Adolescent Sexuality and Reproductive Health
INTRODUCTION
The number of young women and men in the world between ages 15 and 24 is now over one billion and still growing. Their childbearing holds the key to the world’s demographic destiny. In most of the developing world, teenage birth rates are high and family planning programs have been reluctant to address their reproductive health needs.
Although rates have declined recently, the U.S. still has the highest rates of teen pregnancy, birth, and abortion among developed countries.
- By their 18th birthday 60 percent of female teenagers and almost 70 percent of male teenagers in the U.S. will have had intercourse.
- About 40 percent of U.S. girls will become pregnant at least once before age 20, close to 80 percent of these pregnancies are not planned or intended and 79 percent of births to teen mothers are out-of-wedlock.
- There are more than 820,000 teen pregnancies annually in the U.S. Approximately one-third end in abortion.[1]
- About one-third of teens who become pregnant are age 17 or younger.[1]
Among the measures needed to address teen pregnancy are increased schooling, better education about human sexuality for young people, improved access to contraception and abortion services, and in many countries, improvements in the social and economic status and change in the gender norms that contribute to early marriage and childbearing.
RESEARCH
Dr. Claire Brindis, a Co-Director of the Center and Director of the Philip R. Lee Institute for Health Policy Studies, leads the Center’s research efforts in the area of adolescent reproductive health. Studies in this area address issues of acculturation and its intersection with reproductive health services, explore strategies for decreasing unmet needs for reproductive health services, and are using geomapping to better ascertain the effects of publicly-funded programs on reducing the incidence of adolescent births.
Improving Reproductive Health Outcomes for Latino Adolescents
A project to review the current state of reproductive health knowledge, attitudes, and behaviors and outcomes of Latino youth living in the U.S. The study, funded by the Annie E. Casey Foundation, examines this population within a historical, social, family and communal context, and identifies the relationship between reproductive health outcomes, youth development, health care access, and policy as they affect Latino youth. This project found that although Latino teen sexual activity rates are falling, risk behaviors (e.g. unprotected sex, multiple sex partners) continue to put many sexually active teens at risk for unintended pregnancies and STIs. Given that Latinos are rapidly changing the face and culture of the U.S. — 1 in 4 U.S. youth will be Latino by 2025 — it is crucial to invest in this growing segment of the population. Project findings illustrate how the growth of the Latino population represents both challenges and opportunities for policy makers, health care providers, programmers, and educators. Currently, project staff are engaged in completing a chartbook on Latino adolescent reproductive health and disseminating a series of fact sheets based on this study.
Teen Pregnancy in Asian and Pacific Islander American Communities
The APIA sub-population is often not considered by researchers and program planners. This project seeks to include APIAs in discussions about teen pregnancy prevention and simultaneously understand the larger context in which the problem of teen pregnancy is situated. Findings from the exploration of these issues are the first to be published. They highlight the differences between APIA subgroups, and they provide crucial information to program planners and clinicians not just in California, but also in other states with APIA populations.
EVALUATION PROJECTS
Center faculty have received numerous federal, state, and private contracts to monitor and evaluate programs designed to improve access to information, education, counseling, services, and expanded life opportunities for youth in California. These evaluation studies include the following projects:
Teenage Pregnancy Prevention Grant Program
UCSF conducted an evaluation of the California Department of Education’s 5-year Teenage Pregnancy Prevention Grant Program (TPPGP). The evaluation assessed program effectiveness on specific outcome measures that were required by the program’s authorizing statute – sexual activity, birth rates, educational results, protective factors, school and community involvement, and participant and provider satisfaction. Additionally, UCSF examined TPPGP’s influence on the development of learning support systems (LSS).
The cumulative quantitative and qualitative evidence indicated that TPPGP contributed to larger-than-expected decreases in teen births, encouraged teens to delay sexual activity, and helped teens in targeted programs to talk more frequently with their parents about issues related to sexuality. Families, schools, and community partners collaborated through TPPGP to enhance students’ emotional, social, vocational, and civic competencies and academic achievement by using comprehensive approaches to teenage pregnancy prevention.
Based on these findings, the evaluation team recommended that future school-based programs to reduce teenage pregnancy include the strongest elements of the TPPGP model: targeting of communities with the highest teen birth rates; combining research-based family life education and youth development strategies; increasing teachers’ expertise through professional development; working with parents and families; and supporting local leadership and school-community collaboration. In addition, future programs should also enhance learning support systems to strengthen health and education results.
