Abstinence Education [1 ed.] 9781617281198, 9781606921548

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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

HEALTH PSYCHOLOGY RESEARCH FOCUS

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ABSTINENCE EDUCATION

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central, contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in

HEALTH PSYCHOLOGY RESEARCH FOCUS SERIES Parental Treatment and Mental Health of Personality Ferenc Margitics and Zsuzsa Pauwlik 2009 ISBN: 978-1-60741-318-9 Pain Control Support for People with Cancer National Cancer Institute 2009 ISBN: 978-1-60692-848-6

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Abstinence Education Isabella E. Rossi (Editor) 2009 ISBN: 978-1-60692-154-8

Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

HEALTH PSYCHOLOGY RESEARCH FOCUS

ABSTINENCE EDUCATION

ISABELLA E. ROSSI Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

EDITOR

Nova Science Publishers, Inc. New York

Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication.

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This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Abstinence education / Isabella E. Rossi. p. cm. Includes index. ISBN H%RRN 1. Teenagers--Sexual behavior--United States. 2. Sexual abstinence--Study and teaching--United States. 3. Sexual abstinence--Study and teaching--United States--Evaluation. I. Rossi, Isabella E. HQ31.A312 2009 306.73'208350973--dc22 2009029243

Published by Nova Science Publishers, Inc.  New York

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CONTENTS Preface Chapter 1

Chapter 2

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Chapter 3

vii Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs United States Government Accountability Office Assessing the Accuracy and Effectiveness of Federally Funded Programs Statement of Marcia Crosse Testimony on DHHS Abstinence Edcucation Programs before House Committee on Oversight and Government Reform Statement by Charles Keckner

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83

Chapter 4

Report Released on Four Title V Abstinence Education Programs 93 United States Department of Health and Human Services

Chapter 5

Scientific Evaluations of Approaches to Prevent Teen Pregnancy Congressional Research Service

Index

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97 107

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In: Abstinence Education Editor: Isabella E. Rossi

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PREFACE This book explores teenage sexual activity and non-marital childbearing which have serious consequences for teens, their families, their communities and our society. The two greatest risk factors for teen pregnancy and transmission of STDs are the age at first onset, and the number of partners. By definition, abstinence education programs aim to do just that. Abstinence is the only 100 percent effective method to prevent pregnancy and sexually transmitted diseases. Through education, mentoring, counseling and peer support, abstinence education services help teens delay the onset of sexual activity and reduce the number of sexual partners they have. The State Abstinence Education Program and the Community-Based Abstinence Education (CBAE) Program of the Administration for Children and Families, together with the Adolescent and Family Life Program from the Office of Population Affairs, provide useful tools to help parents, schools, communities and States guide our Nation’s youth away from these devastating outcomes.

Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Abstinence Education, edited by Isabella E. Rossi, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

In: Abstinence Education Editor: Isabella E. Rossi

ISBN: 978-1-60692-154-8 © 2009 Nova Science Publishers, Inc.

Chapter 1

EFFORTS TO ASSESS THE ACCURACY AND EFFECTIVENESS OF FEDERALLY FUNDED PROGRAMS *

United States Government Accountability Office

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WHY GAO DID THIS STUDY Reducing the incidence of sexually transmitted diseases and unintended pregnancies is one objective of the Department of Health and Human Services (HHS). HHS provides funding to states and organizations that provide abstinence-untilmarriage education as one approach to address this objective. GAO was asked to describe the oversight of federally funded abstinence-untilmarriage education programs. GAO is reporting on (1) efforts by HHS and states to assess the scientific accuracy of materials used in these programs and (2) efforts by HHS, states, and researchers to assess the effectiveness of these programs. GAO reviewed documents and interviewed HHS officials in the Administration for Children and Families (ACF) and the Office of Population Affairs (OPA) that award grants for these programs.

*

This is an edited, reformatted and augmented version of a Report to Congressional Requesters, GAO-07-87, dated October 2006.

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WHAT GAO RECOMMENDS To address concerns about the scientific accuracy of materials used in abstinence-until-marriage education programs, GAO recommends that the Secretary of HHS develop procedures to help assure the accuracy of such materials used in programs administered by ACF. HHS agreed to consider this recommendation. HHS also provided information on steps it takes to assure accuracy, which we have incorporated into the report, as appropriate. www.gao.gov/cgi-bin/getrpt?GAO-07-87.

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WHAT GAO FOUND Efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs have been limited. This is because HHS’s ACF—which awards grants to two programs that account for the largest portion of federal spending on abstinence-until-marriage education—does not review its grantees’ education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy. In contrast, OPA does review the scientific accuracy of grantees’ proposed educational materials. In addition, not all states that receive funding from ACF have chosen to review their program materials for scientific accuracy. In particular, 5 of the 10 states that GAO contacted conduct such reviews. Officials from these states reported using a variety of approaches in their reviews. While the extent to which federally funded abstinence-until-marriage education materials are inaccurate is not known, in the course of their reviews OPA and some states reported that they have found inaccuracies in abstinence-until-marriage education materials. For example, one state official described an instance in which abstinence-until-marriage materials incorrectly suggested that HIV can pass through condoms because the latex used in condoms is porous. HHS, states, and researchers have made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs; however, a number of factors limit the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. ACF and OPA have required their grantees to report on various outcomes that the agencies use to measure the effectiveness of grantees’ abstinence-untilmarriage education programs. In addition, 6 of the 10 states in GAO’s review have worked with third-party evaluators to assess the effectiveness of abstinence-until-marriage education

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programs in their states. Several factors, however, limit the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. Most of the efforts to evaluate the effectiveness of abstinence-untilmarriage education programs included in GAO’s review have not met certain minimum scientific criteria— such as random assignment of participants and sufficient follow-up periods and sample sizes—that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid, in part because such designs can be expensive and time-consuming to carry out. In addition, the results of efforts that meet the criteria of a scientifically valid assessment have varied and two key studies funded by HHS that meet these criteria have not yet been completed. When completed, these HHS-funded studies may add substantively to the body of research on the effectiveness of abstinenceuntil-marriage education programs.

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ABBREVIATIONS ACF AFL ASPE Evaluation CDC FAR HHS HIV HPV HRSA NAC NIH OMB OPA RFP STD TANF

Administration for Children and Families Adolescent Family Life Office of the Assistant Secretary for Planning and Centers for Disease Control and Prevention Federal Acquisition Regulation Department of Health and Human Services human immunodeficiency virus human papillomavirus Health Resources and Services Administration National Abstinence Clearinghouse National Institutes of Health Office of Management and Budget Office of Population Affairs request for proposal sexually transmitted disease Temporary Assistance for Needy Families

LETTER October 3, 2006 Congressional Requesters

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Preventing sexually transmitted diseases (STD) and unintended pregnancies among adolescents is an important public health challenge. Although pregnancy and birth rates among female adolescents in the United States have been declining since the early 1990s, the rates continue to be high when compared with those in other industrialized nations. The Centers for Disease Control and Prevention (CDC) reports that about 141,000 children were born to girls 17 years old and younger in the United States in 2003. CDC also reports that STDs disproportionately affect adolescents, with adolescents and young adults ages 15 to 24 acquiring almost half of the estimated 19 million new infections each year. Reducing the incidence of STDs and unintended pregnancies among adolescents is an important objective for the Department of Health and Human Services (HHS), which identifies as one of its goals the need to reduce major threats to the health and well-being of Americans. Among the efforts it supports to reduce the incidence of STDs and unintended pregnancies among adolescents, HHS funds abstinence-until-marriage education programs. Abstinence-untilmarriage education programs, also referred to as abstinence-only education programs, teach adolescents to abstain from sexual activity until marriage in order to avoid risks of unintended pregnancy, STDs, and related health problems.1 The content of federally funded abstinence-until-marriage programs is required to be consistent with several principles, such as teaching that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity, and that abstinence from sexual activity is the only certain way to avoid STDs. Abstinence-until-marriage education programs are delivered by a variety of entities, including schools, human service agencies, faith-based organizations, youth development groups, and pregnancy crisis centers. Instructors can incorporate a variety of educational materials into their abstinenceuntilmarriage education programs, including textbooks, student manuals, brochures, slide presentations, and videos. The three main federally funded abstinence-until-marriage programs are the Abstinence Education Program (State Program), which is administered by HHS’s Administration for Children and Families (ACF); the Community- Based Abstinence Education Program (Community-Based Program), which is also administered by ACF; and the Adolescent Family Life (AFL) Program, which is administered by HHS’s Office of Population Affairs (OPA) within the Office of Public Health and Science. Funding provided by HHS for the three abstinence1

Abstinence-until-marriage education programs also support HHS’s objective to promote family formation and healthy marriages.

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until-marriage programs increased from about $73 million in fiscal year 2001 to about $158 million in fiscal year 2005. Recent studies have raised concerns about the accuracy of educational materials used in abstinence-until-marriage education programs and about the effectiveness of these programs. These studies have reported that some of the materials used in abstinence-until-marriage education programs contain, for example, scientifically inaccurate information about anatomy and physiology as they relate to reproductive health as well as misleading information about contraceptive failure rates and STDs.2 State and federal agencies have also documented inaccuracies in abstinenceuntil-marriage educational materials. Further, studies examining the effectiveness of these programs have reported varied results. For example, some researchers have reported that abstinence-untilmarriage education programs have resulted in adolescents reporting less frequent sexual intercourse or fewer sexual partners, while other researchers have reported that these types of programs did not affect the frequency of sexual intercourse or were ineffective in delaying the initiation of sexual intercourse.3 You asked us to describe certain aspects of the oversight of federally funded abstinence-until-marriage education programs. Our objectives were to report on (1) efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs and (2) efforts by HHS, states, and researchers to assess the effectiveness of abstinence-until-marriage education programs. You also asked us to describe how HHS selected a contractor for the abstinenceuntil-marriage technical assistance contract that was awarded in September 2002. This information is provided in appendix I. To describe the efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs, we reviewed 2

3

See K. L. Wilson et al., “A Review of 21 Curricula for Abstinence-Only-UntilMarriage Programs,” The Journal of School Health, vol. 75, no. 3 (2005), and The Content of Federally Funded Abstinence-Only Education Programs, United States House of Representatives, Committee on Government ReformMinority Staff, Special Investigations Division (2004). See, for example, E. A. Borawski et al., “Effectiveness of Abstinence-only Intervention in Middle School Teens,” American Journal of Health Behavior, vol. 29, no. 5 (2005), and J. B. Jemmott III, L. S. Jemmott, and G. T. Fong, “Abstinence and Safer Sex HIV Risk- Reduction Interventions for African American Adolescents: A Randomized Controlled Trial,” Journal of the American Medical Association, vol. 279, no. 19 (1998).

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United States Government Accountability Office

published reports, program announcements, Federal Register notices, agency Web sites, and other documents related to abstinenceuntil-marriage education. We focused our review on efforts related to the three main federally funded abstinence-until-marriage education programs administered by HHS, as well as efforts to review the accuracy of scientific facts included in abstinence-untilmarriage education materials. We did not assess the criteria used to determine the scientific accuracy of education materials or the quality of the reviews. We interviewed officials from ACF, the Health Resources and Services Administration (HRSA), OPA, and CDC. We also interviewed officials from the 10 states that received the largest share of federal funding (together accounting for 51 percent of the total funding in fiscal year 2005) through the State Program for abstinence-until-marriage education.4 To describe efforts by HHS, states, and researchers to assess the effectiveness of abstinence-until-marriage education programs, we focused on efforts that examined the extent to which these programs achieved their program goals. In general, these goals include teaching adolescents to abstain from sexual activity until marriage in order to avoid unintended pregnancies, STDs, and related health problems. As part of our review, we compared these efforts to the design characteristics that experts have identified as important for a scientifically valid study of program effectiveness.5 We reviewed journal articles and other published

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5

The 10 states that received the largest share of funding in fiscal year 2005 through the State Program were Arizona, Florida, Georgia, Illinois, Louisiana, Michigan, New York, North Carolina, Ohio, and Texas. See Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001). The experts identifying the design characteristics of a scientifically valid study for the National Campaign to Prevent Teen Pregnancy were drawn from institutions that include the National Institutes of Health, the Medical Institute for Sexual Health, the Alan Guttmacher Institute, the Institute for Research and Evaluation, and various universities. See David Satcher, The National Consensus Process on Sexual Health and Responsible Sexual Behavior: Interim Report (Atlanta: Morehouse School of Medicine, 2006). The panel convened by David Satcher included experts from a variety of organizations, including the Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American Academy of Pediatrics. In addition, characteristics of a scientifically valid study have been identified by other experts in the field of evaluation research. For example, see Carol H. Weiss,

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reports, agency budget submissions, program announcements, agency and grantee performance reports, Federal Register notices, agency Web sites, and other documents related to abstinence-until-marriage education. (For a more detailed description of our literature review methodology, see app. II). We also interviewed officials from ACF, HRSA, OPA, CDC, the National Institutes of Health (NIH), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and 10 states that received the largest share of federal funding for abstinence-only education through the State Program in fiscal year 2005. We also interviewed individuals from the National Campaign to Prevent Teen Pregnancy, The Brookings Institution, ETR Associates, The Heritage Foundation, and Advocates for Youth, and researchers from Case Western Reserve University and Columbia University to obtain general information regarding the state of the research on abstinence-until-marriage education. We focused our review on efforts to assess the scientific accuracy of materials and the effectiveness of the programs during fiscal year 2006, and also reviewed the administration of the programs back to fiscal year 2001. We also attended conferences organized by ACF and OPA to learn about training that is provided to grantees on scientific accuracy and program evaluations. To describe how HHS selected a contractor for the abstinence-untilmarriage technical assistance contract that was awarded in September 2002, we reviewed the Request for Proposals and other related contract documents. We also interviewed officials at HRSA, ACF, and the National Abstinence Clearinghouse about the technical assistance contract. We performed our work from October 2005 through September 2006 in accordance with generally accepted government auditing standards.

RESULTS IN BRIEF Efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs have been limited. This is because ACF—which awards grants through two programs that account for the largest portion of federal spending on abstinence-untilmarriage education—does not review its grantees’ education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy. In addition, not all states that receive funding through ACF’s State Program have chosen to review their program materials for scientific accuracy. In Evaluation (Upper Saddle River: Prentice Hall, 1998).

