Because of the continuing unacceptably high birth rate among young people, preventing teenage pregnancy raises some questions that need to be answered. For example, what do we know about approaches that might be used to reduce teenage pregnancy? What can we learn from past program attempts? What new program models appear to hold promise? Also, we need to ask if we have accepted some answers that hinder our understanding of what needs to be done to reduce teen pregnancy.
A decade ago, Richard Jessor described experimentation with many of the behaviors that place youth at risk for potentially harmful outcomes (smoking, drinking, early sex, and drug use) as becoming the norm for adolescents. He theorized that these behaviors are chosen by young people in a purposeful way-they serve as functional transition markers, helping young people move from a more childlike state to self and peer affirmation of a more adult status. One can become a drinker as opposed to a nondrinker, a smoker as opposed to a nonsmoker, and sexually experienced as opposed to being a virgin. Society legitimizes these markers by defining an age below which the behaviors are deemed to be inappropriate and, therefore, illegal. For example, there is an age below which one is not allowed to drink, an age below which one is not permitted to buy cigarettes, and an age below which an act of sexual intercourse is considered a crime (statutory rape). Therefore, certain behaviors are associated formally with a more grown' up status.
At one time, smoking, drinking, or having sex was thought to be engaged in only by so-called problem youth; now such behavior has become part of the adolescent experience. Currently, 8 million of the nation's 30 million 7th to 12th grade students drink almost weekly. Moreover, 41% of white youth, 17% of black youth, and 32% of Hispanic youth smoke. Half of all high school seniors have had some experience with marijuana. The average age of first intercourse for American teens is 15.2 for girls and 15.7 for boys. Jessor concluded that telling youth to "just say no"-that is, never to engage in such behaviors, is unrealistic. Instead, he suggested three approaches to help youth manage their participation in such behaviors: insulation, minimization, and delay of onset.
As applied to interventions in the field of teenage pregnancy prevention, it is clear that insulating young people from the harmful effects of sexual behavior has been the path most chosen over the last two decades by health professionals and the one still most strongly advocated. Because pregnancy at a young age is recognized to be harmful to both the teenage parents and their offspring, proponents of health service intervention have pushed for provision of birth control services to young people, considering use of contraceptives as potentially the most successful intervention in pregnancy prevention.
The difficulty in applying this insulating approach has been the ambivalence of society regarding sexual behavior, particularly sexual behavior among young people. Although there generally has been positive acceptance of other health measures designed to protect children-such as childhood immunizations-there has been no such mandate for contraceptive use. For example, it is acceptable for schools to require immunizations before children can attend, but schools become battlegrounds when condom distribution is suggested. Schools may allow comprehensive health services to be set up within their walls but the provision of birth control devices in such health centers may be forbidden. Even the notion of providing factual information in school classrooms about the various kinds of birth control methods and how to use them effectively has met with strong opposition from many sources.
Adults who wonder why adolescents do not use contraceptives often cannot conceptualize the world as it is experienced by adolescents-a world in which confusing and conflicting messages occur. For example, there is no advertising of contraceptives on television, even for adults. There is no role modeling in the movies or on television of adults using contraceptives either as a part of daily lives (such as taking a birth control pill in the morning) or using methods precoitally (such as foam and condoms). There are no sanctioned supportive measures such as using school buses to transport young people to health facilities to obtain birth control. Because society is fundamentally ambivalent about sexual behavior among youth, there are no public attitudes that make teenage contracep' tive users "heroes" or "heroines" in their own lives-no one conveys they are proud of youth who use contraception. When birth control information is given to young people, there are no "pep talks" or rallies to support its use. There are no incentives or rewards.
Most often, it is left to each individual adolescent to overcome their own ignorance and concerns about birth control, to find their own motivation to use birth control, to arrange their own transportation to get to services, and to develop their own courage to face adults, many of whom are likely to disapprove of adolescent sexual behavior and, by association, their need for and use of contraception. Lack of perceived parental support for contraceptive use further complicates adolescent efficacy in this area. One study of suburban youth indicated that over 40% of adolescents would seek birth control only if their parents didn't know.
Given this climate, it is not surprising that numbers of school-aged youth do not use contraception at first intercourse nor with consistency on subsequent occasions. It also is not surprising that sex education by itself does not improve contraceptive use by adolescents under the age of 17. For example, a knowledgeable 13 year old is no more likely to use contraceptives than is an uninformed 13 year old. Only when adolescents are older and reach some kind of independence and psychosocial maturity do they seem to be able to use birth control with any degree of consistency and effectiveness. The 400 000 abortions performed on teenage girls annually are vivid testimony to the fact that adolescents do not use contraception well even in the face of totally unwanted pregnancies.
