August 2000 // Volume 38 // Number 4 // Feature Articles // 4FEA1
Teen Pregnancy Prevention Programs: Linking Research and Practice
Although the overall rate of teen pregnancy in the United States has been declining, rates have remained high for younger unmarried teens. Evaluation studies of pregnancy prevention programs indicate that many are ineffective or not well evaluated. The focus of this article is to identify and share 10 suggested "best practices" from the field and literature. Three critical practices identified are: a youth development component, family involvement, and culturally relevant practices. Implications for Cooperative Extension programming are discussed.
The United States has the highest teen pregnancy rate of any industrialized country, and California continues to have one of the highest teen pregnancy rates in the nation. Although the overall rate of teen pregnancy has been declining since 1991, the rates have remained high for teens who are most vulnerable, such as younger unmarried teens. The national unmarried teen birth rate steadily decreased from 62 in 1991 to 54 births per 1,000 females in 1996--a 12% decline. The teen birth rate decreased among all races (Annie E. Casey Foundation, 1998).
Comparable to the rest of the nation, California's teen pregnancy rates have also decreased since 1991 by 16%. In 1996, the teen birth rate was 63 births per 1000 females. Although the teen (ages 15-19) birth rate in California has also decreased among all races since 1991, Hispanic teens showed the smallest decrease, from 122 in 1991 to 104 births per 1,000 females in 1996--a 15% decline. This is compared to a 23% decrease in African Americans and a 24% decrease in Non-Hispanic Whites (Annie E. Casey Foundation, 1998).
California's population of 13-19 year olds is expected to increase dramatically to 6 million (a 35% increase) by the year 2005. This is compared to an expected 13% increase in teens nationally. Unless the teen birth rate declines markedly, there will be a significant increase in the number of pregnant and parenting teens. By 2005, Hispanic youth will be the largest ethnic youth group (California Department of Health Services, 2000).
The persistent and complex problem of teen pregnancy prompted Cooperative Extension Human Resource (Family & Consumer Sciences and Youth Development) staff in three urban California counties, San Francisco, San Mateo, and Santa Clara, to jointly focus efforts on a research project in this area. These three urban San Francisco Bay Area counties have a combined population of nearly two million, with an increasing ethnic diversity that is presently 20% Hispanic, 25% Asian, 6% African American, and 49% Caucasian (1999, Association of Bay Area Governments Data Center).
What role might Cooperative Extension play in strengthening community-based programs working with pregnant and parenting teens? We synthesize "best practices" from the literature and from the field, and work with community practitioners to implement these practices as a model for improved teen pregnancy prevention.
Literature Review of "Best Practices"
Major reviews of best practices aimed at preventing adolescent pregnancy have generally focused on organized programs (Card et al., 1996; Franklin & Corcoran, 2000; Frost & Forrest, 1995; Kirby, 1997; Miller et al., 1992; Moore et al., 1995). The National Campaign to Prevent Teen Pregnancy recently released a comprehensive report reviewing research on the roles of parents and families in reducing teen pregnancy (Miller, 1998). This document indicates the important influence of parents/families in preventing teen pregnancy and highlights programs that are culturally sensitive.
Adolescent pregnancy is a complex problem. There is no single or simple approach that will reduce adolescent pregnancy among all groups of teenagers. Because the causes of teen pregnancy are complicated, the strategies should be multi-pronged (Kirby, 1997).
Over the past two decades, there has been dramatic growth in the number and variety of programs aimed at preventing adolescent pregnancy. These have included education programs, family planning/contraceptive services, school-based health centers, youth development programs, and multi-component programs. Unfortunately, recent comprehensive reviews of adolescent pregnancy prevention programs concluded that few programs have been well evaluated. Of those that have been evaluated, none have been significantly successful in reducing adolescent pregnancy. However, although there are studies that indicate that some programs can have some success at reducing one or more sexual behaviors for at least a brief period of time, few studies have measured long-term effects (Kirby, 1997, 1999; Moore et al., 1995).
There are several examples of creative programmatic approaches that have shown to be promising. The National Campaign to Prevent Teen Pregnancy (Kirby, 1997) examined nearly 200 research articles on more than 75 programs and recommended components that should be integrated into more comprehensive pregnancy prevention initiatives.
An Assessment of Current Practices
Assessments of schools and community agencies with teen pregnancy prevention programs in San Francisco, San Mateo, and Santa Clara (California) counties were conducted using surveys, interviews, and site visits.