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United States Government Accountability Office

particular, 5 of the 10 states in our review conduct such reviews. Officials from these states reported using a variety of approaches in their reviews. In contrast, OPA does review the scientific accuracy of AFL grantees’ proposed educational materials and any inaccuracies found must be corrected before the materials can be used. While the extent to which federally funded abstinence-until-marriage education materials are inaccurate is not known, in the course of their reviews OPA and some states reported that they have found some inaccuracies in abstinence-until-marriage education materials. For example, OPA has required that a grantee correct several statements in a true/false quiz—including statements about STDs and condom use—in order for the quiz to be approved for use in its curriculum. In addition, one state official described an instance in which abstinence-until-marriage materials incorrectly suggested that HIV can pass through condoms because the latex used in condoms is porous. HHS, states, and researchers have made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs; however, a number of factors limit the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. To assess the effectiveness of their abstinence-until-marriage education programs, ACF and OPA have required their grantees to report on various outcomes that the agencies use to measure the effectiveness of grantees’ abstinenceuntil-marriage education programs. For example, as of fiscal year 2006, states that receive funding through the State Program are required to report annually on four measures of the prevalence of adolescent sexual behavior in their state, such as the rate of pregnancy among adolescents aged 15 to 17 years. To assess the effectiveness of both its State and Community-Based Programs, ACF also analyzes trends in adolescent behavior, as reflected in national data on birth rates among teens and the proportion of surveyed high school students reporting that they have had sexual intercourse. OPA requires grantees of the AFL Program to develop and report on outcome measures that demonstrate the extent to which grantees’ programs are having an effect on program participants. In addition, other HHS agencies and offices— ASPE, CDC and NIH—are making efforts to assess the effectiveness of abstinence-until-marriage education programs. Further, 6 of the 10 states in our review that receive funding through the State Program have worked with thirdparty evaluators to assess the effectiveness of abstinence-until-marriage education programs in their states. Several factors, however, limit the conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts to evaluate the effectiveness of abstinence-until-marriage education programs that we describe in our review have not met certain minimum criteria—such as random assignment of participants and sufficient follow-up

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periods and sample sizes—that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid, in part because such designs can be expensive and time-consuming to carry out. In addition, the results of efforts that meet the criteria of a scientifically valid assessment have varied and two key studies funded by HHS that meet these criteria have not yet been completed. When completed, these HHS-funded studies may add substantively to the body of research on the effectiveness of abstinence-untilmarriage education programs. To address concerns about the scientific accuracy of materials used in abstinence-until-marriage education programs, we recommend that the Secretary of HHS develop procedures to help assure the accuracy of such materials used in the State and Community-Based Programs. To help provide such assurance, the Secretary could consider alternatives such as (1) extending the approach currently used by OPA to review the scientific accuracy of the factual statements included in abstinence-until-marriage education to materials used by grantees of ACF’s Community-Based Program and requiring grantees of ACF’s State Program to conduct such reviews or (2) requiring grantees of both programs to sign written assurances in their grant applications that the materials they propose using are accurate. In commenting on a draft of this report, HHS agreed to consider requiring grantees of both ACF programs to sign written assurances in grant applications that the materials they use are accurate. In addition, HHS noted that all federal grant applicants attest on a standard form that information in their applications is correct. However, it is not clear that this serves the purpose of assuring the scientific accuracy of the educational materials. Further, the curricula to be used are not required to be included with states’ applications. HHS’s written comments also stated that ACF requires that the Community-Based Program curricula conform to standards that are grounded in scientific literature by requiring certain types of information. However, the inclusion of certain types of information does not necessarily ensure the accuracy of the scientific facts included in the abstinence-until-marriage materials. In addition, HHS noted in its written comments that we did not define the term scientific accuracy and stated that it disagreed with certain findings of the report because it was difficult to precisely determine the criteria employed by GAO in making the recommendation as to scientific accuracy. However, the objective of our work was to focus on efforts by HHS and states to review the accuracy of scientific facts included in abstinenceuntilmarriage education materials and not to perform an independent assessment of the criteria used or the quality of the reviews. With regard to effectiveness,

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HHS agreed that it may be too soon to draw conclusions about the effectiveness of ACF’s and OPA’s programs.

BACKGROUND Recent statistics from CDC show that many high school students engage in sexual behavior that places them at risk for unintended pregnancy and STDs. In 2005, 46.8 percent of high school students reported that they have ever had sexual intercourse, with 14.3 percent of students reporting that they had had sexual intercourse with four or more persons. The likelihood of ever having sexual intercourse varied by grade, with the highest rate among 12th grade students (63.1 percent) and the lowest rate among 9th grade students (34.3 percent). CDC also has reported that the prevalence of certain STDs—including the rate of chlamydia infection, the most frequently reported STD in the United States—peaks in adolescence and young adulthood. According to CDC, in 2004 the chlamydia rates among adolescents 15 to 19 years old (1,579 cases per 100,000 adolescents) and young adults 20 to 24 years old (1,660 cases per 100,000) were each more than twice the rates among all other age groups.

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Table 1: Definition of Abstinence Education Abstinence education refers to an educational or motivational program that: A. as as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; B. teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; C. teaches that abstinence from sexual activity is the only certain way to avoid out-ofwedlock pregnancy, sexually transmitted diseases, and other associated health problems; D. teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; E. teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; G. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and H. teaches the importance of attaining self-sufficiency before engaging in sexual activity.

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Source: Social Security Act, § 510(b)(2) (codified at 42 U.S.C. § 710(b)(2)).

HHS’s current strategic plan includes the objectives to reduce the incidence of STDs and unintended pregnancies and to promote family formation and healthy marriages. These two objectives support HHS’s goals to reduce the major threats to the health and well-being of Americans and to improve the stability and healthy development of American children and youth, respectively. Abstinence-untilmarriage education programs are one of several types of programs that support these objectives.6 The three main federal abstinence-until-marriage education programs— the State Program, the Community-Based Program, and the AFL Program—provide grants to support the recipients’ own efforts to provide abstinence-until-marriage education at the local level.7 These programs must comply with the statutory definition of abstinence education (see table 1).8

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HHS’s Family Planning Program, for example, also supports the objective to reduce the incidence of STDs and unintended pregnancies by providing access to contraceptive supplies and family planning information, especially for low-income persons, at community health clinics. This program is authorized under Title X of the Public Health Service Act. 7 There are other federal sources of funding that are used for abstinence education, such as the Temporary Assistance for Needy Families (TANF) Program that is administered by ACF. Some states have allocated some of their TANF funding for abstinence education programs. For example, Florida has used TANF funds to provide community-based and faith-based organizations with contracts to carry out abstinence education. Other sources of funding that are used for abstinence education include ACF’s Compassion Capital Fund and CDC’s Division of Adolescent and School Health grants. 8 42 U.S.C. § 710(b)(2). This definition is also referred to as the A-H definition. This statutory provision defines abstinence education for purposes of the State Program. Annual appropriations acts and program announcements have extended this definition to the Community-Based and AFL Programs. See, e.g , Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2006,Pub. L. No. 109- 149,119 Stat. 2833, 2855-56.

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The State Program

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The State Program, administered by ACF, provides funding to its grantees— states—for the provision of abstinence-until-marriage education to those most likely to have children outside of marriage.9 States that receive grants through the State Program have discretion in how they use their funding to provide abstinence-until-marriage education. Some require that organizations apply for funds and use them to administer abstinenceuntil-marriage education programs. Others may directly administer such programs. At their discretion, states may also provide mentoring, counseling, and adult supervision to adolescents to promote abstinence from sexual activity until marriage. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 established the State Program, and states were awarded grants beginning in fiscal year 1998.10 Funds are allotted to each state that submits the required annual application based on the ratio of the number of low-income children in the state to the total number of low-income children in all states. States are required to match every $4 they receive in federal money with $3 of nonfederal money and are required to report annually on the performance of the abstinence-until-marriage education programs that they support or administer. In fiscal year 2005, 47 states, the District of Columbia, and 3 insular areas were awarded funding.11,12

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Through the State Program funds are also provided to insular areas and the District of Columbia. 10 Pub. L. No. 104-193, § 912; 110 Stat. 2353-54 (codified at 42 U.S.C. § 710). 11 In this report, we refer to U.S. territories and commonwealths as “insular areas.” 12 Some states and insular areas have not applied for funding under the State Program. California, Maine, and Pennsylvania did not apply for funding under the State Program in fiscal year 2005. In this report, when we refer to “states,” we are referring to all grantees of the State Program—including states, insular areas, and the District of Columbia.

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The Community-Based Program The Community-Based Program, which is also administered by ACF, is focused on funding public and private entities that provide abstinenceuntilmarriage education for adolescents from 12 to 18 years old, with the purpose of creating an environment within communities that supports adolescent decisions to postpone sexual activity until marriage. The Community-Based Program provides grants for school-based programs, adult and peer mentoring, and parent education groups. The Community- Based Program first awarded grants in fiscal year 2001.13 Grantees of the Community-Based Program are selected through a competitive process and are evaluated according to several criteria, such as the extent to which they have demonstrated that a need exists for abstinence-untilmarriage education for a targeted population or in a specific geographic location. Grantees are required to report to ACF, on a semiannual basis, on the performance of their programs. For fiscal year 2005, 63 grants were awarded to organizations and other entities.14

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The AFL Program The AFL Program supports programs that provide abstinence-untilmarriage education.15 The primary purpose of these programs is to find effective means of reaching preadolescents and adolescents before they become sexually active in order to encourage them to abstain from sexual activity and other risky behaviors. Under the AFL Program, OPA awards competitive grants to public or private nonprofit organizations or agencies, including community-based and faith-based organizations, to facilitate abstinence-until-marriage education in a variety of 13

The Community-Based Program is conducted under section 1110 of the Social Security Act. See 42 U.S.C. § 1310. 14 In addition to the 63 grants awarded in fiscal year 2005, ACF is also responsible for other grants that the agency awarded before 2005. 15 See 42 U.S.C. § 300z et seq. The AFL Program also supports other projects for pregnant and parenting adolescents, their infants, male partners, and family members. The purpose of these projects is to improve the outcomes of early childbearing for teen parents, their infants, and their families. However, in this report, when we use the term “AFL Program,” we are referring only to the abstinence-until-marriage component of the AFL Program.

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settings, including schools and community centers. Established in 1981, the AFL Program began awarding grants in fiscal year 1982. AFL Program grantees include school districts, youth development groups, and medical centers. Grant applicants are evaluated based on several criteria, such as the extent to which they provide a clear statement of mission, goals, measurable objectives, and a reasonable method for achieving their objectives. Grantees are required to conduct evaluations of certain aspects of their programs and report annually on their performance. As of August 2006, OPA funded 58 abstinence-until-marriage education programs, and most of these were focused on reaching young adolescents from the ages of 9 to 14. Table 2. Funding Provided by HHS for the Three Main Abstinence-until-Marriage Education Programs.

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Dollars in millions Fiscal year

State Programa,b

Community-Based Program

AFL Program

2001

$43

$20

$10

2002

43

40

12

2003

44

55

13

2004

41

75

13

2005

41

104

13

Sources: ACF, OPA, and HRSA. Notes: Figures are rounded to nearest $1 ,000,000. Funding levels represent the total amount of grants awarded and funding for program-related support, such as technical assistance and evaluation. aStates that receive funding are required to match every $4 they receive of federal funds with $3 of nonfederal money. bThe amount of funding provided by HHS for the State Program has generally varied by year because the states that have applied for funding each year have varied.

Funding for Abstinence-Until-Marriage Education Has Increased Funding provided by HHS for abstinence-until-marriage education programs has increased steadily since 2001 (see table 2). For the three main programs combined—the State Program, the Community-Based Program, and the AFL Program—the amount of agency funding increased from about $73 million in fiscal year 2001 to about $158 million in fiscal year 2005. Nearly all of this

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increase was for the Community-Based program; funding under this program increased by about $84 million from fiscal years 2001 through 2005. In fiscal year 2005, agency funding for the Community-Based Program constituted the largest share of the total funding (about 66 percent) for the three main programs combined. Within each of the three main abstinence-until-marriage education programs, the amount of individual grants varied.16 In fiscal year 2005, the State Program’s annual grants ranged from $57,057 to $4,777,916 and the median annual grant amount was $569,675. That same year, the Community-Based Program’s annual grants ranged from $213,276 to $800,000 and the median grant amount was $642,250. In fiscal year 2006, the AFL Program’s annual grants ranged from $95,676 to $300,000 and the median grant amount was $225,000.

Federal Agency Responsibilities Related to Abstinence-untilMarriage Education

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Five organizational units located within HHS—ACF, OPA, CDC, ASPE, and NIH—have responsibilities related to abstinence-until-marriage education. ACF and OPA administer the three main federal abstinence-until-marriage education programs. CDC supports abstinence-until-marriage education at the national, state, and local levels. CDC, ASPE, and NIH are sponsoring research on the effectiveness of abstinence-until-marriage programs.

ACF ACF is responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities. ACF administers and provides oversight of both the State Program and the CommunityBased Program by, among other things, awarding grants, providing training and technical assistance to grantees, and requiring annual performance reporting from grantees. ACF has been responsible for the State Program since June 2004 and the 16

ACF awards formula grants under the State Program each year, and states have 2 years to spend the funds they are awarded. In the Community-Based Program and AFL Program, grantees develop multiyear projects—up to 5 years—for which the first year of funding is provided through competitive grants; for subsequent years, grantees may obtain funding through noncompetitive continuation grants.

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Community-Based Program since October 2005. HRSA previously administered these programs.

OPA OPA has responsibility for advising the Secretary of HHS on a wide range of reproductive health topics, including adolescent pregnancy and family planning. The office is also responsible for administering programs that provide services for pregnant and parenting teens and prevention programs, such as abstinence-untilmarriage education programs. OPA administers and provides oversight of the AFL Program by awarding grants, providing training and technical assistance to grantees, and requiring annual performance reporting from grantees.

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CDC CDC is primarily responsible for the prevention and control of infectious and chronic diseases, including STDs. CDC provides funding to state and local education agencies in their efforts to support comprehensive school health education and HIV/STD prevention education programs, and CDC officials told us that some of these are focused on abstinence. CDC also provides funding to several state education agencies to implement various abstinence projects, such as collaboration-building among agencies to increase the impact of their efforts to encourage abstinence. Further, CDC develops tools to assist state and local education agencies with their health education programs. CDC provides funding to several national organizations to build the capacity of abstinence-until-marriage education providers. Organizations’ activities include, but are not limited to, the development and distribution of educational materials. CDC is also sponsoring research on the effectiveness of an abstinence-until-marriage education program.