Another suggested strategy is to help young people minimize their involvement in sexual behavior, thereby reducing the likelihood of harmful outcomes. This might include limiting involvement in sex to shortterm experimentation or limiting the number of partners an adolescent might have over an extended period. Although pregnancy can occur at any time, satisfying curiosity about sex, particularly if birth control is used, and then not engaging in sexual relations further could reduce the possibility of pregnancy. Because adolescents who obtain birth control have difficulty using it consistently, minimization of sexual involvement could reduce the likelihood of pregnancy even among youth who have sought out contraceptive methods. This approach rarely has been tried with adolescents. Because of societal ambivalence about teenage sexual involvement, interventions aimed at minimizing (not preventing) sexual involvement have not been forthcoming. And because it is difficult for the adolescent to envision the future and thus the number of dating partners they may have beyond their teen years, they may not set limits on themselves without outside intervention. Often they think that the particular person they are sexually attracted to at the moment will be in their lives forever.
Minimization has been applied to reduction of teenage pregnancy. Sixty percent of adolescents under age 16 who give birth to a child are likely, without intervention, to give birth to another child while still of school age. Rapid repeat childbearing is associated with increased risk for poor pregnancy outcome. Therefore, some programs have been designed to provide interconceptional care to adolescents who already have given birth to one child. They focus on minimizing the amount of childbearing at a young age, helping young people delay further childbirths until they are older. Such programs are heavily oriented toward birth control but also can help the young mother find child care, get back in school if she has dropped out, undertake job training, and solve other problems that may have led to or been caused by the pregnancy. Research on one such program indicated that with intensive intervention, 80% of lowincome minority youth who give birth at the age of 16 years and younger can be helped to remain pregnancy free until they are out of their teens. However, this approach to minimization still makes the young person pay a "one pregnancy penalty" before intensive support is given.
DELAY OF ONSET
Yet another approach is to help adolescents delay the onset of behaviors that have potentially harmful consequences. This approach may be a particularly appropriate one for application to sexual behavior, as sexual intercourse is the one behavior-as opposed to smoking, drinking, or drug use-that adults expect and want young people to engage in later on in life.
Delaying the onset of sexual behaviors has long been an implicit approach to preventing teenage pregnancy. Most of the older adults in our society grew up in a time when it was generally understood by adults and youth alike that young people were not to have sexual intercourse. However, recently it has been necessary to make messages about remaining abstinent more explicit. This alternation has been needed because of a change in adult sexual values and behaviors that has led to a change in adolescent sexual behavior. In the 1970s, abstinence among adolescents was the norm. For example, only 4.7% of 15-year-old girls had sexual intercourse. By the late 1980s, however, more than five times as many girls were sexually involved at that age. The inappropriateness of elementary and junior high students becoming sexually involved galvanized thinking about the need to give actual assistance to young people to help them remain abstinent, particularly as many such adolescents indicated what they most wanted to know was how to say no without hurting the other person's feelings, and the majority of sexually involved youth were saying they had sexual intercourse because of social and peer pressures.
The philosophy of "delaying onset" is to allow young people to postpone behaviors with potentially harmful consequences until they are older and can see more clearly the implications of their behavior on their future. The delay also is intended to help young people postpone such behaviors until they are old enough to take full responsibility for the consequences of their actions.
WHAT PROGRAMS WORK?
One question that needs to be answered is what kinds of intervention programs show promise in reducing teenage pregnancy? Indeed, several categories of programs have been developed-some focus on abstinence only, others focus on increases in knowledge including detailed instruction about birth control use. Still others combine abstinence education with support for use of birth control, and others substitute or add an actual health services component to the mix. A final model deals with life skills and options.
At one time, the beginning of sexual activity more nearly coincided with what was considered to be a practical age for marriage-around 17 or 18 years of age. This occurred at a point when it was not necessary for young people to have a high school diploma to find work, and careers for young women were not emphasized. In contrast, young people today are expected minimally to have completed high school, usually to have gone on for further education and training, and probably to have worked for awhile before undertaking marriage and childbearing. For many young people, that places the appropriate time for marriage in the mid-to-late 20s. Therefore, a new generation of programs has sprung up trying to help young people delay sexual intercourse for a longer period of time than was needed in the past-that is, until marriage at an older age.
