roles as males, to define masculinity that supports responsible sexuality and parenting, and to work towards healthy relationship skills (Oregon Department of Human Services, 2003). Young fathers need communication and relationship skills to be a positive force in their children’s lives. Fathers who are involved in their children’s lives are less likely to have sons who become teen fathers themselves (Furstenberg, 1996). A study from The University of North Carolina found that daughters are less likely to engage in early sexual activity when their fathers spend time with them in activities and develop warm, close relationships with them (Harris, 1998). Responsible and engaged fathers can have positive effects on the reproductive and sexual lives of their children.
Utilize mass media, especially television, to reach males (Bradner, Ku & Lindberg, 2000). Television and other media are a common source of health information for young males. One study showed that 91 percent of sexually experienced males ages 15 to 19 said that they got most of their information about contraception from television (Sonenstien et al., 1997). If the resources are available, savvy media campaigns can be an important tool for outreach to males, although it should not be the whole of prevention efforts or a substitute for interpersonal communication with service providers. Media may, however, be a first step in getting males involved in services. Media campaigns that include prevention messages around STI or HIV/AIDS may be helpful by addressing more pressing concerns of young men. Messages about STIs and HIV may get them to access health services. Once they are in the door, pregnancy prevention messages and overall reproductive health nurturance and guidance can occur.
Work with teen couples to help them maintain responsible behaviors and communicate well (National Campaign to Prevent Teen Pregnancy, 1999). Few programs work with couples as units even though this approach is likely to have a positive effect because it puts the burden to prevent pregnancy on both partners and allows for both partners to hear the same information. Programs should work with young couples around communication skills and encourage them to make decisions about contraception use if they are becoming sexually active.
Address substance use proactively. Teens who engage in one type of risky behavior are more likely to engage in other risky behaviors. Youth who start drinking or experimenting with drugs at an early age are also likely to have early sexual experiences (Kandel, 1990). Of teenage males who report using illegal drugs in the past 12 months, including marijuana, cocaine, crack, and injection drugs, three-fourths are sexually experienced (Sonenstein et al, 1997). The National Center on Addiction and Substance Abuse at Columbia University (1999) reports that nearly one quarter (23 percent) of sexually active teens and young adults ages 15 to 24 report having unprotected sex because of the use of alcohol or drugs at the time. Additionally, 29 percent said they “did more than they had planned” due to alcohol or other substance use. Males are more likely than females to report using alcohol or drugs at their last sexual encounter (CDC, 1999), which underlies a need to address connections between drug and alcohol use and sexual behavior with males.
Deal with complex issues contributing to violence and sexual assault. A study showed that of women who reported experiencing a rape, 54 percent were younger than 18 at the time, while 22 percent were 12 years old or younger (Tjaden & Thoennes, 2000). The same study showed that nearly 75 percent of the men involved in rape or sexual assault against women were their intimate partners–be they husbands, boyfriends, or cohabiting partners. Complex social, cultural, and other factors pertaining to specific events contribute to male violence directed at women. Unfortunately, violence against women is common during pregnancy. In a survey of 14 states, it was found that 9 percent of women who had had a child in the previous 2 to 6 months had experienced some form of physical violence or abuse during their pregnancy. Women were more at risk for violence during pregnancy if they were teenagers (19 percent), if the pregnancy was unwanted (15 percent) or mistimed (13 percent), if they were black (14 percent), or unmarried (18 percent), if they were Medicaid recipients (21 percent), and if their partners did not want the pregnancy (24 percent) (Gazmararian et al., 2000). Violence is associated with unintended pregnancies and while further research is needed in this area, it is important to develop prevention strategies and interventions that can address the complex emotional and social issues that affect men who may cause a pregnancy. In addition to addressing men as perpetrators, men are also targets of sexual assault, which certainly affects men’s reproductive and sexual health.
Create an inviting, male-positive environment. The environment of a clinic or other service center should display positive images of men and be an engaging space that men can feel comfortable and have fun in (Oregon Department of Human Services, 2003). Involve men in making the space their so that it truly reflects who they are and becomes a place where they want to spend their time.