ASPE ASPE advises the Secretary of HHS in several areas, including policy development in health, human services, data, and science. ASPE is responsible for the development of policy analyses and it conducts research and evaluation studies in several areas, including the health of children and adolescents. ASPE is currently sponsoring research on the effectiveness of abstinence-until-marriage education programs.

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NIH NIH is the primary federal agency that conducts and supports medical and behavioral research among various populations, including children and adolescents. NIH is currently sponsoring research on the effectiveness of abstinence-until-marriage education programs.

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FEDERAL AND STATE EFFORTS TO ASSESS THE SCIENTIFIC ACCURACY OF MATERIALS USED IN ABSTINENCEUNTIL-MARRIAGE EDUCATION PROGRAMS HAVE BEEN LIMITED Efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs have been limited. ACF—which awards grants to two programs that account for the largest portion of federal spending on abstinence-until-marriage education—does not review its grantees’ education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy. In addition, not all states funded through the State Program have chosen to review their program materials for scientific accuracy. In contrast to ACF, OPA has reviewed the scientific accuracy of grantees’ proposed educational materials and corrected inaccuracies in these materials.

ACF does not Review Program Materials for Scientific Accuracy and does not Require Grantees to do so, though Some State Grantees have Conducted Such Reviews There have been limited efforts to review the scientific accuracy of educational materials used in ACF’s State and Community-Based Programs—the two programs that account for the largest portion of federal spending on abstinence education. ACF does not review materials for scientific accuracy in either reviewing grant applications17 or in overseeing grantees’ performance. Prior 17

In reviewing grantees applications, ACF does examine several issues, including applicants’ stated program goals and need for assistance, their compliance with the A-H definition of abstinence education, their intended approach in

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to fiscal year 2006, State Program and Community-Based Program applicants were not required to submit copies of their proposed educational materials with their applications. While ACF required grantees of the Community-Based Program—but not the State Program—to submit their educational materials with their fiscal year 2006 applications, ACF officials told us that grantee applications and materials are only reviewed to ensure that they address all aspects of the scope of the Community-Based Program, such as the A-H definition of abstinence education.18 Further, documents provided to us by ACF indicate that the agency does not review grantees’ educational materials for scientific accuracy as a routine part of its oversight activities. In addition, ACF also does not require its grantees to review their own materials for scientific accuracy. Similarly, when HRSA was responsible for the State and Community-Based Programs, the agency did not review materials used by grantees for scientific accuracy or require grantees to review their own materials. Not all grantees of the State Program have chosen to review the scientific accuracy of their educational materials. Officials from 5 of the 10 states in our review reported that their states have chosen to conduct such reviews.19,20 Officials in these states identified a variety of reasons why their states reviewed abstinence-until-marriage educational materials, including program requirements, state education laws and guidelines, and past lawsuits, to ensure that materials used in abstinence-until-marriage programs were accurate. For example, Michigan’s Revised School Code states that materials and instruction in the sex

18

19

20

carrying out their objectives, and their budget plan. HHS officials told us that if ACF finds inaccurate statements during this more general review process or if inaccuracies are brought to their attention at any time during the grant period, ACF officials work with the grantees to take corrective action. In addition to reviewing materials for accuracy, one state requires abstinenceuntilmarriage providers to sign a written assurance that their materials are scientifically accurate. Officials from this state also reported providing abstinence-until-marriage education programs with public health consultants to provide technical assistance and training to help ensure the accuracy of their educational materials. In addition, some state officials we interviewed told us that review committees for local school districts may review the scientific accuracy of educational materials that include information about HIV and other STDs, including abstinence-until-marriage education materials.

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education curricula, including information on abstinence, “shall not be medically inaccurate,”21 and Ohio’s fiscal year 2007 abstinence-until-marriage education program guidance states that abstinence-until-marriage educational materials “should be medically accurate in all assertions.”22 The five states we contacted that review abstinence-until-marriage educational materials for scientific accuracy have used a variety of approaches in their reviews. Some states contracted with medical professionals—such as nurses, gynecologists, and pediatricians—to serve as medical advisors who review program materials and use their expertise to determine what is and is not scientifically accurate. Some states have created checklists or worksheets to guide their staff conducting the review and document findings of inaccuracy or verification of a statement. All five states use medical professionals in conducting these reviews. One of the states requires that all statistics or scientific statements cited in a program’s materials are sourced to CDC or a peer-reviewed medical journal. Officials from this state told us that if statements in these materials cannot be attributed to these sources, the statements are required to be removed until citations are provided and materials are approved. Officials from this state told us they have also supplemented their review of program materials with on-site classroom observations to assess the scientific accuracy of the information presented to students. Officials from two of the five states reported that they have found inaccuracies as a result of their reviews. For example, one state official stated that because information is constantly evolving, state officials have had to correct outof-date scientific information. In addition, this official cited an instance where materials incorrectly suggested that HIV can pass through condoms because the latex used in condoms is porous. In addition, this official provided documentation that the state has had to correct a statement indicating that when a person is infected with the human papillomavirus,23 the virus is “present for life” because, in almost all cases, this is not true. State officials who have identified inaccuracies told us that they informed their grantees of inaccuracies so that they could make corrections in their individual programs. One state official added that she contacted the authors of the materials to report an inaccuracy.

21

Mich. Comp. Laws Ann. § 380. 1507b(2)(West 2004). See Ohio Department of Health, “Abstinence Education Program Request for Proposals for Fiscal Year 2007,” (program announcement, 2005). 23 The human papillomavirus (HPV) causes an STD called genital HPV infection. 22

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Some of the educational materials that states have reviewed are materials that are commonly used in the Community–Based Program. Officials from four of the five states that review materials for scientific accuracy told us that they have each reviewed at least one of the five curricula most commonly used in the Community-Based Program because programs in their state were using them: Choosing the Best, WAIT Training, Sex Can Wait, A. C. Green’s Game Plan Abstinence Program, and Worth the Wait. Based on ACF documents, we found that there were 58 different curricula used by grantees of the Community-Based Program in fiscal year 2005. However, more than half of the grantees of the Community-Based Program reported using at least one of these five curricula.24 While there has been limited review of materials used in the State and Community-Based Programs, grantees of these programs have received some technical assistance designed to improve the scientific accuracy of their materials. For example, ACF officials reported that the agency provided a conference for grantees of the Community-Based Program in February 2006 that included a presentation focused on medical accuracy, including a discussion of state legislative proposals that would require medical accuracy in abstinence-untilmarriage education, and how to identify reliable data. In addition, in 2002, HRSA awarded a contract to the National Abstinence Clearinghouse requiring, among other things, that the contractor develop and implement a program to provide medically accurate information and training to grantees of the State and Community- Based Programs.25 (See app. I for a description of HRSA’s process for awarding this contract). The portion of the contract that focused on providing medically accurate information to grantees was subcontracted to the Medical Institute for Sexual Health (Medical Institute),26 which has conducted presentations at regional educational conferences to provide grantees with medical and scientific information, such as updated information on condoms and STD transmission. The Medical Institute has also provided consultative services to grantees by responding to medical and scientific questions.

24

Some grantees of the Community-Based Program reported using more than one of these curricula in fiscal year 2005. 25 The administration of this contract was transferred to ACF in May 2005. 26 The Medical Institute is a nonprofit organization that provides educational resources, conferences, and seminars to educators, health professionals, pregnancy care centers, and faith-based groups about behaviors to decrease STDs and out-of-wedlock pregnancies, including abstinence.

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OPA Reviews Materials Used by AFL Program Grantees for Scientific Accuracy In contrast to ACF, OPA reviews for scientific accuracy the educational materials used by AFL Program grantees. Specifically, OPA reviews its grantees’ proposed educational materials for scientific accuracy before they are used. Agency officials stated that they began to review these materials while litigation concerning the AFL Program was ongoing. OPA continued to review these materials as part of a 1993 settlement to this lawsuit.27 The settlement agreement expired in 1998, though the agency has continued to review grantees’ proposed educational materials for accuracy as a matter of policy. OPA officials told us that grant applicants submit summaries of materials they propose to use, though the materials are not reviewed for scientific accuracy until after grantees have been selected. OPA officials said that after grants are awarded, a medical education specialist (in consultation with several part-time medical experts) reviews the grantees’ printed materials and other educational media, such as videos. OPA officials explained that the medical education specialist must approve all materials before they are used. On many occasions, OPA grantees have proposed using— and therefore OPA has reviewed— materials commonly used in the CommunityBased Program. For example, an OPA official told us that the agency had reviewed three of the Community-Based Program’s commonly used curricula— Choosing the Best, Sex Can Wait, and A. C. Green’s Game Plan Abstinence Program— and is also currently reviewing another curriculum commonly used by Community-Based Program grantees, WAIT Training.28 OPA officials stated that the medical education specialist has occasionally found and addressed inaccuracies in grantees’ proposed educational materials. OPA officials 27

28

See generally Bowen v. Kendrick, 487 U.S. 589 (1988), 657 F. Supp 1547 (D.D.C. 1987). In addition, a CDC official told us that some of its grantees are producing educational materials with CDC funds to be used by abstinence-untilmarriage education programs, which are likely to include State and Community-Based Program grantees. These materials are required to be reviewed for scientific accuracy. CDC officials told us that they have made corrections to some of these materials. Materials used in school-based HIV prevention education programs that are supported with CDC funds are also reviewed for scientific accuracy. A CDC official told us that some of these programs are abstinenceuntil-marriage education programs.

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stated that these inaccuracies are often the result of information being out of date because, for example, medical and statistical information on STDs changes frequently. OPA has addressed these inaccuracies by either not approving the materials in which they appeared or correcting the materials through discussions with the grantees and, in some cases, the authors of the materials. In fiscal year 2005, OPA disapproved of a grantee using a specific pamphlet about STDs because the pamphlet contained statements about STD prevention and HIV transmission that were considered incomplete or inaccurate. For example, the pamphlet stated that there was no cure for hepatitis B, but the medical education specialist required the grantee to add that there was a preventive vaccine for hepatitis B. In addition, OPA required that a grantee correct several statements in a true/false quiz—including statements about STDs and condom use—in order for the quiz to be approved for use. For example, the medical education specialist changed a sentence from “The only 100% effective way of avoiding STDs or unwanted pregnancies is to not have sexual intercourse.” to “The only 100% effective way of avoiding STDs or unwanted pregnancies is to not have sexual intercourse and engage in other risky behaviors.” While OPA and some states have reviewed their grantees’ abstinence-untilmarriage education materials for scientific accuracy,29 these types of reviews have the potential to affect abstinence-until-marriage education providers more broadly. Such efforts may create an incentive for authors of abstinence-untilmarriage education materials to ensure they are accurate. Thus, some authors of abstinence-until-marriage education materials have recently updated materials in their curricula following reports that questioned their accuracy. For example, one of the most widely used curricula used by grantees of the Community-Based Program—WAIT Training—has been recently updated and provides the updated information on its Web site. A representative from WAIT Training stated that the company recently revised its curriculum, in part, in response to a congressional review that found inaccuracies in its abstinence-until-marriage education materials.

29

In addition to OPA and some states, others have also reviewed the scientific accuracy of abstinence-until-marriage education materials. See, for example, Wilson et al.

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A VARIETY OF EFFORTS HAVE BEEN MADE TO ASSESS THE EFFECTIVENESS OF ABSTINENCE-UNTIL-MARRIAGE EDUCATION PROGRAMS, BUT A NUMBER OF FACTORS LIMIT THE CONCLUSIONS HHS, states, and researchers have made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs; however, a number of factors limit the conclusions that can be drawn about the effectiveness of these programs. ACF and OPA have required their grantees to report on various outcomes used to measure the effectiveness of grantees’ abstinence-until-marriage education programs,30 though the reporting requirements for each of the three abstinence-until-marriage programs differ. In addition, to assess the effectiveness of the State and Community-Based Programs, ACF has analyzed national data on adolescent birth rates and the proportion of adolescents who report having had sexual intercourse. Other organizational units within HHS— ASPE, CDC, and NIH—are funding studies designed to assess the effectiveness of abstinence-untilmarriage education programs in delaying sexual initiation, reducing pregnancy and STD rates, and reducing the frequency of sexual activity. Despite these efforts, several factors limit the conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts to evaluate the effectiveness of abstinence-until-marriage education programs that we describe in our review have not met certain minimum criteria that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid, in part because such designs can be expensive and timeconsuming to carry out. In addition, the results of some efforts that meet the criteria of a scientifically valid assessment have varied, and two key studies that meet these criteria have not yet been completed. 30

This reporting is a part of ACF’s efforts to collect evaluative information about these programs. These efforts include both performance measurement—the ongoing monitoring and reporting of program accomplishments toward preestablished goals—and program evaluation—individual systematic studies to assess how well a program is working. Both types of assessments aim to support decisions to improve service delivery and program effectiveness. See GAO, Performance Measurement and Evaluation: Definitions and Relationships, GAO-05-739SP (Washington, D.C.: May 2005), for more information on types of assessments.

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HHS, States, and Researchers Have Made a Variety of Efforts to Assess the Effectiveness of Abstinence-until-Marriage Education Programs Efforts of HHS, states, and researchers to assess the effectiveness of abstinence-until-marriage education programs have included ACF and OPA requiring grantees to report data on outcomes of their abstinenceuntil-marriage education programs; ACF analyzing national data on adolescent behavior and birth rates; and other HHS agencies, states, and researchers funding or conducting studies to assess the effectiveness of abstinence-until-marriage education programs.

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ACF and OPA Have Required Grantee Reporting of Data on Outcomes ACF has made efforts to assess the effectiveness of abstinence-untilmarriage education programs funded by the State Program and the Community-Based Program. One of ACF’s efforts has been to require grantees of both programs to report data on outcomes, though the two programs have different requirements for the outcomes grantees must report. For the State Program, as of fiscal year 2006, grantees must report annually on four measures of the prevalence of adolescent sexual behavior in their states, such as the rate of pregnancy among adolescents aged 15 to 17 years, and compare these data to program targets over 5 years. To report on these four measures, states may choose the data sources they will use.31 States must also develop and report on two additional performance measures that are related to the goals of their programs.32

31

Previously, to report on the four measures, states have relied on either state or national data sources, such as CDC’s Youth Risk Behavior Surveillance System. 32 For example, in fiscal year 2002, state grantees developed such measures as the percentage of teens surveyed who show an increase in participating in structured activities after school hours; the percentage of live births to women younger than 18, fathered by men age 20 and older; the percentage of program participants proficient in refusal skills; the percentage of high school students who reported using drugs or alcohol before intercourse; and the percentage of high school students who had sexual intercourse for the first time before age 13.