Abstinence-only programs, however, have been caught in a crossfire between those who feel young people should postpone sexual intercourse until marriage and those who support abstinence education but feel young people need only postpone sexual intercourse until they are more mature and skilled, and thus more likely to be able to handle sexual involvement in a responsible fashion.
Research evidence to date does not indicate that this new generation of programs produces the desired results. In 1990, based on an analysis of data presented on several abstinence-only programs, plus their own evaluation of an abstinence program entitled "Success Express," researchers Roosa and Christopher concluded that there is "no support for the notion that this type of primary prevention program will be successful in achieving its ultimate goal-reducing teen pregnancy rates in the communities served." Although current studies underway on other abstinence-only programs may modify such conclusions, at present such efforts do not seem to offer promise for reducing teen pregnancy. However, abstinence-focused programs given in combination with information about reproductive health and family planning do appear to have an effect on reduction of sexual involvement.
Programs designed to give young people knowledge about their bodies and contraceptives have not been much more effective than abstinence programs. In an evaluation of 28 exemplary sex education programs, Kirby found that although young people learned a great deal from such programs, the information gained did not have an important effect on their behaviors. The youth involved were not more likely to postpone sexual involvement nor, over time, to use contraceptives. Some large cross-sectional studies since then have tended to show some positive correlation between sex education and use of contraceptives, particularly among older adolescents but do not seem to be helpful to adolescents in reducing the amount of sexual activity. Furthermore, the marginal increases in contraceptive use do not appear likely to have a great impact on teenage pregnancy.
There was much optimism that clinics based in schools would prove to be a key to reducing adolescent pregnancy and, indeed, early reports seemed to document that effect. However, more careful research and a reanalysis of some earlier program data appears to indicate that school-based clinics do not show a dramatic impact on the use of contraceptives or a real reduction in birth rates. For example, some school-based clinic data are misleading because of a displacement effect-although young people use birth control services at the school-based clinics, some of these youth already were doing so elsewhere and switched providers. That is not to say that school-based clinics do not provide a meaningful health-care function and do not make contraception more available to larger numbers of youth. It appears that their establishment primarily to decrease teenage pregnancy is not cost effective at present.
Multiple Intervention Approaches
One group of programs that appears to offer more promise are those that incorporate more than one approach. These more successful programs combine a number of elements aimed at helping young people manage their sexual behavior, both refraining from sexual activity and protecting themselves if they do have sexual intercourse. A few examples of these kinds of programs are Reducing the Risk, Postponing Sexual Involvement, the Baltimore Pregnancy Prevention Program, and the Group Cognitive-Behavioral Training Program. These programs tend not to be didactic but are more experiential for young people and help them to personalize risks. Such programs are developmentally appropriate, presenting information and services one way to younger adolescents and another way to older adolescents. They also are skill-based, helping young people actually develop abilities to deal with social and peer pressures toward sexual involvement or negotiate systems and interpersonal relationships to obtain and use birth control. These programs try to change perceptions of peer norms-making it more acceptable to refrain from sexual activity or more acceptable to use contraception. Such programs are value based-often they are designed to support a given value-such as avoidance of sexual intercourse at a young age or avoidance of pregnancy at young ages. Some of the programs also are linked to health-care settings that offer birth control services.
Figure. Percentage of youth who remained abstinent post-program by grade.
Several such successful program models have received intensive evaluation. These programs have demonstrated reduction in sexual involvement, increase in birth control use, and reduction in teenage pregnancy. If such programs show promise, it is important to ask if they are being replicated. Indeed, although one or two of the programs are being widely used (albeit sometimes in part, not in whole) most of the programs that demonstrated a positive impact on youth behaviors and a reduction in teenage pregnancy are no longer in existence. Thus, it would appear that widespread adoption of proven models is not related to demonstrated success alone, and reduction of teenage pregnancy may well be a far more complex task than is usually envisioned from a program development and evaluation point of view.
