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Summary
of ReCAPP Forum: On February 6, 2002, Doug Kirby, Ph.D., Senior Research Scientist at ETR Associates and author of Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, joined moderator Lori Rolleri to answer forum participants' questions about Emerging Answers. After a
brief description of Emerging Answers,
Dr. Kirby fielded questions about the following topics:
Resources mentioned throughout the summary are listed at the end. Note:
Links on this page with the Portable Document Format icon
In Emerging Answers, published by the National Campaign to Prevent Teen Pregnancy, Dr. Kirby reviewed more than 250 studies of antecedents and 73 studies of the impact of teen pregnancy prevention programs. Compared with a similar review five years ago, Emerging Answers found increasing evidence that some programs do reduce unprotected sex among teens. Some of the programs do this by delaying sex, decreasing the frequency of sex among sexually experienced youth, and increasing the use of condoms or contraceptives. Some of the program evaluations also offered evidence that the programs actually reduce pregnancy and/or birth rates. In his
review, Dr. Kirby found that four groups of programs had particularly strong
evidence for effectiveness:
Is the glass half empty, or half full? One participant found the short list of successful, effective programs in Emerging Answers to be a depressingly poor success ratio, given the many programs and studies reviewed. "Isn't this a reason for pessimism?" he asked Dr. Kirby. Dr. Kirby disagreed, pointing to the stringent criteria for studies to be included in the Emerging Answers review. "Emerging Answers identifies eight programs that have particularly strong evidence for success," he said. "The studies that evaluated these programs had to have very strong evaluation designs — e.g., random assignment, large sample sizes, long-term follow-up for at least a year, measurement of behavior, etc. Or, alternatively, there had to be multiple weaker studies conducted by independent evaluators providing evidence that the same program changed behavior in a positive direction. These are rather demanding criteria." However, he continued, "Emerging Answers also identified many other programs with less rigorous evidence for positively changing behavior. For example, the table on page 87 shows that nine out of 28 sex and HIV education programs delayed the initiation of sex, five out of 19 reduced the frequency of sex, ten out of 18 increased the use of condoms, and four out of 11 increased contraceptive use." "In addition, four out of five studies of clinic-based protocols found positive behavior effects, multiple studies of many service learning programs found evidence they reduced teen pregnancy, and the Children's Aid Society-Carrera program in multiple sites around the country reduced pregnancy and childbearing. Thus, I think these studies are quite encouraging." Another issue is whether positive changes occurred but remained undetected. "Some programs undoubtedly did change behavior in a positive direction," Dr. Kirby said, "but the studies were not able to find statistically significant changes, either because of small sample sizes, poor evaluation designs, or methodological errors of many kinds." "Having said this," he continued, "it is also true that many programs do not effectively change behavior. We should not be naive. Not everything works. For example, programs that are short or not sufficiently intensive may not change behavior. And sex and HIV education programs that fail to give a clear message about avoiding sex or always using protection against pregnancy and STD [sexually transmitted diseases] may not have an impact." "I think the good news is that we have rather consistent evidence that certain types of programs with identifiable characteristics can change behavior in desired directions," he concluded, "and we have even stronger evidence that a few (eight) specific programs can be effective." (In other words, the glass is at least half full, in Dr. Kirby's view.) The Executive Summary of Emerging Answers is available from the publications section of The National Campaign to Prevent Teen Pregnancy’s web site, www.teenpregnancy.org.