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(See table 3 for a list of ACF’s fiscal year 2006 reporting requirements for the State Program.) As of fiscal year 2006, ACF requires Community-Based Program grantees to develop and report on outcome measures designed to demonstrate the extent to which grantees’ community-based abstinence education programs are accomplishing their program goals.33 ACF requires grantees of the CommunityBased Program to contract with third-party evaluators, who are responsible for both helping grantees develop the outcome measures and monitoring grantee performance against the measures,34 but because this is a new requirement established for fiscal year 2006 grantees, ACF has not yet received the results of these evaluations. In addition to outcome reporting, ACF requires grantees of the Community-Based Program to report on program “outputs,” which measure the quantity of program activities and other deliverables, such as the number of participants who are served by the abstinence-until-marriage education programs. According to ACF officials, the agency requires grantees of both the State Program and the Community-Based Program to report on program outcomes in order to monitor grantees’ performance, target training, and technical assistance, and help grantees improve service delivery. (See table 3 for a list of ACF’s fiscal year 2006 reporting requirements for the Community-Based Program.)

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Table 3: ACF’s Reporting Requirements for the State Program and the Community- Based Program, Fiscal Year 2006. State Program • Report on four performance measures: (1) rate of pregnancy among female teenagers aged 15 to 17, (2) proportion of adolescents who have engaged in sexual intercourse, (3) incidence of youths 15 to 19 years old who have 33

34

Community-Based Program • Report on program goals that are developed by grantees with a thirdparty evaluator. Such outcomes could include changes in knowledge about abstinence or declared behavior among participants of abstinence-until-

The fiscal year 2006 program announcement for the Community-Based Program provides examples of outcome measures that grantees could use, including increased knowledge of the benefits of abstinence, the number of youths who commit to abstaining from premarital sexual activity, and increased knowledge of how to avoid high-risk situations and risk behaviors. Fiscal year 2006 Community-Based Program grantees are required to devote a minimum of 15 percent of their requested budgets to performance monitoring by third-party contractors.

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•

contracted selected STDs, and (4) rate of births among female teenagers aged 15 to 17. Develop and report on two additional performance measures that are related to individual program goals. Past examples of these additional measures have included the percentage of high school students who reported using drugs or alcohol before intercourse and the percentage of high school students who had sexual intercourse for the first time before age 13.

marriage programs.

•

Report on program “outputs”: the number of youth served, the hours of service provided to each youth, and the number of youths who complete the program. Grantees choose additional outputs that allow for effective monitoring and management of the project. The additional outputs may include tracking the number of staff trained to provide services, the number of events hosted, number of marketing materials distributed, and so forth.

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Sources: State and Community-Based Programs’ announcements, fiscal year 2006.

ACF’s fiscal year 2006 reporting requirements for grantees of the State Program are the same as HRSA’s when it administered the State Program. In contrast, ACF’s fiscal year 2006 reporting requirements for the CommunityBased Program differ from HRSA’s reporting requirements for the program. For example, for Community-Based Program grants awarded in fiscal year 2001, HRSA required35 grantees to report on the effectiveness of their programs, as measured by program participation as well as behavioral and biological outcomes.36 These performance measures were modified for fiscal year 2002, in 35

Some grantees of the Community-Based Program may have to meet reporting requirements established by HRSA. Grants under this program are awarded for projects that may extend over a period of several years. Grantees that were awarded grants when HRSA administered the program and have since received noncompetitive continuation grants for these projects are required to meet the reporting requirements in place at the time they first received the competitively awarded grants. 36 In fiscal year 2001, HRSA required grantees of the Community-Based Program to report on the following four performance measures: the proportion of program participants who successfully complete or remain enrolled in an abstinence-only education program; the proportion of program participants who have engaged in sexual intercourse; the proportion of program participants who report a reduction in risk behaviors, such as tobacco, alcohol, and drug use; and the rate of births to female program participants.

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part HHS officials explained, because of concerns expressed by members of the abstinence-education community that the original performance measures did not accurately reflect the efforts of the grantees of the Community-Based Program. For grants awarded from fiscal years 2002 through 2004, HRSA required grantees of the Community-Based Program to report on a combination of program outputs, such as the proportion of adolescents who completed an abstinence-until-marriage education program, and measures of adolescent intentions, such as the proportion of adolescents who committed to abstaining from sexual activity until marriage.37 For grants awarded in fiscal year 2005, when ACF assumed responsibility for the Community- Based Program from HRSA, grantees were not required to report on any specific performance measures. OPA has also made efforts to assess the effectiveness of the AFL Program. Specifically, OPA requires grantees of the AFL Program to develop and report on outcome measures that are used to help demonstrate the extent to which grantees’ programs are having an effect on program participants.38,39 According to OPA officials, the agency recommends that grantees report on outcome measures, such as participants’ knowledge of the benefits of abstinence and their reported intentions to abstain from sexually activity, reported beliefs in their ability to remain abstinent, and reported parental involvement in their lives. To collect data

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37

Specifically, HRSA required grantees of the Community-Based Program to report annually on the following six performance measures: the proportion of program participants who successfully completed or remained enrolled in an abstinence-only education program; the proportion of adolescents who understood that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy and STDs; the proportion of adolescents who indicated an understanding of the social, psychological, and health gains to be realized by abstaining from premarital sexual activity; the proportion of participants who reported that they had the skills necessary to resist sexual urges and advances; the proportion of youth who committed to abstaining from sexual activity until marriage; and the proportion of participants who intended to avoid situations and risk behaviors, such as drug use and alcohol consumption, which make them more vulnerable to sexual advances and urges. 38 In addition to these outcomes, grantees of the AFL Program are required to report on program outputs, such as the number of program participants, the average number of participants per session, and the average number of sessions attended by participants. Agency officials stated that OPA has implemented a new format for its grantees’ reports, which is intended to standardize their reporting on these outputs. 39 OPA’s grantees are required to perform evaluations of their programs that are directly tied to their program objectives. For these evaluations, OPA requires grantees to develop research hypotheses that reflect the outcomes the grantees intend to achieve. This type of evaluation is generally considered to be an outcome evaluation—which assesses the extent to which a program achieves its outcomeoriented objectives. These evaluations focus on outputs and outcomes to judge program effectiveness but may also assess program process to understand how outcomes are produced. In addition, grantees of the AFL Program are required to perform implementation evaluations.

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on these outcome measures and any others, OPA requires all grantees funded in fiscal year 2004 and beyond to administer, at a minimum, a standardized questionnaire—developed by OPA—to their program participants, both when participants begin an abstinence-only education program and after the program’s completion.40 The standardized questionnaire includes questions intended to obtain information on participants’ reported involvement in extracurricular activities, behaviors linked to health risks, attitudes and intentions about abstinence, and opinions about the consequences of premarital sexual activity. Like ACF, OPA requires its grantees to contract with independent evaluators, such as colleges or universities, which are responsible for evaluating the effectiveness of grantees’ individual abstinence-until-marriage education programs.41 In addition to evaluating the extent to which grantees are meeting their goals, OPA officials stated that the independent evaluators may also provide input to grantees of the AFL Program on other aspects of the program to improve their service delivery. Unlike ACF, OPA requires that the third- party evaluations incorporate specific methodological characteristics, such as control groups or comparison groups42 and sufficient sample sizes.43 In addition, OPA requires that the evaluations for grantees funded in fiscal year 2004 and beyond account for baseline and follow-up data obtained from the standardized questionnaires. OPA’s requirement that grantees use a standardized set of questionnaires, with data from these questionnaires used in evaluations, differs from OPA’s 40

41

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OPA officials stated that grantees may also supplement the standardized questionnaire with additional data collection instruments to obtain information on the effectiveness of their abstinenceuntil-marriage education programs. OPA has required that its grantees perform independent evaluations of their programs since the program first awarded grants in 1982, and requires that grantees devote from 1 percent to 5 percent of grant funds to the evaluation of their programs. In cases where a more rigorous or comprehensive evaluation is proposed, OPA may allow these grantees to use up to 25 percent of their grant funds. A control group is a group of individuals or communities in a study that is compared to an intervention group—a group in a study that is receiving or participating in the program being studied. A control group is a randomly assigned group that does not receive the program. A comparison group is not randomly assigned like a control group. However, individuals or communities in well-matched comparison groups should have similar characteristics. Specifically, OPA requires that third-party evaluations of grantees of the AFL Program compare, when possible, randomized control or matched comparison groups with groups receiving abstinence-until-marriage education. In addition, OPA requires that these evaluations include a sufficient sample size to ensure that any observed differences between the groups are statistically valid and that the evaluations include a follow-up assessment of program participants at least 6 months after the abstinence-until-marriage intervention has been tested.

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previous requirements. Previously, grantees of the AFL Program were not required to use a standardized method for collecting data that could be used to assess the effectiveness of their programs; instead, grantees chose their own data collection instruments. As a result, an OPA official explained, the collected data varied from one project to another. OPA officials said that the agency developed the standardized questionnaire to ensure uniformity in the data collected and allow the agency to more effectively aggregate the data reported in evaluations of individual abstinence-until-marriage education programs. OPA officials told us that they plan to aggregate information from certain questions in the standardized set of questionnaires in order to report on certain performance measures as part of the agency’s annual performance reports.44 The measures include the extent of parental involvement in adolescents’ lives and the extent to which adolescents understand the benefits of abstinence. An agency official stated that the agency expects to begin receiving data from grantees that are using these questionnaires in January 2007. OPA did not previously have long-term measures of the performance of the AFL Program. Its current measures were developed in collaboration with the Office of Management and Budget (OMB) in response to an OMB review in 2004 that found that the AFL Program did not have any annual performance measures for measuring progress toward long-term goals. In addition to requiring their grantees to report on outcomes used to assess program effectiveness, both ACF and OPA have provided technical assistance and training to their grantees in order to support grantees’ own program evaluation efforts. For example, in November 2005 the two agencies sponsored an evaluation conference for abstinence-untilmarriage grantees that included presentations about evaluations and their methodology. Similarly, ACF’s Office of Planning, Research, and Evaluation sponsors annual evaluation conferences, and an ACF official told us that a recent conference placed “a significant emphasis” on the evaluation of abstinence-until-marriage education programs. In addition, HHS officials told us that ACF, along with ASPE, is funding a multiyear project that is designed to identify gaps in abstinence education evaluation and technical assistance needs, develop materials on abstinence education evaluation, deliver technical assistance and capacity-building activities related to program evaluation, and develop research reports related to abstinence education. OPA officials also 44

OPA prepares annual performance reports as a part of HHS’s responsibilities under the Government Performance and Results Act, which include program performance measures to help link funding decisions with performance and review of related outcome measures.

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told us that they attempt to help ensure grantees’ progress and effectiveness by offering various technical assistance workshops and conferences. For example, in May 2006 OPA provided a 2-day training conference to its grantees on the importance of program evaluations and administering evaluation instruments. In addition, OPA officials stated that the agency contracts with evaluation consultants, who review grantees’ evaluation tools and activities. OPA officials explained that these consultants provide in-depth technical assistance to grantees on how to improve grantees’ evaluations.

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ACF uses national data on adolescent behavior as a measure of the overall effectiveness of its two programs Requiring outcome reporting from state and community-based grantees is not ACF’s only effort to assess the effectiveness of its two programs. ACF also analyzes trends in adolescent behavior, as reflected in national data on birth rates among teens and the proportion of surveyed high school students reporting that they have had sexual intercourse.45 ACF uses these national data as a measure of the overall effectiveness of its State and Community-Based Programs, comparing the national data to program targets. In its annual performance reports, the agency summarizes the progress being made toward lowering the rate of births to unmarried teenage girls and the proportion of students (grades 9-12) who report having ever had sexual intercourse. ACF’s use of national data to assess the effectiveness of the State and Community-Based Programs represents a change from how HRSA assessed the overall effectiveness of these programs. Whereas ACF compares national data on adolescent behavior to program targets, HRSA aggregated data from its state and community-based grantees. HRSA’s state grantees were allowed to select the data sources used to gauge their progress against certain performance measures. For example, in its annual performance reports on the State Program, HRSA reported information on the percentage of its state grantees meeting target rates for reducing the proportion of adolescents who have engaged in sexual intercourse, the incidence of youths aged 15 to 19 who have contracted selected STDs, and the rate of births among youths aged 15 to 17. To determine their progress in meeting 45

Data on teen birth rates and adolescents’ reported sexual behavior are contained in the National Vital Statistics System and the Youth Risk Behavior Surveillance System, respectively. The former is a national data set of public health statistics reported by states to CDC, and the latter is a national data set based on nationwide surveys administered to high school students by CDC.

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their target rates, some state grantees, for example, reported national data from the Youth Risk Behavior Surveillance System, while other grantees reported statecollected data. After ACF assumed responsibility for the State and CommunityBased Programs from HRSA, ACF began using national data on adolescent behavior as a measure of the programs’ effectiveness. According to ACF officials, the agency changed how it assessed its programs out of concern over the quality of the data state grantees were using in their performance reporting and because the agency wanted to use parallel measures of effectiveness for both programs. For example, according to state performance reports for fiscal year 2001 that we reviewed, two reports did not include adolescent pregnancy rates that year because the states did not collect data on abortions among this population.46 In addition, ACF officials told us that they decided not to use national data on STDs as a measure of program effectiveness because the goal of reducing STD rates is not as central to the State and Community-Based Programs as reducing sexual activity and birth rates among teens. However, one official stated that reducing STDs is an important “by-product” of the programs.