Implementation Tips

Gather information about the community and the male population before implementing your program through formal needs assessments, focus groups, or other informal feedback. Find out what participants are interested in.
Consider the things that are important to males in your community and connect with those activities.
Partner with a local sports league or community center that already has programs that attract males.
Develop strong ties with the community and work to build trust and a positive working relationship.
Use messages that are positive. Negative messages may put young men on the defensive and be ineffective.
Hire and retain male staff.
Create opportunities for young males to redefine “manliness” or what it means to “be a man” in their own terms. Having a male facilitator who can act as a positive role model and who is perceived by the young men as “manly” is important.
Offer incentives for participation that appeal to males (movie tickets, gift certificates, music, CDs, etc.).

Male Involvement Program Assessment .pdf

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Section 6. Multi-Component

Since there are so many antecedents to adolescent pregnancy, a variety of adolescent pregnancy prevention approaches are needed to effectively reach diverse populations of youth. Some approaches work for some groups of youth, while others do not. It makes sense that some of the most promising approaches address sexual and non-sexual antecedents to teen pregnancy in a variety of ways. Multi-component programs include classroom instruction, school-wide activities, provision of contraception, media campaigns, and may even include service provision by multiple providers (Kirby, 1997). Multi-component programs can directly address the reproductive health and sexual behavior of teens, while also helping them develop as individuals in more holistic ways. Simplistic solutions will not stem the tide of teen pregnancy. When designing a program, it is important that agencies take a close look at the risk factors and potential protective factors they can foster in their youth, while being realistic about which ones can be effectively addressed.

While using a multi-component approach appears to be desirable for a number of reasons, simply having multiple components will not assure that your program will work (Kirby, 1997). The most effective programs tend to be the most intensive and programs must be maintained for continued success. A few multi-component programs have shown success, but when they ended, use of condoms and/or pregnancy rates returned to their pre-program levels (Kirby, 1997). It is clear that multi-component programs need sustained effort and long-term commitment. The Children’s Aid Society-Carrera Program is a primary example of how a multi- component program can work. This program combines sexuality education, comprehensive health care, including mental health and reproductive health services. In addition, this program incorporates job-readiness activities, sports activities, and artistic self-expression.

The Children’s Aid Society-Carrera Program actively addresses sexual behavior of youth, while working on other fronts to create resiliency, skills, and opportunities for personal and professional growth. This program was found to be highly effective with females, but not effective for males over a three-year period (Philliber et al., 2002; Kirby, 2001). Part of its strength is its intensity and duration, which makes this program expensive.

Many multi-component programs have not reduced the incidence of teen pregnancy or changed sexual behaviors. Replication of programs and more research is needed to get a clearer picture of attributes that make multi-component programs effective with specific populations of youth.

Research Demonstrates

Antecedents of adolescent pregnancy exist at the individual, family, and community level and include biological, psychological, social, economic, and political factors. A multidisciplinary approach looks at a variety of these factors when developing programs, so suggestions from any of the previous sections can all be part of a multi-component approach. The following are additional points that are important to consider when providing multi-component programming:

Address issues on multiple fronts on an ongoing basis. The most effective programs involve teens for many months or years. Intensive long-term programs that address both the reproductive health needs and other emotional and social needs of youth can have a substantial long-term impact on pregnancy prevention (Kirby, 2001). Programs that can sustain intensity for at least five years will have greatest impact on social norms because new teens come into the mix each year and are influenced by the established norms of the group (National Campaign to Prevent Teen Pregnancy, 1999).
Work with parents and community leaders (National Campaign to Prevent Teen Pregnancy, 1999, 2003). Effective programs emphasize building a healthy family and community. Research shows connections between youth who have close relationships with their parents, and choose sexual abstinence or postponement, have fewer sexual partners, and practice consistent use of contraception (National Campaign to Prevent Teen Pregnancy, 1999). Close connection to caregivers, particularly mothers, is shown to have a strong positive effect on young people. It is optimal that youth get messages at home that are consistent with those of your program. Getting parents actively involved can be challenging and requires creative thinking from program staff. Any opportunity to assist parents in healthy communication about sexuality with their children will greatly enhance program messages.
Start prevention efforts before young people begin to feel sexual pressure (National Campaign to Prevent Teen Pregnancy, 1999, 2003). Reports by teens show that they feel pressure about sex by the start of middle school. The Henry J. Kaiser Family Foundation survey (1998) found that teens were dealing with complex sexual situations by ages 13 or 14. These situations often involved alcohol and drug use, relationships moving too fast, and other pressure situations that require forethought and skills to navigate. Mid-adolescence is too late–young people begin to reject messages about postponing sexual involvement by age 15. Programs need to reach youth before they are already in those situations.
Conduct outreach in non-traditional spaces. Some of the teens at highest risk are least likely to be attending school (National Campaign to Prevent Teen Pregnancy, 1999). Research indicates that school attendance correlates with fewer pregnancies. Those not attending school at all are more likely to have or cause a teenage pregnancy. It is important to meet both male and female teens where they are. This may mean doing street outreach to specific hang-out areas or connecting to other recreational spaces in the community. For older males, it could mean outreach in the workplace.
Deal with issues related to drug and alcohol use (National Campaign to Prevent Teen Pregnancy, 1999). Drug and alcohol use is often associated with sexual risk-taking by teens. Teens who engage in one type of risky behavior are more likely to engage in other risky behaviors. Youth who start drinking or experimenting with drugs at an early age are also likely to have early sexual experiences (Kandel, 1990). One study of 14 to 21 year olds who had unplanned pregnancies found that 33 percent of the girls had been drinking when they had sex. The same study found that 91 percent of the sexual encounters were unplanned (Flanigan et al., 1990). The National Center on Addiction and Substance Abuse at Columbia University (1999) reports that nearly one quarter (23 percent) of sexually active teens and young adults ages 15 to 24 report having unprotected sex because of the use of alcohol or drugs at the time. Additionally, 29 percent said they “did more than they had planned” due to alcohol or other substance use. Males were more likely than females to report using alcohol or drugs at their last sexual encounter (CDC, 1999).
Include a community service component. Of all broader youth development approaches, service-learning programs have shown the most promising success (Kirby, 2001). Service learning, with opportunities for reflection on the experience, gives young people an opportunity to connect to their community and to give back, which helps them develop their sense of identity, competence, and connectedness to others.
Involve youth in developing programs that meet their needs and keep them involved over the long term. When youth feel a sense of ownership over the program they will be more invested in it and more likely to stay involved. Everyone benefits from young people’s input in creating programs that interest and excite them.
Create leadership opportunities for youth. In order to build skills, confidence, and a sense of control over their lives, youth need opportunities to lead, to take responsibility, and to make a difference. Build on young people’s strengths and give them opportunities to excel. Building on their assets will increase self-esteem, self-worth, and motivate them to mature into healthy adults (Lezin, 2002).

Implementation Tips

Work specifically with teens on skills to help them communicate effectively with adults and encourage them to communicate with parents or caregivers.
Include parents as much as possible in your programming.
Find out where young people in your community spend their free time (whether they are in school or out) and target your media messages to those areas (pamphlets, flyers, etc.).
Talk often, specifically about drug and alcohol use, its consequences, and potential negative outcomes.
Seek sponsorship for programs from local businesses that can offer training or career readiness experiences for your teens.
Partner with organizations that offer job-readiness or summer job opportunities.
Build partnerships with local faith organizations by asking leaders there what they believe would be helpful to their teens.

Multi-Component Programming Program Assessment .pdf

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