Teen Pregnancy Prevention Initiative
The UCSF Evaluation Team has partnered with the Philliber Research Associates and Stanford Research Institute to conduct a process and outcome evaluation of The California Wellness Foundation’s Teen Pregnancy Prevention Initiative (TPPI),a 10-year, $60-million effort. Apart from helping to guide the overall evaluation of the Initiative, the UCSF team is responsible for evaluating the Public Education and Policy Advocacy grantees of the TPPI.
Since 1998, Ogillvy Public Relations Worldwide, the Public Education grantee, has worked to inform target audiences, primarily policy makers, about issues of teen pregnancy prevention and healthy adolescent sexuality through a variety of media outreach strategies such as placing print advertisements in major daily and ethnic-specific newspapers, developing fact sheets and monographs, and training key regional spokespeople for the campaign. Each component of the campaign is developed based on extensive community research, including ethnic-specific roundtables of community leaders. Interviews conducted during the Summer of 2002 with a sample of key stakeholders from the target audience in the reproductive health field (program directors, policymakers, and opinion leaders) showed that many of the products and reports developed for the campaign are seen as effective educational and advocacy tools. However, findings from a survey administered at the state Capitol in January 2003, indicate that the public education campaign has only slightly moderate name recognition among key staff of California senators and assembly members.
UCSF findings indicate that training programs and events conducted by Policy Advocacy grantees increased the skills and engagement of a cadre of youth and adults in policy advocacy work on behalf of teen pregnancy policies. Moreover, their work educating and/or mobilizing the public through policy briefs, forums and reports have shown success in policy change, despite the challenging political and economic climate. Policies to increase teen access to contraceptive services have been more successful than those that would increase access to comprehensive sexuality education.
School-Based Health Centers
Since 1998, the UCSF Evaluation Team has partnered with the Alameda County School-Based Health Center (SBHC) Coalition to conduct a process and outcome evaluation of the SBHCs in Alameda County.
The UCSF Evaluation Team has worked with the Coalition and the SBHC staff to develop a set of evaluation indicators for the adolescent SBHCs, to establish common evaluation tools, and to collect and analyze data.
To date, the evaluation findings support the need for comprehensive SBHCs and students’ increased access to health care services:
- The Alameda County SBHCs collectively provide more than 18,000 visits to over 5,000 students annually. The majority of visits are for medical services, such as first aid/acute care (47%) and reproductive health services (38%).
- More than two-thirds (68%) of students in Alameda County schools with SBHCs reported that they always received medical care when they felt they needed it in the past year. This was significantly higher (p<0.01) than Alameda County students in schools without SBHCs where only 61% received the care they needed.
- Many adolescents indicate that they prefer SBHCs even if they have other sources of health care, because they are often more responsive to their needs. Alameda County SBHC clients reported that they decided to visit the SBHC even if they had other health care options because the school-based services were private and confidential (50%), the hours and location were convenient (33%), the SBHC offered the services they needed (26%), and services were free and low cost (19%).[2]
- Over half (53%) of the SBHC clients report that other than the SBHC, they did not know or were not sure where else to get care without having to involve their parents, disrupting their workday in order to access care.
Evaluation findings suggest that school-based health centers can make an increasingly important contribution to access to and utilization of health care for adolescents.
In October 2002, the UCSF Evaluation Team was awarded a Centers for Disease Control & Prevention (CDC) Community-Based Participatory Prevention Research Grant to conduct the School-Based Health Center (SBHC) Participatory Research project. This project aims to enhance the current SBHC evaluation research efforts by increasing the participation and capacity of the Alameda County SBHC Coalition, creating seven school-based Student Research Teams and seven Coordinated School Health Teams to engage in research and programmatic change to improve the long-term sustainability of the SBHCs and the health of the student population.
Peer Providers of Reproductive Health Services
The Peer Providers of Reproductive Health Services delivery model is implemented in five clinics in California. The Peer Provider model is an outreach and service delivery model in which trained and certified young adults provide individual and group outreach to teens, and provide non-clinical reproductive health services to their peers in a clinical setting. Findings from the evaluation demonstrate that the model is a successful strategy that increases male and female reproductive health client visits and continuity, improves birth control and condom use, and reduces pregnancy rates over time. This model has not been fully implemented in international settings, yet holds much potential in countries where youth are in need of reproductive health education and services, and also employment and vocational training.