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Some states have made additional efforts to assess the effectiveness of abstinenceuntil-marriage education programs Some states have made additional efforts to assess the effectiveness of abstinence-until-marriage education programs, although they are not required by ACF.47 Specifically, we found that 6 of the 10 states in our review that receive funding through ACF’s State Program have made efforts to conduct evaluations of selected abstinence-until-marriage programs in their state. All 6 of the states worked with third-party evaluators, such as university researchers or private research firms, to perform the evaluations, which in general measure self-reported changes in program participants’ behavior and attitudes related to sex and abstinence as indicators of program effectiveness. To obtain this information, the third-party evaluators have typically relied on surveys administered to program participants at the start of a program, its conclusion, and during a follow-up period anywhere from 3 months to almost 3 years after the conclusion. The third-party

46

In order to estimate pregnancy rates among adolescents, states use data on both birth rates and abortions among adolescents.

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evaluations for 4 of the 6 states in our review have been completed as of February 2006, and the results of these studies have varied.48 Among the 4 states that have completed third-party evaluations, 3 states require the abstinence programs in their state to measure reported changes in participants’ behavior as an indicator of program effectiveness—both at the start of the program and after its completion. The 3 states require their programs to track participants’ reported incidence of sexual intercourse. In addition, 2 states require their programs to track biological outcomes, such as pregnancies, births, or STDs. In addition, 6 of the 10 states in our review require their programs to track participants’ attitudes about abstinence and sex, such as the number of participants who make pledges to remain abstinent. Some states also provide technical assistance to the abstinence-untilmarriage programs they support in their state. This assistance is designed to help programs evaluate and improve their effectiveness. Officials from 5 of the 10 states in our review either told us or provided documentation that they provide technical assistance on evaluations to abstinence programs in their state. One state official said that the abstinence-untilmarriage programs supported by the state were found to be ill-prepared to conduct evaluations themselves, and that she now requires these programs to dedicate a portion of their grants to contract with a third-party or state evaluator to assist them in program-level evaluations. Officials from another state told us that they contract with a private organization of public health professionals in order to provide evaluation consultation and technical assistance for the abstinence-until-marriage programs the state supports.

ASPE, CDC, and NIH are funding studies designed to assess the effectiveness of abstinence-until-marriage education programs In addition to ACF and OPA, other organizational units within HHS have made efforts to assess the effectiveness of abstinence-until-marriage education programs. ASPE is currently sponsoring a study of the Community-Based

48

See, for example, LeCroy & Milligan Associates, Inc., Abstinence Only Education Program: Fifth Year Evaluation Report, a report prepared for the Arizona Department of Health Services, 2003; Patricia Goodson et al., Abstinence Education Evaluation: Phase 6, a report prepared for the Texas Department of State Health Services, 2005; MGT of America, Evaluation of Georgia Abstinence Education Programs Funded Under Title V, Section 510, a report prepared for the Georgia Department of Human Resources, 2005; Thomas E. Smith, It’s Great to Wait: An Interim Evaluation, a report prepared for the Florida Department of Health, 2001.

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Program and a study of the State Program.49 For the former program, ASPE has contracted with Abt Associates to help design the study, and an ASPE official told us that once the agency selects an appropriate design, it will competitively award a contract to conduct the study.50 For the latter program, ASPE has contracted with Mathematica Policy Research, Inc. (Mathematica), which is in the process of examining the impact of five programs funded through the State Program on participants’ attitudes and behaviors related to abstinence and sex.51 As of August 2006, Mathematica has published two reports on findings from its study—an interim report documenting the experiences of schools and communities that receive abstinence-until-marriage education funding, and a report on the first-year impacts of selected state abstinence-until-marriage education programs.52,53 Mathematica’s final report, which has not been completed, will examine the impact of the State Program on behavioral outcomes, including abstinence, sexual activity, risk of STDs, risk of pregnancy, and drug and alcohol use.54 An ASPE official told us that the agency expects a final report to be published in 2007. Like ASPE, CDC has made its own effort to assess the effectiveness of abstinence-until-marriage education. CDC is sponsoring a study to evaluate the effectiveness of two middle school curricula—one that complies with abstinence

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49

According to the House Appropriations Committee report accompanying the fiscal year 2005 appropriation act for Labor, HHS, Education, and related agencies, the effectiveness of abstinence education programs should be determined by measures that include the prevention and reduction of adolescent pregnancies and STD infections, age at first sexual activity and intercourse, frequency of sexual activity and intercourse, and numbers who postpone sexual activity or intercourse through adolescence. See H.R. Rep. No. 108-636, at 139-140 (2004). 50 According to ASPE officials, one factor that has contributed to delays in the initiation of this study is the difficulty in recruiting schools to participate. 51 The five abstinence-until-marriage education programs being studied are My Choice, My Future! in Powhatan, Virginia; ReCapturing the Vision in Miami, Florida; Teens in Control in Clarksdale, Mississippi; Families United to Prevent Teen Pregnancy in Milwaukee, Wisconsin; and Heritage Keepers in Edgefield, South Carolina. 52 See B. Devaney et al., The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report, a report prepared for ASPE, 2002. 53 See R. Maynard et al., First-Year Impacts of Four Title V, Section 510 Abstinence Education Programs, a report prepared for ASPE, 2005. Mathematica’s report on the first- year impacts of selected state abstinence-until-marriage education programs focused on intermediate outcomes, including attitudes about abstinence, teen sex, and marriage; perceived consequences of teen and nonmarital sex; and expectations to abstain from sexual intercourse. 54 An impact evaluation assesses the net effect of a program by comparing program outcomes with an estimate of what would have happened in the absence of the program. This form of evaluation is employed when external factors are known to influence the program’s outcomes, in order to isolate the program’s contribution to achievement of its objectives.

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education program requirements and one that teaches a combination of abstinence and contraceptive information and skills.55 In CDC’s study, five middle schools chosen at random will receive a program consisting of abstinence-until-marriage education exclusively; five schools will receive comprehensive sex education, which also includes information on contraception; and five schools will be assigned to a control group. The study will examine the relative effectiveness of the programs on behavioral outcomes such as reported sexual risk behaviors and changes in attitudes related to abstinence and sex. CDC plans to recruit approximately 1,500 seventh grade students into its study and will follow them over a 2-year period. The agency expects to complete the study in 2009. NIH has funded studies comparing the effectiveness of education programs that focus only on abstinence with the effectiveness of sex education programs that teach both abstinence and information about contraception. As of August 2006, NIH is funding five studies, which in general are comparing the effects of these two types of programs on the sexual behavior and related attitudes among groups of either middle school or high school students. For example, in one NIH study, researchers are using groups of seventh and eighth grade adolescents to assess the impact of a variety of programs on, among other issues, adolescents’ reported sexual activities, knowledge, and beliefs. For this study, researchers are comparing these outcomes among students who received abstinence-untilmarriage education; students who received a combination of abstinence and contraceptive education; and students who participated in a general health class, who serve as a comparison group. NIH expects both this study and its other four studies to be competed in 2006.

Other researchers have also made efforts to assess the effectiveness of abstinenceuntil-marriage education programs In addition to the efforts of researchers working on behalf of HHS and states, other researchers—such as those affiliated with universities and various advocacy groups—have made efforts to study the effectiveness of abstinence-until-marriage education programs. This work includes studies of the outcomes of individual programs and reviews of other studies on the effectiveness of individual abstinence-until-marriage education programs. In general, research studies on the effectiveness of individual abstinence-until-marriage education programs have 55

HHS officials told us that the two curricula being tested are intended to be comparable in length, intensity, and other characteristics.

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examined the extent to which they changed participants’ demonstrated knowledge, declared intentions, and reported behavior related to sexual activity and abstinence. For example, some studies examined the impact of abstinenceuntilmarriage education programs on participants’ knowledge of concepts taught in the programs, as well as participants’ declared attitudes about abstinence and teen sex. Some studies examined the impact of these programs on such outcomes as participants’ declared commitment to abstain from sex until marriage, participants’ understanding of the potential consequences of having intercourse, and participants’ reported ability to resist pressures to engage in sexual activity. Some of the studies we reviewed examined the impact of abstinence-untilmarriage programs on participants’ sexual behavior, as measured, for example, by the proportion of participants who reported having had sexual intercourse and the frequency of sexual intercourse reported by participants. In general, the efforts to study and build a body of research on the effectiveness of most abstinence education programs have been under way for only a few years, in part because grants under the two programs that account for the largest portion of federal spending on abstinence education—the State Program and the Community-Based Program—were not awarded until 1998 and 2001, respectively.

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Several Factors Limit the Conclusions That Can Be Drawn about the Effectiveness of Abstinence-until-Marriage Education Programs Most of the efforts of HHS, states, and other researchers to evaluate the effectiveness of abstinence-until-marriage education programs included in our review have not met certain minimum criteria that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid. For example, most of the efforts included in our review did not include experimental or quasi-experimental designs, nor did they measure behavioral or biological outcomes. In addition, the results of some assessment efforts that meet the criteria of a scientifically valid assessment have varied, and two key studies that meet these criteria have not yet been completed.

Experts have developed criteria to evaluate efforts to assess abstinence-untilmarriage education programs In an effort to better assess the merits of the studies that have been conducted on the effectiveness of sexual health programs—including abstinence-until-

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marriage education programs—scientific experts have developed criteria that can be used to gauge the scientific rigor of these evaluations. For example, in 2001, the National Campaign to Prevent Teen Pregnancy—an organization focused on reducing teen pregnancy— published a report by a panel of scientific experts that assessed the evidence reported on abstinence-until-marriage education programs in peer-reviewed journals and other literature.56 The panel developed criteria that an evaluation of a program’s effectiveness must meet in order for the program’s results to be considered scientifically valid. In addition, in 2004, former U.S. Surgeon General David Satcher convened a panel of experts to discuss, among other things, best practices for evaluating the effectiveness of sexual health education programs—including abstinence-until-marriage education programs.57 This panel published a report in 2006 that describes similar scientific criteria that assessments of program effectiveness need to meet in order for their results to be scientifically valid. Further, experts we interviewed agreed that these criteria are important for ensuring that the results of a study support valid conclusions. In general, these panels, as well as the experts we interviewed, agreed that scientifically valid studies of a program’s effectiveness should include the following characteristics: • An experimental design that randomly assigns individuals or schools to either an intervention group or control group, or a quasi-experimental design that uses nonrandomly assigned but well-matched comparison groups. According to the panel of scientific experts convened by the National Campaign to Prevent Teen Pregnancy, experimental designs or quasi-experimental designs with wellmatched comparison groups have at least three important strengths that are typically not found in other studies, such as those that use aggregated data: they evaluate specific programs with known characteristics, they can clearly distinguish between participants who did and did not receive an intervention, and they control for other factors that may affect study outcomes. Therefore, experimental and quasi-experimental study designs have a greater ability to assess the causal impact of specific programs than other types of studies.58 56

See Kirby. This panel included experts from NIH, the Medical Institute for Sexual Health, the Alan Guttmacher Institute, the Institute for Research and Evaluation, and various universities. 57 See Satcher. This panel included experts from a variety of organizations, including the Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American Academy of Pediatrics. 58 For example, experts have reported that the use of randomly assigned intervention and control groups is particularly important when assessing the effectiveness of abstinenceuntil-marriage programs because adolescents who voluntarily participate in such programs may be self-selecting—that

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According to scientific experts, studies that include experimental or quasiexperimental designs should also collect follow-up data for a minimum number of months after subjects receive an intervention.59 Experts reported that follow-up periods are important in order to identify the effects of a program that are not immediately apparent or to determine whether these effects diminish over time. In addition, experts have reported that studies should have a sample size of at least 100 individuals for study results to be considered scientifically valid.60 Studies should assess or measure changes in biological outcomes or reported behaviors instead of attitudes or intentions. According to scientific experts, biological outcomes—such as pregnancy rates, birth rates, and STD rates—and reported behaviors—such as reported initiation and frequency of sexual activity—are better measures of the effectiveness of abstinence-until-marriage programs, because adolescent attitudes and intentions may or may not be indicative of actual behavior. For example, adolescents may report that they intend to abstain from sexual intercourse but may not actually do so.

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Most efforts to assess the effectiveness of abstinenceuntil-marriage education programs have not used an experimental or quasi- experimental design Many of the efforts by HHS, states, and other researchers that we identified in our review lack at least one of the characteristics of a scientifically valid study of program effectiveness. That is, most of the efforts to assess the effectiveness of these programs have not used experimental or quasi-experimental designs with sufficient follow-up periods and sample sizes to make their conclusions scientifically valid. For example, ACF—and before it, HRSA—used, according to

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is, they may be more willing to accept the principles of—and be influenced by—such programs when compared with other adolescents. Mathematica’s interim report on the evaluation of the State Program noted that selection bias can “seriously undermine the credibility” of study results. For example, one expert reported that studies assessing program effectiveness should obtain information on participants for at least 3 months after the conclusion of a program when they are measuring behaviors that can change quickly, such as frequency of sex. For behaviors or outcomes that change less quickly, such as initiation of sex or pregnancy rates, information on participants should be collected for at least 6 months after the conclusion of a program. The panel of experts convened by the National Campaign to Prevent Teen Pregnancy agreed that large sample sizes are necessary to determine the magnitude of any discernable program effect and to ensure that results of any study of effectiveness are statistically valid.

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ACF officials, grantee reporting on outcomes in order to monitor grantees’ performance, target training and technical assistance, and help grantees improve service delivery. However, because the outcomes reported by grantees have not been produced through experimentally or quasi-experimentally designed studies, such information cannot be causally attributed to any particular abstinence-untilmarriage education program. While ACF requires its fiscal year 2006 grantees of the Community-Based Program to contract with third-party evaluators to select and monitor outcomes for their programs, ACF is not specifically requiring these grantees to use experimental or quasi-experimental designs. Therefore, it is not clear whether these evaluations will include such designs. Similarly, ACF’s use of national data on adolescent behavior and birth rates to assess its State and Community- Based Programs is of limited value because these data do not distinguish between those who participated in abstinence-until-marriage education programs and those who did not. Consequently, these national data sets, which represent state-reported vital statistics and a nationwide survey of high school students, cannot be used to causally link declines in birth rates and adolescent sexual activity to the effects of specific abstinence-untilmarriage education programs.61 Similarly, the efforts we identified by states and researchers to assess the effectiveness of abstinence-until-marriage education programs often did not include experimental or quasi-experimental designs. None of the state evaluations we reviewed that have been completed included randomly assigned control groups. For instance, one state evaluation that we reviewed only included students who volunteered to participate in the study. This evaluation report stated that the absence of a randomly assigned control group in the evaluation did not allow the evaluators to determine whether observed changes in participants’ reported sexual behavior—as indicated through surveys administered at the beginning and end of a program—could be attributed to the abstinence-until-marriage education program.62 Similarly, some of the journal articles that we reviewed described studies to assess the effectiveness of abstinence-until-marriage programs that did not include experimental or quasi- experimental designs needed to support scientifically valid conclusions about the programs’ effectiveness. In these studies, researchers administered questionnaires to study participants before and 61

In addition, according to ACF and CDC officials, it is difficult to draw conclusions from national data sets about the effectiveness of abstinence-until-marriage education programs because the national survey questions used to produce these data often do not identify the specific type of program or intervention survey respondents may have participated in or received. 62 See Goodson et al.