Karen Canova, with the National Organization on Adolescent Pregnancy, Parenting and Prevention (NOAPPP) in Washington, DC, kicked off the discussion with a question for Dr. Kirby about how he would respond to supporters of abstinence-only programs. (President Bush's recently proposed budget seeks $33 million — a 100% increase — for these programs.) Dr. Kirby, noting that the question was both important and politically loaded, offered these thoughts (adding that there were probably multiple ways to answer the question):
Taking the Pledge Several participants from the Center for Law and Social Policy asked Dr. Kirby to comment on a study of abstinence or virginity pledges. "The Bearman and Bruckner study of the effects of taking an abstinence pledge was not included in the main text or the tables of Emerging Answers," Dr. Kirby explained, "because it did not meet the criteria for inclusion." This study did not rely upon a quasi-experimental design and instead used youths' self reports of whether or not they had taken the pledge. "It is possible that youth were more likely to remember that they had taken the pledge if it was meaningful to them," Dr. Kirby said, adding that "this biased self-reporting could affect results." Despite these limitations, because virginity pledges and the Bearman study have received so much attention nationally, the study was summarized in a footnote on page 88 of Emerging Answers. Dr. Kirby added: "The Bearman and Bruckner study does suggest that taking an abstinence pledge will delay the onset of sexual intercourse under some conditions (e.g., at least a few take it, but not too many take it) and among some youth (e.g., among younger girls), but not others. It also indicates that when youth who took the pledge do initiate sex, they are less likely to use contraception than if they had not taken the pledge. Thus, in terms of risk of pregnancy, taking the pledge may produce both positive consequences (delaying sex) and negative consequences (reduced use of contraception)." "Without rereading that paper," Dr. Kirby said, "I'm not sure how these balance out. This finding does represent weak evidence that abstinence-only programs might decrease contraceptive use." Somewhat stronger evidence comes from the three studies of abstinence-only programs that are reviewed in Emerging Answers. While none of these three studies delayed sex, decreased the frequency of sex, or decreased the number of sexual partners, it is also true that none of them decreased contraceptive use either. (Of course, Dr. Kirby noted, none of these three programs was an abstinence-until-marriage program.) "Given the great diversity of abstinence-only programs," he concluded, "the safest thing to say is that we just don't know what their effects are, and undoubtedly the effects will vary with the characteristics of the programs, just as the effects of comprehensive sex and HIV education programs vary with the characteristics of those programs (although none that focused upon sexuality had any negative effects)." A Level Playing Field? Steven Bignell of Journeyworks asked, "It took hundreds of thousands of dollars and the best expertise in the country to produce the positive effects from the original Reducing the Risk (RTR) program . . . If a level of effort and expertise similar to ETR's RTR program went into developing an abstinence-only approach, do you think it could be effective or do you think an abstinence-only approach is intrinsically flawed?" Dr. Kirby responded by saying that demonstrating results for the RTR program involved not only dollars and expertise, but also a decade of failure. "For about the first 12 years of my professional career in this field," he wrote, "everything I evaluated failed to have a behavioral impact. Thus, we should make sure that abstinence-only programs are given the time and resources to develop effective programs. That is only fair." However, having said that, he continued, "It should be quickly recognized that people have been developing many different abstinence-only programs for more than a decade and have learned some from these efforts. (OAPP has funded these programs for years.)" Dr. Kirby noted that the problem lies less in the lack of developed programs — for there are many — but in the failure to evaluate them. This is due in part to scarce funding for evaluating these programs, but is also due to "the discomfort that some proponents of abstinence-only programs have about asking youth about their sexual behavior (a prerequisite for measuring program impact upon that behavior)." He added that a rigorous and fair evaluation of several abstinence-only programs is currently underway but emphasized that additional studies also need to be conducted. What will these evaluations show, once they are conducted? "I suspect that ultimately some abstinence-only programs, like some comprehensive sex and HIV education programs, will be found to be effective," Dr. Kirby predicted, "and others will not. However, until then, we don't know which ones are effective." Dr. Kirby pointed out that the ultimate test is not whether abstinence-only programs can delay sex, but whether they reduce sexual risk-taking more than comprehensive sex and HIV education programs do. "Some abstinence-only programs will probably be able to delay sex," he said, "but it doesn't seem likely that they will increase condom or contraceptive use. In contrast, some sex and HIV education programs both delay sex and increase condom or contraceptive use. Thus, the question will become, can abstinence-only programs delay sex among a sufficient proportion of youth for a sufficiently long period of time that they ultimately provide more protection than sex and HIV education programs that do both?" Unfortunately, he said, "The answer to that question will not be known for years, and until then, the controversy will rage." For more information . . . Moderator
Lori Rolleri suggested two resources for those interested in more information
on evaluations of abstinence-only programs:
Several participants asked Dr. Kirby to comment on what he might recommend for teen pregnancy prevention programs in various situations, such as relying on scarce resources, implementing a program within developing countries, or choosing among programs of varying lengths or intensity.