Thirty-five surveys were sent to schools and agencies known to have pregnant and parenting teen programs, as well as to programs trying to prevent first pregnancies in teens. Every attempt was made to reach as many programs as possible through advisors, networks, coalitions, directories, and staff. Telephone calls and reminders (mail and fax) were made to programs with unreturned surveys. After second mailings, phone calls, and faxes, we received 18 completed surveys, or a 51% response rate. In addition, 25 programs were visited. Staff members were interviewed at these site visits to get more details of their programs and complete the surveys. As a result, 23 surveys were completed (a 66% response rate).
A wide variety of primary prevention efforts was found in clinics, schools, and community agencies. A school district from each county has received a 5-year grant from the California Department of Education for primary pregnancy prevention. In addition, 11 local community-based agencies, schools, and clinics have received California Department of Health Services Community Challenge Grants for primary prevention. All three counties have adolescent sibling pregnancy prevention programs, targeting the high-risk siblings of pregnant/parenting teens. In addition, a few male involvement programs have been included in teen pregnancy prevention efforts. School-based (or school-linked) health clinics also deliver pregnancy prevention services. The primary prevention programs represent a broad spectrum of services focused on the local, specific target population.
Secondary pregnancy prevention programs, providing services and care to pregnant and parenting teenagers, were also surveyed and visited. These included county health services/public health programs, such as Adolescent Family Life Programs (intervention and case management) and Cal-Learn (for Temporary Assistance for Needy Families recipients); school programs, such as Pregnant Minors Program and School Age Parent and Infant Development Program; and community agency programs (home visitation to teen parents).
We identified and applied the following criteria to distill "best practices" based on knowledge gained from the literature and field. It is not always easy or even possible to incorporate all criteria into every program, but these criteria can provide a starting point for assessing program strengths and weaknesses in program efforts.
1. Is the best practice research-based?
2. Does evaluation show positive impact?
3. Does the best practice meet the needs of multi-ethnic audiences? Is the best practice culturally relevant?
4. Does it meet the needs of various socio-economic populations?
5. Does the identified best practice have application in a variety of settings?
6. Is it sustainable? Does it stand the test of time?
Using local program information, as many of these criteria as possible, and additional reviews (Card et al., 1996; Franklin & Corcoran, 2000; Hutchins, 1999; Kirby, 1999; Miller, 1998; Moore et al., 1995; Sonenstein, 1997), we identified the following 10 best practices for practitioners in teen pregnancy prevention (Gong, et al., 1999):
- Youth Development
- Involvement of Family and Other Caring Adults
- Male Involvement
- Cultural Relevance
- Community-Wide Campaigns
- Service Learning Programs
- Programs to Improve Employment Opportunities
- Sexuality Education and AIDS Education Programs
- Outreach in Teen Pregnancy Prevention Programs
- Access to Reproductive Health Services
The Role of Cooperative Extension in Teen Pregnancy Prevention
Of these best practices, we identified three to emphasize in partnering with local agencies to strengthen their practices and produce better outcomes for teens: youth development, family involvement, and cultural relevance. We chose these three because of Cooperative Extension's historic experience and expertise in these areas. Many of the community agencies have youth development and family components. However, schools with pregnant and parenting programs usually have difficulty incorporating family involvement. Practitioners expressed a need for more culturally relevant practices.
Youth development programs focus on supporting and encouraging young people, on providing young people with skills that will help them succeed as adults, and on helping them form meaningful relationships with adults and older peers. Young people need opportunities to acquire a broad range of skills and to build connections within their community. There is a strong relationship between educational and career plans and protection from adolescent pregnancy. Improving girls' education and life options are correlated with reduced pregnancy and birth rates (Kirby, D., 1997).
Recently, there has been a rapid growth of interest in youth development in teen pregnancy prevention efforts. National organizations have recognized youth development as a promising approach to reducing adolescent pregnancy (National Campaign to Prevent Teen Pregnancy, 1998). In addition, some federal agencies are supporting youth development models in adolescent pregnancy prevention (Family and Youth Services Bureau/U.S. Department of health and Human Services, and Community Coalition Partnership/Centers for Disease Control and Prevention). In California, the Departments of Education and Health Services have large initiatives to develop and implement youth development programs to reduce teen pregnancy.
Critical elements of a youth development program include the following characteristics:
- being responsive to the needs and interests of youth and their community;
- staff are knowledgeable about adolescent development and are trained to work with youth;
- young people are regarded as resources in planning and program development; and
- the program collaborates with community organizations, government agencies, schools and families (Carnegie, 1996).
Service learning is one aspect of a youth development program that has a positive impact in reducing teen pregnancy. Service learning results when community service, the experiential learning process, and disciplined reflection are combined. Evaluations of a service learning program, from data collected across the nation, have provided some of the most consistent and strongest evidence that youth development has reduced teen pregnancy (Allen et al., 1997; Philliber and Allen, 1992). In addition to reduced pregnancy rates, service learning was effective in reducing problem behaviors, school suspensions, and school dropouts.