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after they completed an abstinence-until-marriage education program and assessed the extent to which the responses of participants changed.63 These studies did not compare the responses of study participants with a group that did not participate in an abstinence-until-marriage education program. In addition, some of the studies used insufficient follow-up periods, thereby limiting the conclusions that can be drawn about the effectiveness of the abstinence-until-marriage education programs being studied. For example, two journal articles that we reviewed described studies that measured the effectiveness of abstinence-until-marriage programs in delaying the initiation of sexual activity from 1 to 2 months after completion of the program.64 Scientific experts consider this follow-up period too short to assess whether the programs had a valid effect. According to scientific experts, HHS, states, and other researchers face a number of challenges in designing experimental or quasi-experimental studies of program effectiveness. According to these experts, experimental or quasiexperimental studies can be expensive and time-consuming to carry out, and many grantees of abstinence-until-marriage education programs have insufficient time and funding to support these types of studies. Moreover, it can be difficult for researchers assessing abstinenceuntil-marriage education programs to convince school districts to participate in randomized intervention and control groups, in part because of sensitivities to surveying attitudes, intentions, and behaviors related to abstinence and sex. For example, in a third-party evaluation of its program, one grantee of the State Program originally planned to administer follow-up surveys 1 year after participants finished their abstinence education program, but the evaluators decided not to conduct this follow-up because of confidentiality concerns and the difficulty of locating students. In addition, the contractors hired to design ASPE’s study of the effectiveness of the CommunityBased Program have reported difficulties finding school districts that are willing to participate in randomly assigned intervention and control groups receiving either abstinence-until-marriage education or comprehensive sex education. An ASPE official told us that although a “randomized approach” is the best design for 63

See, for example, S. M. Fitzgerald et al., “Effectiveness of the Responsible Social Values Program for 6th Grade Students in One Rural School District,” Psychological Reports, vol. 91 (2002), and J. E. Barnett and C. S. Hurst, “Abstinence Education for Rural Youth: An Evaluation of the Life’s Walk Program, “ The Journal of School Health, vol. 73, no. 7 (2003). 64 See, for example, D. A. Zanis, “Use of a Sexual Abstinence Only Curriculum with Sexually Active Youths,” Children & Schools, vol. 27, no. 1 (2005), and G. Denny et al., “An Evaluation of An Abstinence Education Curriculum Series: Sex Can Wait,” American Journal of Health Behavior, vol. 26, no. 5 (2002).

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assessing the effectiveness of a program, the approach is also the most difficult to conduct.

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Most efforts to assess the effectiveness of abstinenceuntil-marriage education programs have not measured behavioral or biological outcomes Another factor that limits the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs is the fact that most efforts in our review to study the effectiveness of these programs did not measure changes in behavioral or biological outcomes among participants. Instead, most of the efforts we identify in our review used reported intentions and attitudes in order to assess the effectiveness of abstinence-until-marriage programs. For example, neither ACF’s community-based grantees nor OPA’s AFL grantees are required to report on behavioral or biological outcomes, such as rates of intercourse or pregnancy. Similarly, the journal articles we reviewed were more likely to use reported attitudes and intentions—such as study participants’ reported attitudes about premarital sexual activity or their reported intentions to remain abstinent until marriage—rather than their reported behaviors or biological outcomes to assess the effectiveness of abstinence-untilmarriage programs. For example, in one journal article we reviewed, participants were asked to rate the likelihood that they would have sexual intercourse as unmarried teenagers; another journal article described a study in which participants rated the likelihood that they would have sexual intercourse in the next year, before finishing high school, and before marriage.65 Experts, as well as state and HHS officials, have reported that it can be difficult to obtain scientifically valid information on biological outcomes and sexual behaviors. Specifically, experts have reported that when measuring an abstinence-until-marriage education program’s affect on biological outcomes— such as reducing pregnancy or birth rates—it is necessary to have large sample sizes in order to determine whether a small change in biological outcomes is the result of the abstinence-until-marriage education program. In addition, state and federal officials told us that they have experienced difficulties obtaining information on sexual behaviors because of the sensitive nature of the information 65

See, for example, L. Sather and K. Zinn, “Effects of Abstinence-Only Education on Adolescent Attitudes and Values Concerning Premarital Sexual Intercourse, “ Family and Community Health, vol. 25, no. 2 (2002), and G. Denny, M. Young, and C. E. Spear, “An Evaluation of the Sex Can Wait Abstinence Education Curriculum Series,” American Journal of Health

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they were trying to collect. For example, one state official told us that her state’s effort to evaluate abstinence-until-marriage education programs was only able to measure changes in participants’ reported attitudes, instead of behaviors, because the evaluators needed to obtain consent from the parents of the program participants in order to ask them about their sexual behavior. The state official explained that the requirement to obtain consent from parents raised issues of selfselection, and therefore state officials decided to ultimately halt the study and only report on the attitudes that they had measured. In another example, ACF’s fiscal year 2006 budget justification reports that ACF has had some difficulty in obtaining reliable data from state grantees, in part because questions about teenage sexual behavior are sensitive. OPA officials also acknowledged that many communities will not allow grantees to ask program participants questions about their sexual behavior because the communities believe such questions are too intrusive. One OPA official said that such restrictions affect the agency’s ability to measure behavioral outcomes, explaining that OPA cannot measure what it cannot ask about.

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Results of some scientifically valid assessment efforts have varied, and other key studies have not been completed Among the assessment efforts we identified are some studies that meet the criteria of a scientifically valid effectiveness study. However, results of these studies have varied, and this limits the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. Some researchers have reported that abstinence-until-marriage education programs have resulted in adolescents reporting having less frequent sexual intercourse or fewer sexual partners.66 For example, in one study of middle school students, participants in an abstinence-untilmarriage education program who had sexual intercourse during the follow-up period were 50 percent less likely to report having two or more sexual partners when compared with their nonparticipant peers.67 In contrast, other studies have reported that abstinence-until-marriage education programs did not affect the reported frequency of sexual intercourse or number of sexual

Behavior, vol. 23, no. 2 (1999). See Borawski et al. See also T. L. St. Pierre et al., “A 27-Month Evaluation of a Sexual Activity Prevention Program in Boys & Girls Clubs Across the Nation,” Family Relations, vol. 44, no. 1 (1995). 67 See Borawski et al. 66

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partners.68 For example, one study of middle school students found that participants of an abstinence-untilmarriage program were not less likely than nonparticipants at the 1 year follow-up to report less frequent sexual intercourse or fewer sexual partners.69 In addition to these varied findings, one study found that an abstinence-until-marriage program was effective in delaying the initiation of sexual intercourse in the short term but not long term.70 Experts with whom we spoke emphasized that there are still too few scientifically valid studies completed to date that can be used to determine conclusively which, if any, abstinence-untilmarriage programs are effective. Additionally, among the assessment efforts we identified are some studies that experts anticipate will meet the criteria of a scientifically valid effectiveness study but are not yet completed. One of these key studies is the final Mathematica report, contracted by ASPE, on the State Program.71 The final report was originally slated for publication in 2005, but an ASPE official stated that the final report has been delayed until 2007 so that researchers can extend the follow-up period to improve their response rate and the reliability of the information they collect. Another key study is CDC’s research on middle school programs, which is not expected to be completed until 2009. Experts and federal officials we interviewed stated that they expect the results of these two federally funded studies to add substantively to the body of research on the effectiveness of abstinence-until-marriage education programs. One expert with whom we spoke said that she expects the final Mathematica report on participants’ behaviors to provide the groundwork for the field. Another expert we interviewed stated that the CDC study was very well-designed and she expects the results to contribute to the development of effective abstinence-until-marriage education curricula. 68

See N.G. Harrington et al., “Evaluation of the All Stars Character Education and Problem Behavior Prevention Program: Effects on Mediator and Outcome Variables for Middle School Students,” Health Education & Behavior, vol. 28, no. 5 (2001). See also Jemmott, Jemmott, and Fong. 69 See Harrington et al. 70 See Jemmott, Jemmott, and Fong and J. B. Jemmott III, L. S. Jemmott, and G. T. Fong, reply to letter to editor, Journal of the American Medical Association, vol. 281, no. 16 (1999), 1487. This study found that an abstinence-until-marriage program delayed the initiation of sexual intercourse at the 3-month follow-up period but not at 6 and 12 months. 71

According to several scientific experts, Mathematica’s study is an important one, in part because of its sound design: the study randomly assigns and compares control groups with groups receiving abstinence-until-marriage education and uses surveys to follow up with program participants for several months after their completion of a program.

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CONCLUSIONS There have been various efforts—by HHS, states, and others—to assess the scientific accuracy of educational materials used in abstinence-untilmarriage education programs and the effectiveness of these programs. However, efforts to evaluate both the accuracy and effectiveness of abstinence-until-marriage education programs have been, in various ways, limited. ACF, which administers the two programs that account for the largest portion of federal spending on abstinence-until-marriage education, does not review or require its grantees to review program materials for scientific accuracy. In addition, not all grantees of the State Program have chosen to review their materials. Because of these limitations, ACF cannot be assured that the materials used in its State and Community-Based Programs are accurate. Moreover, OPA, which reviews all grantees’ proposed abstinence-until-marriage educational materials, and states that review educational materials have found inaccuracies in some educational materials used by abstinence-until-marriage programs. Similarly, most of the efforts described in our review to assess the effectiveness of abstinence-until-marriage programs have not met minimum scientific criteria needed to draw valid conclusions about their effectiveness. Specifically, most efforts by agencies, states, and other researchers have not included experimental or quasi-experimental designs that can establish whether changes in behaviors or biological outcomes can be causally linked to specific abstinence-until-marriage education programs. While these types of studies are time-consuming and expensive, experts said that they are the only definitive way to draw valid conclusions about the effectiveness of these programs. In addition, among the assessment efforts we identified are some studies funded by HHS that experts anticipate will meet the criteria of a scientifically valid effectiveness study but are not yet completed. When completed, these HHS-funded studies may add substantively to the body of research on the effectiveness of abstinence-untilmarriage education programs.

RECOMMENDATION FOR EXECUTIVE ACTION To address concerns about the scientific accuracy of materials used in abstinence-until-marriage education programs, we recommend that the Secretary of HHS develop procedures to help assure the accuracy of such materials used in

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the State and Community-Based Programs. To help provide such assurances, the Secretary could consider alternatives such as (1) extending the approach currently used by OPA to review the scientific accuracy of the factual statements included in abstinence-until-marriage education to materials used by grantees of ACF’s Community-Based Program and requiring grantees of ACF’s State Program to conduct such reviews or (2) requiring grantees of both programs to sign written assurances in their grant applications that the materials they propose using are accurate.

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AGENCY COMMENTS AND OUR EVALUATION HHS provided written comments on a draft of this report. (See app. III.) In its written comments, HHS stated that it will consider requiring grantees of both ACF programs to sign written assurances in grant applications that the materials they use are accurate. Regarding accuracy, HHS’s written comments also noted that all applicants for federal assistance attest on the application form-Standard Form 424--that all data in their applications are “true and correct,” and that in the view of HHS, this applies to information presented in curricula funded by federal grants. However, as we stated in the draft report, grantees of the State Program are not required to submit curricula as a part of their applications; therefore, the attestation in Standard Form 424 would not apply to curricula used by those grantees. In addition, as stated in the draft report, some states have reviewed materials used in abstinence-until-marriage education programs, but these reviews occurred after they received funding from ACF. Further, while grantees of the Community-Based Program were required to submit copies of their curricula and a Standard Form 424 in fiscal year 2006 as part of their applications, none of the materials specifically require an assurance of scientific accuracy. Further, OPA and states have found inaccuracies in educational materials used by abstinence-untilmarriage programs. HHS’s written comments also stated that ACF requires that curricula conform to HHS’s standards grounded in scientific literature. HHS’s comments refer to the curriculum standards for this program that detail what types of information must be included in abstinence-until-marriage curricula, and the comments stated that the curricula must provide supporting references for this information. Further, HHS’s comments stated that ACF staff review the curricula to ensure compliance with these standards. The draft report stated this. However, a requirement that curricula include certain types of information does not necessarily ensure the

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accuracy of the scientific facts included in the abstinence-untilmarriage materials. For example, while education materials may include information on failure rates associated with contraceptives or STD infections, this information may be outdated or otherwise inaccurate or incomplete. HHS’s written comments also stated that if it finds inaccurate statements during the review process or at any time during the grant period, ACF works with grantees to take corrective action. To ensure completeness, we have added this statement to the report. Further, HHS stated that 2 inaccuracies cited in the draft report had been corrected before our work began. We believe HHS is referring to inaccuracies identified by OPA during its review of materials for scientific accuracy and this reinforces the need for review of materials used by ACF’s grantees. As HHS noted in its written comments, we did not define the term scientific accuracy. HHS stated that it disagreed with certain findings of the report because it was difficult to precisely determine the criteria we employed in making the recommendation as to scientific accuracy. As we stated in the scope and methodology section of the draft report, the objective of our work was to focus on efforts by HHS and states to review the accuracy of scientific facts included in abstinence-until-marriage education materials. Performing an independent assessment of the criteria used by these entities to determine the scientific accuracy of education materials or the quality of the reviews was beyond the scope of the work. Regarding effectiveness, HHS’s written comments also described a number of actions it is taking to determine program effectiveness and improve the quality of programs and research. Specifically, HHS’s comments described (1) studies undertaken or funded by ASPE, CDC, and NIH; (2) technical assistance provided by OPA and ACF; (3) grantee evaluation requirements; and (4) ACF and OPA requirements for the amount of grant funds to be spent on evaluations. All of this information was included in our draft report. HHS’s comments also described a new effort funded by ACF and ASPE that is designed to build capacity for quality research in the field of abstinence education. We added information on this effort to the report. HHS’s written comments also describe evaluations that resulted from an Abstinence Education Evaluation Conference sponsored by ACF and OPA. While this conference was described in the draft report, we added more detail regarding the content of the conference. HHS’s written comments also describe OPA’s efforts to assess the effectiveness of the AFL Program. We had included this information in the draft report. HHS’s written comments stated that it may be too soon to draw conclusions about the effectiveness of ACF’s and OPA’s programs, in part, because key studies have not been completed. We agree and discussed this in the draft report.