Faced with a scenario presented by a forum participant — a rural county with high teen pregnancy rates and scarce funds for teen pregnancy programs — Dr. Kirby made the following suggestions: "Essentially,
your question is a question about what are the most cost-effective approaches
to reducing sexual risk-taking," he said. "The answer, of course, is:
it depends."
"When making decisions about what programs to implement," Dr. Kirby concluded, "you should examine the needs of the youth you serve and try to identify the factors which affect their sexual risk-taking. Then, of course, you should try to address those factors with your programs." Programs in Developing Countries Responding to a question about implementing teen pregnancy programs in another type of resource-poor setting — developing countries — Dr. Kirby said that the answer depends greatly upon the developing country and the conditions there. "Because HIV/AIDS is an enormous problem in many developing countries, in addition to unwanted teen pregnancy," he wrote, "I would typically include approaches that addressed both issues." "I would probably include some combination of in-school more intensive sex and HIV education programs, community programs (because much larger percentages of youth drop out of school early), mass media programs to reach everyone and to enhance awareness, and adolescent friendly clinic programs to provide reproductive health care," Dr. Kirby explained. "In all of these, I would try to give a clear message about abstinence and protection and would try to help young people personalize their risks as well as practice effective strategies to avoid risk. In other words, I would try to incorporate many of the characteristics of effective programs in the United States." "In those countries where gender inequality plays a major role," Dr. Kirby added, " I would try to address that issue through all these programs." As an additional resource on this topic, Dr. Kirby recommended a recently published FOCUS on Young Adults report, entitled, "Advancing Young Adult Reproductive Health: Actions for the Next Decade." The report includes a summary of all the known studies measuring the impact of programs in developing countries. (The report is available through the web site of Pathfinder International: http://www.pathfind.org/focus.htm.) Implementing the CAS/Carrera Program Noting Dr. Kirby's endorsement of the CAS/Carrera program in Emerging Answers, one participant asked him to comment on which elements of the program she should consider adding to her current programming to increase the intervention's power. She already offered program participants the Safer Choices curriculum — which is designed to address the antecedents of teen pregnancy — and the Teen Outreach Program (a service learning program). "Presently, we can't afford to offer the full Carrera program," she wrote, "and I am fishing for what may be important strategies to use for a mixed group of teens — boys and girls — from local junior high schools." Once again, Dr. Kirby noted, the answer would be, "It depends." In addition, he said, he strongly suspected that Michael Carrera, the founder and designer of the CAS/Carrera program, would say that it is the program's complete package — not any particular component — that contributes the most to its success. (For more information on the CAS/Carrera program, visit the program's web site: www.stopteenpregnancy.org.) Despite
that caveat, Dr. Kirby took a stab at an answer. "A very important part
of the CAS/Carrera program is the strength of the relationships that are
formed between the staff and the youth," he observed. "Thus, as you implement
both Safer Choices and service learning, I would encourage you
to try to develop those relationships. Those relationships, combined with
clear messages about avoiding unprotected sex and pregnancy (from Safer
Choices and elsewhere) can be powerful." (For a more detailed discussion,
see Dr. Kirby's "Viewpoint" article in Family Planning Perspectives,
available through the Alan Guttmacher Institute's web site: www.guttmacher.org/pubs/journals/3327601.)