Community Challenge Grants
Since 1997, the Center has designed and conducted the statewide outcome evaluation of the largest state-funded adolescent pregnancy prevention program in the U.S., the Community Challenge Grants (CCG) program. The CCG program, funded by the Department of Health Services in California, provides matching grants to over 100 agencies throughout the state to provide diverse, locally designed, community-based programs to prevent teen pregnancy. The evaluation conducts needs assessments, documents collaboration between agencies, and measures the effects of a wide range of creative interventions. In recent years, the evaluation found that comprehensive family life education alone or combined with youth development interventions contributed the most to increasing protective factors, reducing non-sexual risk behaviors, and increasing sexual behaviors linked to teen pregnancy prevention among youth at high risk of teen pregnancy. Youth development interventions were nearly as effective. Abstinence-focused interventions alone or combined with youth development were the least effective in achieving program goals. The evaluation also found that 98% of pre-adolescents (under age 14) were protecting themselves against teen pregnancy, either by abstaining from sex altogether (93%) or by using contraception (5%). Given the recent debate surrounding abstinence based education, these findings are an additional contribution to literature demonstrating the ineffectiveness of abstinence-only programs. Results for parents were strong and indicated that parent interventions bring a special strength to teen pregnancy prevention in participating California communities.
Male Involvement Program
The Male Involvement Program, funded by the California Department of Health Services, recognizes that males play an essential role in teen pregnancy prevention, and provided funding to 25 community-based agencies throughout the state to design and implement strategies for young men. Evaluation results show that intervention combining information and education about reproductive health with engaging activities (such as school tutoring, employment training, sporting events and leadership opportunities), and direct links to services, are most effective in changing the knowledge, attitudes and practices of young men. Linking MIP programming to clinical services developed into a source of strength for many local projects. The vast majority of MIP agencies created various ways in which to ease and increase access to clinical services, including developing a formal referral system with Family PACT providers, and opening up satellite health centers at local high schools. In addition, nearly half of the MIP agencies changed the environment of the clinic, i.e. paint color, posters, brochures, etc. and hired male staff in order to make males feel more comfortable and welcome in the clinics. The vast majority of the MIP agencies increasingly acknowledged the role of youth development and committed themselves to involving participants in the planning of program activities, making participants stakeholders in the success of the program’s efforts. It is hoped that strengthening these innovative efforts will help spark interest and gain greater support for male involvement in communities throughout the country.
The 13-City Teenage Pregnancy Prevention
This evaluation project, funded by the Centers for Disease Control and Prevention, is studying the impact of a 13-city initiative on adolescent pregnancy prevention. The evaluation focuses on the role of coalitions in helping to mobilize diverse community sectors in meeting the needs of adolescents, including the incorporation of youth development as well as related pregnancy prevention projects.
Women’s Community Health Leadership Program
January 2002 marked the debut of the Women’s Community Health Leadership Program (WCHLP), the result of a partnership between the Johnson & Johnson Company and the National Center of Excellence in Women’s Health at UCSF. The Center was contracted to do the evaluation. Following a competitive bidding process in November 2001, Johnson & Johnson awarded $30,000 grants to each of five California agencies. While diverse in their program content, each of the five grantees exhibited a strong commitment to provide innovative services to improve youth development and women’s access to healthcare in ways that were measurable, sustainable, and replicable.
Family PACT Program Evaluation
For more on the Family PACT Program Evaluation, which includes research on adolescent health, click here.
SERVICE DELIVERY
New Generation Health Center, a clinic of San Francisco General Hospital and the UCSF Dept. of Obstetrics, Gynecology & Reproductive Sciences, offers free, confidential, comprehensive reproductive health services to youth ages 12 to 24 in San Francisco. A dynamic team of providers, including physicians, nurse practitioners, social workers, health educators, and counselors offer a full range of reproductive health services, as well as education and counseling around substance use and abuse, relationship violence, peer and family relationships, and stress management. Clinic staff also conducts extensive outreach, as well as coordinate after school programs for young women and men. Services are provided in English and Spanish.
[1] The Alan Guttmacher Institute. (2004). U.S Teenage Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State Information. New York: The Alan Guttmacher Institute.
[2] Clients could provide more than one answer to this question.