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As we noted in the draft report, key studies funded by HHS that experts anticipate will meet the criteria of a scientifically valid effectiveness study are not yet completed, but when completed these HHS funded studies may add substantively to the body of research on the effectiveness of abstinence-until-marriage education programs. In addition, the comments stated that having an inadequate amount of scientifically valid and conclusive evaluation studies is not unique to abstinenceuntil-marriage education programs, and a recent ASPE review of comprehensive sex education programs found mixed results on their effectiveness. However, the scope of our report was focused on abstinence-until-marriage education programs, and we did not review comprehensive sex education programs or make any comparisons between the two types of programs. HHS also provided technical comments, which we incorporated into the report as appropriate. As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its date. We will then send copies of this report to the Secretary of HHS and to other interested parties. In addition, this report is available at no charge on GAO’s Web site at http://www.gao.gov. We will also make copies available to others upon request. If you or your staff have any questions about this report, please call me at (202) 512-3407 or [email protected]. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix IV.

Marcia Crosse Director, Health Care List of Requesters The Honorable Henry A. Waxman Ranking Minority Member Committee on Government Reform House of Representatives The Honorable Pete Stark Ranking Minority Member Subcommittee on Health Committee on Ways and Means

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House of Representatives The Honorable Sherrod Brown Ranking Minority Member Subcommittee on Health Committee on Energy and Commerce House of Representatives

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The Honorable Barbara Boxer The Honorable Maria Cantwell The Honorable Richard J. Durbin The Honorable Russell D. Feingold The Honorable Dianne Feinstein The Honorable Tom Harkin The Honorable James M. Jeffords The Honorable Edward M. Kennedy The Honorable Frank R. Lautenberg The Honorable Patrick Leahy The Honorable Patty Murray United States Senate The Honorable Howard L. Berman The Honorable Lois Capps The Honorable Jay Inslee The Honorable Barbara Lee The Honorable Nita M. Lowey The Honorable Betty McCollum House of Representatives

APPENDIX I: HRSA’S TECHNICAL ASSISTANCE CONTRACT FOR ABSTINENCE EDUCATION The Health Resources and Services Administration (HRSA) awarded a contract to the National Abstinence Clearinghouse (NAC) in 2002 to provide assistance with its Community-Based Abstinence Education Program

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(Community-Based Program) and Abstinence Education Program (State Program).72 NAC is a nonprofit educational organization whose mission is to promote the appreciation for and practice of sexual abstinence until marriage through the distribution of age appropriate, factual, and medically referenced materials. The purpose of the contract was (1) to develop national criteria for the review of abstinence-untilmarriage educational materials and to create a directory of approved materials; (2) to provide medical accuracy training to grantees; and (3) to provide technical support to grantees, such as assistance with program evaluation.73 We are reporting on the steps that HRSA took to award the contract to NAC in response to concerns that have been raised by a congressional requester. In general, these concerns centered on the extent to which the selection process was competitive and whether HRSA identified the potential for an organizational conflict of interest. HRSA awarded the contract to address three concerns it had with the Community-Based Program during 2001, the first year of its implementation. First, HRSA officials needed guidance to determine whether abstinence-untilmarriage education materials conformed to the definitional requirements of the Social Security Act.74 Second, many grantees lacked the medical background and 72

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73

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The administration of this contract was transferred from HRSA to the Administration of Children and Families (ACF) in May 2005. The contract resulted in the development of criteria for reviewing abstinence-untilmarriage educational materials, and ACF included these criteria in the fiscal year 2006 program announcement for the Community-Based Program. According to the announcement, ACF will evaluate grant applicants’ proposed educational materials to ensure compliance with the criteria. Medical accuracy training and technical support were provided to grantees as a result of the contract. According to an ACF official, a directory of approved abstinence-until-marriage educational materials was not completed. Section 510(b)(2) of the Social Security Act defines abstinence education as an educational or motivational program that: A. has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; B. teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; C. teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; D. teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; E. teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; G. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and H. teaches the importance of attaining self-sufficiency before engaging in sexual activity.

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training to ensure that they would provide medically accurate, science-based information in their programs. Third, grantees also lacked experience with the technical management of federal grants, including how to conduct evaluations of their programs.

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HRSA Used Full and Open Competition Procedures to Award the Contract to NAC HRSA used full and open competition procedures to award the contract to NAC. In doing so, HRSA (1) publicly solicited proposals from potential contractors; (2) conducted technical evaluations of both the original proposals and the revised proposals for those considered to be in the competitive range; and (3) determined that NAC’s proposal represented the best overall value to the government. This process, which took place from May 2002 through September 2002, resulted in HRSA awarding NAC the contract with a potential value of nearly $2.7 million. HRSA issued a notice on May 20, 2002, on the FedBizOpps Web site, the government point of entry for notifying potential contractors of federal contract opportunities, indicating its intent to publicly request proposals from prospective contractors in June 2002.75 On June 20, 2002, HRSA posted the solicitation on the FedBizOpps Web site indicating that the abstinence contract would be awarded using full and open competition procedures, that is, all responsible prospective contractors would be provided the opportunity to compete.76 The solicitation, which was a Request for Proposals (RFP), described the contract objectives, which included (1) the development of national criteria for the review of abstinence-until-marriage educational materials and the development of a directory of approved materials; (2) the provision of medical accuracy training to grantees; and (3) the provision of technical support to grantees, such as assistance with program evaluation. The RFP stated that HRSA intended to award a cost75

The current FedBizOpps Web site address is http://www.fbo.gov /. Prior to October 1, 2005, the Web site address was http://www.eps.gov/. The solicitation number was 240- MCHB-012(02)-abg.

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The Federal Acquisition Regulation (FAR) requires the contracting officer to ensure that prospective contractors are responsible. FAR § 9.103. A responsible source refers to a prospective contractor that has, among other things, adequate financial resources, the necessary experience and technical skills to perform the work of the contract, a satisfactory performance record, and the ability to meet the delivery schedule. FAR § 9.104- 1.

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reimbursement contract with fixed fee for a 1-year base period and 2 option years.6 This was a best value procurement; that is, HRSA reserved the right in the RFP to select for award the proposal that HRSA determined offered the best value to the government, even if it did not offer the lowest cost. Further, the RFP stated that the technical evaluation of the prospective contractors’ proposals would receive paramount consideration in the selection of the contractor. According to the RFP, this evaluation would include an assessment of the prospective contractor’s technical approach, the organizational experience and expertise of the prospective contractor, the plans for personnel and management of the work, and the prospective contractor’s statement and understanding of the project purpose. Other factors, such as the estimated cost, past performance under other contracts for similar services, and the subcontracting plan would also be considered in the selection process. Five prospective contractors submitted proposals to HRSA by July 31, 2002, when proposals were due. HRSA established a review committee to conduct the technical evaluation of the five proposals. This committee included three voting members and a nonvoting chairperson. The Director of HRSA’s Community-Based and State Programs and two analysts from other programs within the Department of Health and Human Services (HHS) served as the voting members, and the chairperson of the review committee was a project officer of HRSA’s Community-Based Program. The committee members conducted the technical evaluation of the proposals, according to the criteria in the RFP, as described above. Three proposals with the highest technical scores were determined to be in the competitive range,77 with NAC’s proposal receiving the highest technical score. HRSA requested in writing that the competitive range offerors address certain technical and cost issues and submit revised proposals to HRSA by September 17, 2002.78 For example, HRSA requested that one of the prospective contractors other than NAC clearly describe its proposed management of day-to-day tasks of the contract and provide justification for several labor and travel expenditures. HRSA did not have oral discussions with the competitive range offerors. HRSA’s review committee evaluated the revised proposals and again gave NAC’s revised proposal the highest technical score.

77

Cost-reimbursement contracts are used only when uncertainties involved in contract performance do not permit costs to be estimated with sufficient accuracy to use any type of fixed-price contract. FAR § 16.30 1-2. 78 Based on the ratings of each proposal against all evaluation criteria, the contracting officer establishes a competitive range consisting of all of the most highly rated proposals. FAR § 15.306(c)(1).

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Although NAC’s estimated cost was not the lowest among the proposals in the competitive range, HRSA determined that NAC had proposed a realistic cost estimate for the contract. Accordingly, and in light of the NAC proposal’s high technical rating and the RFP’s evaluation criteria giving paramount consideration to the technical evaluation, HRSA determined that NAC’s proposal represented the best value to the government. HRSA awarded a contract to NAC on September 27, 2002. The contract had a 1-year base period of performance with an estimated value of $854,681, and included 2 option years for a total potential value of $2,673,784. According to a HRSA official, this cost-reimbursement contract did not include a fee. All of the prospective contractors were made aware that a debriefing to explain the selection decision and contract award would be provided at their request. One prospective contractor requested and received a debriefing from HRSA. No protests were filed with the agency challenging the award of the contract to NAC. There were no bid protests filed with GAO.79

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HRSA Identified No Actual or Potential Organizational Conflicts of Interest HRSA officials told us that they did not identify any actual or potential organizational conflicts of interest during the acquisition process. As defined in the Federal Acquisition Regulation (FAR), an organizational conflict of interest arises where • because of other activities or relationships, a person is unable or potentially unable to provide impartial assistance or advice to the government; or • the person’s objectivity in performing the contract work is or might be otherwise impaired; or • a person has an unfair competitive advantage.80 An organizational conflict of interest may result when factors create an actual or potential conflict of interest during performance of a contract, or when the nature of the work to be performed under one contract creates an actual or potential conflict of interest involving a future acquisition.81 Under the FAR, 79

HRSA officials, including an auditor, reviewed the cost proposals in the competitive range. GAO’s Office of General Counsel resolves disputes concerning awards of federal contracts, which are known as bid protests. 81 FAR § 2.101. 80

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contracting officers are required to analyze planned acquisitions to identify and evaluate potential organizational conflicts of interest as early in the acquisition process as possible, and to take steps to avoid, neutralize, or mitigate significant potential conflicts of interest before a contract is awarded.82 According to HRSA’s contracting officer, HRSA did not identify any actual or potential organizational conflicts of interest. In reaching this conclusion, the contracting officer told us that he reviewed the statement of work, including the background and objectives of the proposed contract, the stated purpose of the contact, the criteria established to evaluate the proposals, the past performance of the competitors, and NAC’s proposal. HRSA’s contracting officer also told us that he did not formally document his assessment of organizational conflict of interest.83

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APPENDIX II: METHODOLOGY FOR IDENTIFYING AND REVIEWING RESEARCH STUDIES To identify research studies that examine the effectiveness of abstinenceuntilmarriage education programs among adolescents and young adults, we searched two reference database systems, PubMed and ProQuest. We used the following keywords to search for research studies that were published from January 1, 1998, through May 22, 2006: “virginity,” “abstinence education,” “abstinence and curriculum,” “abstinence only,” “teen pregnancy and prevention,” and “abstinence until marriage.”84 We reviewed the research article titles that were generated from the PubMed and ProQuest searches and identified articles that appeared to focus on the evaluation of the effectiveness of abstinence-until-marriage education programs. In cases where we could not determine, based on the title, whether a study appeared to focus on an abstinence-until-marriage education program evaluation, we reviewed a summary of the article to obtain more information

82

FAR § 9.502(c). The FAR requires contracting officers to exercise common sense, good judgment, and sound discretion in determining whether a significant potential conflict of interest exists. FAR § 9.505. 84 The FAR requires HRSA’s contracting officers to formally document their assessment only when a substantive issue concerning a potential organizational conflict of interest exists. FAR § 9.504(d). HHS acquisition regulations do not explicitly address the assessment of organizational conflict of interest. Therefore, FAR subpart 9.5 is the controlling regulation when HHS encounters an issue related to an organizational conflict of interest. 83

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about the research study. We also examined previous summaries of the literature to identify additional research studies. We then selected research studies for inclusion in our literature review if they met three criteria. First, the study evaluated a group-based, abstinence-untilmarriage education program. We did not select studies that evaluated one-on-one interactions, such as education programs focused exclusively on parent-child interactions, or that evaluated media campaigns. We reviewed the description of each education program and curriculum, as described in the study, to determine whether an abstinenceuntil-marriage education program was being evaluated. Education programs that were described as including detailed contraceptive information in their curricula, for example, were not classified as abstinence-untilmarriage programs. Second, the study targeted adolescents and young adults in the United States, for example, by indicating that participants in the evaluation were high school or middle school students. Third, the study was a quantitative rather than a qualitative evaluation of an abstinence-until-marriage education program. We selected 13 research studies for inclusion in our literature review. We reviewed the selected research studies to obtain detailed information about their methodologies and outcome variables. For example, we determined whether each study used an experimental or quasi- experimental design and whether the outcome measures included attitudes, behavioral intentions, behaviors such as initiation of sexual intercourse, or a combination of these.

APPENDIX IV: GAO CONTACT AND STAFF ACKNOWLEDGMENTS GAO CONTACT Marcia Crosse, (202) 512-7119 or [email protected]

ACKNOWLEDGMENTS In addition to the contact named above, Kristi Peterson, Assistant Director; Kelly DeMots; Pam Dooley; Krister Friday; Julian Klazkin; and Amy Shefrin made key contributions to this report.

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TO REPORT FRAUD, WASTE, AND ABUSE IN FEDERAL PROGRAMS Contact: Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: [email protected] Automated answering system: (800) 424-5454 or (202) 512-7470

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PUBLIC AFFAIRS

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Paul Anderson, Managing Director, [email protected] (202) 512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, D.C. 20548

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Chapter 2

ASSESSING THE ACCURACY AND EFFECTIVENESS OF FEDERALLY FUNDED PROGRAMS *

Statement of Marcia Crosse

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WHY GAO DID THIS STUDY Among the efforts of the Department of Health and Human Services (HHS) to reduce the incidence of sexually transmitted diseases and unintended pregnancies, the agency provides funding to states and organizations that offer abstinence-untilmarriage education. GAO was asked to testify on the oversight of federally funded abstinence-untilmarriage education programs. This testimony is primarily based on Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs, GAO-07-87 (Oct. 3, 2006). In this testimony, GAO discusses efforts by (1) HHS and states to assess the scientific accuracy of materials used in abstinenceuntil-marriage education programs and (2) HHS, states, and researchers to assess the effectiveness of abstinenceuntil-marriage education programs. GAO also discusses a

*

This is an edited, reformatted and augmented version of remarks delivered as Testimony before the Committee on Oversight and Government Reform delivered by Marcia Crosse, Director, Health Care, GAO-08-664T, April 23, 2008.