"However, all of this assumes that your participants who are sexually active do have access to condoms and contraceptives," he continued. "If not, then that should be an important component. In addition, this assumes that your youth have some motivation to avoid early pregnancy. If not, then a whole host of components to get them to believe in their future, to recognize career possibilities, and to increase that motivation to avoid early childbearing may be needed." Ideal Program Length and Intensity Another participant asked Dr. Kirby what he considers to be an adequate length and intensity for an effective sexuality education program. "The shortest sex or HIV education program with good evidence that it changed behavior for as long as one year is Making a Difference (the not-yet-published sequel to Be Proud! Be Responsible!) and it lasted for eight hours — four hours on each of two Saturdays," Dr. Kirby said. However,
he made two observations about features that may have affected the results:
"When youth join a program voluntarily and freshly," Dr. Kirby said, "they may be more receptive to the messages, and it may be more effective. Similarly, when youth participate in small groups, the instructors can tailor the program to their particular questions, can be more efficient, and thus can be more effective. If the same type of program were implemented in a large classroom where students are captive, it might need to be longer to be effective." Aside from Be Proud! Be Responsible!, most of the effective programs were considerably longer, typically lasting between 16 to 20 sessions. Dr. Kirby noted that the only program that demonstrated an impact for as long as 31 months was Safer Choices, which included 10 sessions in the 9th grade and 10 more sessions in the 10th grade. Designing a "Super Program" A participant from Ohio posed this question for Dr. Kirby: "If you could build a 'super teen pregnancy program' by combining key program elements of the most successful programs you have studied, what would those elements be?" Dr. Kirby
replied, "When I look across all the factors affecting sexual risk-taking
and all the studies of program effectiveness, an important theme that
emerges is the importance of positive norms and attachment to people who
express those norms clearly. By positive norms, I mean norms that favor
youth delaying sex, and youth always using condoms and contraception if
they do have sex. Thus, a critically important theme or component in any
ideal program would be an emphasis upon these norms." (Dr. Kirby recently
expanded on this topic in his "Viewpoint"
"If by a 'super teen pregnancy prevention program' you mean a single program," he added, "then I would choose a program like Safer Choices if the youth did not lack a great many social supports, or a program like the CAS/Carrera program if they did lack these supports." "If by
a 'super teen pregnancy prevention program' you mean a combination of programs
that would fit into an overall pregnancy prevention initiative," he continued,
"then I would include the following:
"Of course," Dr. Kirby said, "what I have just done is put together all the groups of effective programs (no surprise!). However, as I said at the beginning, the common theme would be that of expressing clear norms about avoiding unprotected sex and pregnancy and increasing attachment to those who express or embody those norms."
Several forum participants wondered about data comparing the costs and benefits of specific programs or curricula. Dr. Kirby pointed out that the costs of programs vary considerably, depending upon where the program is implemented and which costs are counted. "For example," he said, "most of the curricula for the effective sex and HIV education programs cost less than $50. However, once an agency has the curriculum, it probably needs training, and that cost varies with the number of teachers, length of training, etc. Given the curriculum and training, teachers can then implement the program. There are few other out-of-pocket expenses." "However," Dr. Kirby asked, "once the teachers implement the program, how do you then count the cost of classroom time, of the correct portion of the teachers' salaries, etc.?" The same is true for clinics, he observed, in that changes in clinic protocols sometimes require more clinic staff time. Aside from this cost and the cost of training the staff, though, there typically are few other costs. Dr. Kirby said that the CAS/Carrera program is the most costly of the four groups of effective programs, if all the staff costs are included. "I have heard estimates from $4,000 per youth per year upward," he wrote, "but I'm sure this varies with each community . . . Although the CAS/Carrera program costs more, it should be fully recognized that it is a comprehensive youth development program that should have multiple long-term benefits beyond pregnancy reduction. These should be recognized in any cost-benefit analysis." Karen Canova, of the National Organization on Adolescent Pregnancy, Parenting and Prevention (NOAPPP), recommended an article entitled "Taking Costs Into Consideration in Teen Pregnancy Prevention Programs," which compares various cost-effectiveness measures for ten programs. The article, by Wilhelmina Leigh, Senior Research Associate at the Joint Center for Political and Economic Studies in Washington DC, appeared in the Summer 2001 issue of "NOAPPP Network." (For a copy of the article, contact Ms. Canova by e-mail at kcanova@noappp.org.)