One widely disseminated program model, Postponing Sexual Involvement for Young Teens and Postponing Sexual Involvement in Preteens, consists of a module for delaying sexual involvement that is structured so it can be given independently or added to other program modules. Postponing Sexual Involvement provides information designed to help adolescents explore attitudes and feelings about managing physical feelings within relationships. It also teaches adolescents skills to resist social and peer pressures to become sexually involved. As implemented in its home community of Atlanta, Georgia, Postponing Sexual Involvement for Young Teens was added to a Human Sexuality module that provided factual information on anatomy and physiology of the reproductive system, becoming a parent, sexually transmitted diseases, birth control, and decision-making. One unique feature of the combined program was that family planning counselors from a local hospital taught the five classroom periods of the Human Sexuality part of the program while trained 11th and 12th grade Teen Leaders presented the five classroom periods of the Postponing Sexual Involvement for Young Teens part of the program under the supervision of the family planning counselors.
Implemented in middle schools with all 8th grade students in a large school system, the two-module program was able to significantly delay sexual involvement throughout both the 8th and 9th grades among low-income male and female youth who were given the program compared with their counterparts who did not have the program. More than 4000 youth were given the program; however, the evaluation was done on a sample of 685 of the poorest youth in the area. In the 8th grade, youth who did not have the program were four to five times more likely to become sexually involved. At the end of the 9th grade, there was still a one-third reduction in sexual involvement of boys and girls who had the program as opposed to those who had not participated.
Moreover, at the end of the 9th grade, youth who had the combined program were more likely to use birth control and twice as likely to say they used it because of what they learned in school. Although increasing numbers of youth became sexually involved from the 10th through the 12th grades, there was still a difference between the study and comparison groups with respect to sexual involvement at the end of the 12th grade. (Youth who had dropped out of school were followed as well as youth who were still in school at the end of the 12th grade.) Data indicated clearly that those given the combined Postponing Sexual Involvement and Human Sexuality modules delayed sexual involvement longer than the comparison group throughout the 5-year study period, as shown in the Figure.
Because of the small sample size, it is important to view the data on pregnancies generated from the Ford Foundation-funded Postponing Sexual Involvement research study with caution. At the end of the 9th grade, there was a one-third reduction in pregnancies among female youth who had not yet had sex when they had the program. However, it is important to note that this reduction was based on the programs primary effectiveness-reducing sexual involvement-because once sexually involved, the differences between the two groups disappeared. The findings on both sexual involvement and pregnancy rates for females were validated by a hospital record search conducted 10 months after students had completed the 9th grade.
At the end of the 12th grade, when increased numbers of youth had become sexually involved, there was a 13% difference in involvement in the number of pregnancies (not statistically significant) between youth who had the program and those who had not had it, based on a hospital record search conducted 10 months following the end of 12th grade combined with the self-reports given at the end of the 12th grade. It is important to note that although the program's primary effect on preventing pregnancy occurred in the lower grades, that finding has enhanced value because the younger the girl, the greater the risk of poor pregnancy outcome.
However, for those interested in pregnancy prevention among school-aged youth until high school completion, the results are discouraging. As increasing numbers of youth became sexually involved in the 10th through 12th grades, pregnancies increased. By the end of the 12th grade, based on self-reports and hospital records, more than half of all girls in the study had been involved in a pregnancy. Whether abstinence booster programs given in later grades could have sustained early gains in reducing sexual involvement is unknown. Nor is it known whether contraceptive booster programs given in later grades would have had a further impact on pregnancy rates.
At the end of the 12th grade, the students in the study were asked how old a person should be before starting to have sex, before having a child, and before marrying. Although more than three quarters of the girls had sex while still of school age, by the end of the study only slightly more than a third thought a person should start having sex before age 18, with only 3% stating that starting to have sex in the 8th or 9th grade was appropriate. Despite their high rate of childbearing during their school years, only 3% of the girls felt that under age 18 was an appropriate time for childbearing, and less than one fifth thought it was appropriate any time during the teen years. Even fewer (1%) thought marriage was appropriate while still of school age (under age 18) with only about 7% thinking it appropriate during the teen years.
Boys were more positively inclined about beginning to have sex during the school years, with around 60% thinking that under age 18 a person could begin having sex. However, only one fifth of the boys thought a person was old enough to start having sex in the 8th or 9th grade. Almost no boys (2%) thought having a child while still of school age was a good idea and only about one out of every 10 boys saw it as appropriate during the teen years. None of the boys wanted to marry while still of high school age and only 6% wanted to marry in their teens.
The purpose of the Postponing Sexual Involvement program given in the 8th grade was to "buy some time" for young people, allowing them to mature cognitively and psychosocially for a few years without sexual involvement, hoping that with added maturity they could make and carry out constructive decisions about sexual involvement and protection against pregnancy. However, it would appear that intervention in the upper grades is mandated as well.