Cooperative Extension has a comparative advantage in youth development and has played a key role in developing programs such as academic enrichment, sports, job training, mentoring, community service, service learning, and leadership development. The role of Cooperative Extension is to continue promoting youth development programs and to document the positive impact these programs have on adolescents, specifically pregnant and parenting teens.
Involvement of Family and Other Caring Adults
While some of the programs surveyed involved families and other caring adults, most did not. Family dynamics are embedded in culture. Programs need a broad perspective, including strategies that develop family strengths and enhance parenting skills, and provide information about reproduction and contraceptive services (Moore et al., 1995).
Families play a critical role in affecting the risk of adolescent pregnancy. Family involvement should complement any program's best practices recommendations (Moore et al., 1995). The following factors have been noted to reduce the risk of adolescent pregnancy: parents with higher education and income; parental supervision; parents who hold strong opinions about the value of abstinence (or protected intercourse); teens who have supportive family relationships (connectedness) (Miller, 1998); and teens who participate in a large number of shared activities with parents (Resnick et al., 1997). The following factors can increase the risk for adolescent pregnancy: little supervision for teens; strict/overly controlling parents; low socioeconomic status; a single parent; older, sexually active siblings or pregnant/parenting teenage sisters (Miller, 1998); lack of religious affiliation (Kirby, 1997); and the experience of violence or abuse (Miller, 1998).
Family members, particularly parents if appropriate, need to be incorporated into teen pregnancy prevention programs in order to enhance the life opportunities of pregnant and parenting teenagers and their infants (Hanson, 1992). The complexities of multigenerational families need to be addressed (Chase-Lansdale et al., 1992). Although family involvement is labor-intensive, involving families and developing stronger family connectedness are recommended best practices in adolescent pregnancy prevention efforts.
An appropriate role for Cooperative Extension is to promote family involvement to practitioners working with pregnant and parenting teens, and to document the involvement efforts through formative and summative evaluation.
Choosing culturally appropriate and locally relevant interventions will increase the effectiveness of efforts to reduce teen pregnancy. Understanding and sensitivity to the cultural and individual needs of the population are important in the design and implementation of any program.
According to the National Council of La Raza, Hispanic teens 15-19 years of age are twice as likely to become parents as Caucasian teens. Hispanic teenage mothers are considerably less likely to complete high school. A large percentage of Hispanic teen births are out-of-wedlock, contributing to the increase in single-parent families and the greater likelihood that these girls and their children will spend some or all of their lives in poverty (Perez and Duany, 1992). The Latino population is the fastest growing major racial/ethnic group in the United States; Latinas have the highest teen birth rate among major groups in the U.S. (National Campaign to Prevent Teen Pregnancy, May 1999).
The National Council of La Raza identified key characteristics of effective programs targeting Hispanic pregnant and parenting teens (Perez and Duany, 1992). These include recognizing and sensitively responding to cultural values regarding gender roles; for example, some Hispanic teen mothers might not immediately see the importance of becoming self-sufficient.
Adolescent pregnancy in the Hispanic community warrants attention; however, research on this group is limited. Programs targeting Hispanic sub-groups have been identified, but rigorous evaluations are lacking.
Cooperative Extension has extensive experience and knowledge in working with multicultural populations through both the Expanded Food and Nutrition Education Program and the 4-H Youth Development Program. In conducting the literature review, we found limited science-based information on culturally appropriate practices with Hispanics, African Americans, and Asian Americans. Our challenge is to conduct applied research in this multicultural context to identify culturally appropriate practices that work with pregnant and parenting teens.
This article focused on suggested "best practices" from the literature and from the field, and identified the role that Cooperative Extension can play to strengthen community-based programs to improve outcomes for teen parents and their children, with a focus on multi-ethnic teenagers living in urban communities. Multiple strategies for addressing the risk factors of adolescent sexual behaviors, pregnancy, and childbearing are recommended.
For our communities in San Francisco, San Mateo, and Santa Clara Counties, we focused on the "best practices" of including youth development, involvement of family and other caring adults, and culturally relevant practices to provide activities to encourage teens to think about the future and life opportunities. With the large percentage of Hispanic adolescent pregnancies, it is important to address the unique characteristics and needs of this group.
We are currently partnering with six local sites that conduct teen pregnancy prevention programs, to strengthen their capacity to deliver improved programs by incorporating the "best practices" identified in our literature and field research. We are working now to provide technical assistance in the adoption and implementation of "best practices" and in program evaluation. In this way, we renew our historic role as providers of science-based information in response to a contemporary need in our communities.
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