A forum participant from California asked, "What do we know about the training teachers get to prepare them to teach family life sexuality education/HIV prevention?" She continued, "Since so much of the message sent to youth is influenced by the messenger, what can we do to influence teacher training, especially in the teacher credential programs? Are there evaluated teacher training programs that look at program content, training process, and attitudes of the teachers? Dr. Kirby concurred that teacher training is a critical factor — and an ongoing challenge. "Teachers not only need to know a diverse array of information about sexuality," he observed, "they also need to be comfortable talking about sex, able to express clear messages about avoiding unprotected sex, able to conduct role plays and other interactive group activities effectively, and able to deal with potential controversy in a responsible manner." ("This is not easy," he added.) All the effective sex and HIV education programs reviewed in Emerging Answers provided training for the instructors. "In addition," he wrote, "there is some evidence that the teachers' values about sexuality do affect the effectiveness of their instruction. Although we don't have good research to support it, at ETR we strongly believe that training must be skill-based and include practice in order to be effective." Lori Rolleri,
the forum's moderator, offered several suggestions of organizations that
provide professional training for sexuality educators:
Considering other ways to reach teens and communities with pregnancy prevention messages, an Ohio participant wondered about the impact of billboards, public service announcements, and other one-time presentations. The strength of these methods, Dr. Kirby replied, is that they allow you to reach large numbers of people at relatively low cost. "Furthermore," he said, "they may increase awareness of an issue." However, Dr. Kirby concluded, "alone, they are probably insufficient to change actual sexual or contraceptive behavior." Beth Chaton shared her positive experiences using these methods through her program Teen-Adult Partnerships Enhancing Strategies Toward Responsible Youth (TAPESTRY). "TAPESTRY has created some fun and creative media messages through 30-second TV ads over the last five years," she wrote. "What I'm told on the streets by people who see the ads on TV is that positive family communication around responsible sexuality was stimulated. Even if the conversation is just between the parents, it helps them clarify their thoughts and feelings around their kids' sexuality. When messages are consistently and concretely delivered and combined with comprehensive education, I would hope that overall behavior would be impacted." TAPESTRY's materials are available for a nominal fee, and another organization's tag line can be inserted. For more information, contact Ms. Chaton at Tapestry's offices at the Humboldt County Office of Education in Eureka, California, 707-445-7179.
A participant from Ohio asked, "Does any research support the thinking that programs which focus on improving general communication between parents and their children carry over to improving parent-child communication about sexual behavior issues, or do services have to specifically be directed at helping parents and kids improve their abilities to communicate about sexual behavior issues?" Dr. Kirby replied that he was unaware of any research directly related to this question. "However," he wrote, "we have learned that, in general, the more directly related the topic, the greater the impact. Programs that taught youth generic values, generic decision-making skills, and generic communication skills were not effective at changing sexual behavior (as best as we could measure), whereas those programs for youth that focused directly upon sexuality and talked about sexuality-specific communication skills were more likely to be effective." He added, "I don't know whether we can generalize from this to parent-child communication." Dr. Kirby observed that program staff should keep in mind that attachment or connectedness between youth and their parents is related to sexual risk-taking. "Thus," he said, "if you can increase general attachment, you may decrease risk-taking." (However, he noted, he is unaware of any programs specifically geared to increasing attachment.)
A Canadian forum participant wondered about the future of the condom. "It appears to me that a large population of teenagers and young adults engage in serial monogamy," he wrote. "Within these individual relationships, there seems to be a tendency to stop using condoms once the individuals feel they know each other." If the average person just isn't going to use a condom every time, he wrote, perhaps condoms will be promoted in the future only for high-risk behaviors. "Is society ready for social marketing such as 'Tired of using condoms? Get tested first!'?" he asked Dr. Kirby. "Besides," he added, "some STDs (sexually transmitted diseases such as HPV and herpes) are not prevented by condoms and the user failure rates remain high ... When are we going to admit the condom cannot save us?" Dr. Kirby agreed that our messages regarding STDs have focused primarily upon either abstinence or condom use. "This is clearly inadequate," he said, "for at least two reasons" (as the forum participant had noted): most youth stop using condoms after they have had sex several times with the same partner, and condoms do not provide nearly as much protection against all STDs as we would like. "This raises very important questions," Dr. Kirby said. "What should we add to the message? Will more complex messages be too confusing to young people? Are there good alternatives?" One possibility is for all people in long-term, mutually monogamous relationships to use condoms until they are both tested for STDs. There would be many positive benefits for doing this. However, not all clinics test for all STDs, and some STDs would go undetected. Also, Dr. Kirby noted, if everyone did get tested, it would substantially add to the burden on public health STD clinics. Another possibility is to follow the approach used in some developing countries that emphasize the "ABCs" — "Abstinence, Be faithful (i.e., have few sexual partners), and Condomize." Dr. Kirby said he doesn't know the answer but is encouraged by attention to this issue from the CDC and others, and looks forward to learning more.
Emerging Answers
Abstinence-Only Programs and Pledges
Programs in Developing Countries
CAS/Carrera Program
Features of Effective Programs
Cost Effectiveness
Professional Training for Sexuality Educators
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