Based on the knowledge that as they reached an age where they could graduate from high school, young people were likely to feel they were not old enough to marry or have children, a new upper-grade combination program is being developed. It is clear from the previously developed data that although many boys and girls became sexually involved, most young people clearly felt that a person should be even older than they were when they began to have sex. Only about 10% of the boys and girls felt that a person was old enough to begin having sex in the 8th or 9th grade, and at least half felt one should probably be out of high school (18 or older) before starting to have sex.
The fact that young people feel they should act differently shows that creative programmatic efforts have a good chance of being helpful to young people. The maturational process creates a time of ambivalence, of sorting out, of experimentation. With adult guidance and support during high school, many youth can be helped to avoid becoming sexually involved or becoming pregnant. Certainly, for adults who wish to close the gap between the onset of sexual involvement and marriage or who wish to help young people postpone childbearing until they finish high school, it will be important to reach young people at an age when they begin sexual decision-making. However, it is apparent that efforts cannot end there but that help must be extended to young people throughout their school careers, particularly as they advance through high school and have more opportunities and choices. Combining delay of onset, minimization, and insulation in a single program can provide a positive underpinning for such efforts.
SOME ANSWERS TO BE QUESTIONED
As we struggle with how to prevent teenage pregnancy, defining teenage pregnancy prevention as the problem may structure thinking about solutions in ways that prevent the very outcomes we are trying to achieve. Indeed, teenage pregnancy itself may be a consequence of some other problem that we as a society are facing. If so, is it realistic to expect that program strategies such as those outlined above can overcome fundamental societal deficits in ways that will lower teenage pregnancy to acceptable levels? For example:
* Is the real problem that biological maturity has outstripped psychosocial maturity for our youth? Puberty is now occurring earlier (average age 12 years for girls) while cognitive, psychosocial maturation is not completed until much later in adolescence. Is it truly possible for such immature youth to manage sexual feelings and behaviors in ways that avoid risk?
* Is the real problem that, in our society where unskilled, untrained labor is not needed, we have no role for youth until they are out of their teens and educated? Do young people think they have to have sex or have a baby to "be somebody" because they are coming through systems that do not show them we love them, care about them, and have an immediate genuine need for them?
* Is the real problem that the media keeps sexual images constantly on the minds of young people and shows sex in a superficial, stereotyped way? Crossculturally, young people have usually become sexually involved around the time of puberty unless there have been strong societal restraints. Currently there are few societal constraints; indeed, there are many societal pressures toward unhealthy sexual involvement.
* Is the real problem how we view parenthood or acting as parents? For the first time in 1990, the majority of children in the United States will have lived, at one time or another, in a single-parent home. Today, children may see one or both parents date and become sexually involved with someone to whom they are not married. Do parents need to be given a clearer indication of how their changed attitudes and behaviors affect our country's youth?
* Is the real problem the economic situation in our nation and our communities? Adolescents who have little or no hope of finding jobs that will help them escape from poverty are less likely than others to see the merit of future planning, including family planning. Even if one graduates from high school, if the best job one is ever going to have is behind the counter at McDonald's, why postpone parenthood?
* Is the real problem that we tend to compartmentalize our thinking and responses? When we ignore the fact that young people who engage in sex at young ages are more likely to be involved in smoking, drinking, or drug use as well, we are less likely to help youth conceptualize alternatives for living. They must get the message that being drug free, pregnancy free, and infection free is a way to be free to be whatever they want to be.
* Is the real problem that adults have not resolved problems between the sexes and the legacy is being passed to the young? Battering, rape, and incest affect more women in our country than any other industrialized nation. Who teaches young men and young women to be caring and respectful of each other? Without that as a basis for a relationship, how can issues of sexual abstinence and pregnancy prevention be resolved by youth?
Teenage pregnancy has become an enduring problem in our society. There are no simple solutions. Until we are able to honestly answer some of our questions about what intervention programs work and question whether such programmatic answers deal directly enough with some of the societal issues that impact on teenage pregnancy, we will be unable to contribute to its solution in the most effective manner possible.
Let us hold up a mirror to ourselves and other adults around us and ask: how do we, and society as a whole, demonstrate what it means to be a man or a woman and what responsible sexual behavior is? What do we need to change? How can we do it? When we can answer that, we will be closer to finding a solution for preventing teenage pregnancy.
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