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Statement by Marcia Crosse

Public Health Service Act requirement regarding medically accurate information about condom effectiveness. GAO focused on the three main federally funded abstinence-untilmarriage programs and reviewed documents and interviewed HHS officials in the Administration for Children and Families (ACF) and the Office of Population Affairs (OPA). To update certain information, GAO contacted officials from ACF and OPA.

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WHAT GAO FOUND Efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs have been limited. As of October 2006, HHS’s ACF—which awards grants under two programs that account for the largest portion of federal spending on abstinence education— did not review its grantees’ education materials for scientific accuracy, nor did it require grantees of either program to do so. Not all states that receive funding from ACF had chosen to review their program materials for scientific accuracy. OPA reviewed the scientific accuracy of grantees’ proposed education materials, and any inaccuracies found had to be corrected before those materials could be used. The extent to which federally funded abstinence-until-marriage education materials are inaccurate was not known, but OPA and some states reported finding inaccuracies. GAO recommended that the Secretary of HHS develop procedures to help assure the accuracy of abstinence-until-marriage education materials. An ACF official reported that ACF is currently implementing a process to review the accuracy of Community-based grantees’ curricula and has required those grantees to sign assurances that the materials they propose using are accurate. The official also reported that, in the future, state grantees will have to provide ACF with descriptions of their strategies for reviewing the accuracy of their programs. As of August 2006, HHS, states, and researchers had made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs, but a number of factors limit the conclusions that can be drawn about the programs’ effectiveness. ACF and OPA have required their grantees to report on various outcomes used to measure program effectiveness. To assess the effectiveness of its grantees’ programs, ACF has analyzed national data on adolescent birth rates and the proportion of adolescents who report having had sexual intercourse. Additionally, 6 of the 10 states in GAO’s review worked with third-party evaluators to assess the effectiveness of abstinenceuntil-marriage programs in their states. However, the conclusions that can be drawn are limited because most

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of the efforts to evaluate program effectiveness have not met certain minimum criteria that experts have concluded are necessary for such assessments to be scientifically valid. Additionally, the results of some efforts that do meet such criteria have varied. While conducting work for its October 2006 report, GAO identified a legal matter that required the attention of HHS. Section 317P(c)(2) of the Public Health Service Act requires certain educational materials to contain medically accurate information about condom effectiveness. GAO concluded that this requirement would apply to abstinence education materials prepared and used by federal grant recipients, depending on their substantive content, and recommended that HHS adopt measures to ensure that, where applicable, abstinence education materials comply with this requirement. The fiscal year 2007 program announcement for the Community-based Program provides information about the applicability of this requirement, and future State and Community-based Program announcements are to include this information.

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Mr. Chairman and Members of the Committee I am pleased to be here today as you examine federally funded abstinenceuntil-marriage education programs. Reducing the incidence of sexually transmitted diseases (STD) and unintended pregnancies among adolescents has been an important objective of the Department of Health and Human Services (HHS). Among its efforts to do so, HHS funds abstinence-until-marriage education programs. These programs are delivered by a variety of entities, including schools, human service agencies, and faith-based organizations. Studies have raised concerns about the accuracy of the educational materials that are incorporated into these programs, as well as the effectiveness of the programs themselves. My remarks today are primarily based on our October 2006 report on the oversight of federally funded abstinence-until-marriage programs, Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs (GAO-07-87).1 In that report, we recommended that the Secretary of Health and Human Services develop procedures to help assure the accuracy of such materials. Today, I will discuss findings from our report on (1) efforts by 1

GAO, Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs, GAO-07-87 (Washington, D.C.: Oct. 3, 2006). This report is available online at http://www.gao.gov.

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HHS and states to assess the scientific accuracy of materials used in abstinenceuntil-marriage programs, and (2) efforts by HHS, states, and researchers to assess the effectiveness of abstinence-until-marriage education programs as well as updates on selected information. I will also discuss a legal matter that came to our attention during the course of our work regarding the applicability of section 317P(c)(2) of the Public Health Service Act to Abstinence Education programs. We recommended in a letter dated October 18, 2006, that HHS adopt measures to ensure that, where applicable, abstinence-until-marriage education materials comply with the requirement that educational materials specifically designed to address STDs contain medically accurate information about condom effectiveness in preventing the STDs the materials were designed to address.2 For our assessment of the accuracy and effectiveness of abstinence-untilmarriage education programs, we focused our review on the three main federally funded abstinence-until-marriage programs: the Abstinence Education Program (State Program), the Community-Based Abstinence Education Program (Community-Based Program), and the Adolescent Family Life (AFL) Program. The State Program and the Community-Based Program are both administered by HHS’s Administration for Children and Families (ACF); AFL is administered by HHS’s Office of Population Affairs (OPA). According to HHS, funding for the three abstinence-until-marriage programs was about $165 million in fiscal year 2007. In order to describe the efforts to assess the scientific accuracy of program materials, we reviewed published reports, program announcements, Federal Register notices, agency Web sites, and other documents related to abstinenceuntil-marriage education. We did not assess the criteria used to determine the scientific accuracy of education materials or the quality of the reviews. We interviewed officials from ACF and OPA. We also interviewed officials from the 10 states that received the largest share of federal funding (together accounting for 51 percent of the total funding in fiscal year 2005) through the State Program for abstinenceuntil-marriage education.3 To describe efforts by HHS, states, and researchers to assess the effectiveness of abstinence-until-marriage education programs, we focused on efforts that 2

3

42 U.S.C. § 247b-17(c)(2) (2000); see GAO, Abstinence Education: Applicability of Section 31 7P of the Public Health Service Act, B-308128 (Washington, D.C.: Oct. 18, 2006). This letter is available online at http://www.gao.gov The 10 states that received the largest share of funding in fiscal year 2005 through the State Program were Arizona, Florida, Georgia, Illinois, Louisiana, Michigan, New York, North Carolina, Ohio, and Texas.

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examined the extent to which these programs achieved their program goals. In general, these goals include teaching adolescents to abstain from sexual activity until marriage in order to avoid unintended pregnancies, STDs, and related health problems. As part of our review, we compared these efforts to the design characteristics that experts have identified as important for a scientifically valid study of program effectiveness.4 We reviewed journal articles and other published reports, agency budget submissions, program announcements, agency and grantee performance reports, Federal Register notices, agency Web sites, and other documents related to abstinence-untilmarriage education.5 We also interviewed officials from ACF, OPA, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and 10 states that received the largest share of federal funding for abstinence- only education through the State Program in fiscal year 2005. We focused our review on efforts to assess the scientific accuracy of materials and the effectiveness of the programs during fiscal year 2006. We conducted this work from October 2005 through September 2006 and during April 2008 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. To assess the applicability of section 317P(c)(2) of the Public Health Service Act to abstinence-until-marriage education programs, we reviewed the statute, pertinent legislative history, and relevant program guidance. In addition, we solicited the views of HHS officials on this issue. 4

See Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001). The experts identifying the design characteristics of a scientifically valid study for the National Campaign to Prevent Teen Pregnancy were drawn from institutions that include the National Institutes of Health, the Medical Institute for Sexual Health, the Alan Guttmacher Institute, the Institute for Research and Evaluation, and various universities. See David Satcher, The National Consensus Process on Sexual Health and Responsible Sexual Behavior: Interim Report (Atlanta: Morehouse School of Medicine, 2006). The panel convened by former Surgeon General David Satcher included experts from a variety of organizations, including the Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American Academy of Pediatrics. In addition, characteristics of a scientifically valid study have been identified by other experts in the field of evaluation research. For example, see Carol H. Weiss, Evaluation (Upper Saddle River: Prentice Hall, 1998). 5 For a more detailed description of our literature review methodology, see GAO-07-87.

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In summary, we found that efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs had been limited. ACF did not review its grantees’ education materials for scientific accuracy and did not require that grantees of either the State Program or the Community-Based Program do so. In addition, not all states that received funding through ACF’s State Program chose to review their program materials for scientific accuracy. Five of the 10 states in our review conducted such reviews. In contrast to ACF, OPA did review the scientific accuracy of AFL grantees’ proposed educational materials and any inaccuracies found had to be corrected before the materials could be used. While we reported that the extent to which federally funded abstinence-until-marriage education materials are inaccurate was not known, in the course of their reviews OPA and some states reported that they had found some inaccuracies in abstinence-untilmarriage education materials. For example, one state official described an instance in which abstinence-untilmarriage materials incorrectly suggested that HIV can pass through condoms because the latex used in condoms is porous. To address concerns about the scientific accuracy of materials used in abstinence-until-marriage programs, we recommended that the Secretary of HHS develop procedures to help assure the accuracy of such materials, and HHS agreed to consider this recommendation. In April 2008, an ACF official reported that, in response to our recommendation, ACF began requiring in fiscal year 2007 that community- based grantees sign written assurances that the materials they propose using are accurate. This official also reported that, starting in fiscal year 2008, grantees of the State Program will also be required to sign these written assurances. In addition, this official reported that ACF is implementing a process to review the accuracy of the proposed curricula of fiscal year 2007 Community-based grantees. The ACF official reported that the curricula will be reviewed by a research analyst to ensure that all statements are referenced to source documents, and then by a healthcare professional who will compare the information in the curricula to information in the source documents. The official also reported that, in the future, ACF will require states to provide the agency with descriptions of their strategies for reviewing the accuracy of their abstinence-untilmarriage education programs. HHS, states, and researchers have made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs; however, a number of factors limit the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. To assess the effectiveness of their abstinence-until-marriage education programs, ACF and OPA have required their grantees to report on various outcomes. For example, as of fiscal year 2006, states that received funding through the State Program were required to report

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annually on four measures of the prevalence of adolescent sexual behavior in their state, such as the rate of pregnancy among adolescents aged 15 to 17 years. To assess the effectiveness of both its State and Community-Based Programs, ACF also analyzed trends in adolescent behavior, as reflected in national data on birth rates among teens and the proportion of surveyed high school students reporting that they have had sexual intercourse. OPA required grantees of the AFL Program to develop and report on outcome measures that demonstrated the extent to which grantees’ programs are having an effect on program participants. Further, 6 of the 10 states in our review that received funding through the State Program worked with third-party evaluators to assess the effectiveness of abstinence-until-marriage education programs in their states. Several factors, however, limit the conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts to evaluate the effectiveness of abstinence-untilmarriage education programs that we described in our report did not meet certain minimum criteria—such as random assignment of participants and sufficient follow-up periods and sample sizes—that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid. During the course of our work on abstinence-until-marriage education, we identified a legal matter that required the attention of HHS. Section 317P(c)(2) of the Public Health Service Act requires educational materials specifically designed to address STDs to contain medically accurate information about condom effectiveness in preventing the diseases the educational materials are designed to address. We concluded that this requirement would apply to abstinence-untilmarriage education materials prepared by and used by federal grant recipients, depending upon the substantive content of those materials. In other words, in materials otherwise meeting the statutory criteria, HHS’ grantees are required to include information on condom effectiveness, and that information must be medically accurate. At the time of our review, an ACF official reported that materials prepared by abstinence-until-marriage education grantees were not subject to section 317P(c)(2). Therefore, we recommended in a letter dated October 18, 2006, that HHS reexamine its position and adopt measures to ensure that, where applicable, abstinence-until-marriage education materials comply with this requirement. The fiscal year 2007 Community-Based Program announcement states that mass produced materials that as their primary purpose are specifically about STDs are required to contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the STDs the educational materials are designed to address. An ACF official also told us that future State and Community-Based Program announcements would include this language.

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BACKGROUND Statistics reported by CDC show that many high school students engage in sexual behavior that places them at risk for unintended pregnancy and STDs. In 2005, 46.8 percent of high school students reported that they have had sexual intercourse, with 14.3 percent of students reporting that they had had sexual intercourse with four or more persons. CDC also has reported that the prevalence of certain STDs—including the rate of chlamydia infection, the most frequently reported STD in the United States—peaks in adolescence and young adulthood. At the time of our 2006 report, HHS’s strategic plan included the objectives to reduce the incidence of STDs and unintended pregnancies and to promote family formation and healthy marriages. These two objectives supported HHS’s goals to reduce the major threats to the health and wellbeing of Americans and to improve the stability and healthy development of American children and youth. Abstinence-until-marriage education programs were one of several types of programs that supported these objectives. The State Program, the CommunityBased Program, and the AFL Program provide grants to support the recipients’ own efforts to provide abstinence-until-marriage education at the local level. These programs must comply with the statutory definition of abstinence education (see table 1).6 The State Program, administered by ACF, provides funding to its grantees— states—for the provision of abstinence-until-marriage education to those most likely to have children outside of marriage.7 States that receive grants through the State Program have discretion in how they use their funding to provide abstinence-until-marriage education. Funds are allotted to each state that submits the required annual application based on the ratio of the number of low-income children in the state to the total number of low-income children in all states. States are required to match every $4 they receive in federal money with $3 of nonfederal money and are required to report annually on the performance of the 6

7

42 U.S.C. § 710(b)(2). This definition is also referred to as the A-H definition. This statutory provision defines abstinence education for purposes of the State Program. Annual appropriations acts and program announcements have extended this definition to the Community-Based and AFL Programs. See, e.g., Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2006, Pub. L. No. 109- 149, 119 Stat. 2833, 2855-56. Funds are also provided through the State Program to the District of Columbia and insular areas, which include U.S. territories and commonwealths. In this statement, we refer to U.S. territories and commonwealths as “insular areas.” When we refer to “states,” we are referring to all grantees of the State Program—including states, insular areas, and the District of Columbia.

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abstinence-untilmarriage education programs that they support or administer. In fiscal year 2007, 40 states, the District of Columbia, and 3 insular areas were awarded funding. Table 1. Definition of Abstinence Education Abstinence education refers to an educational or motivational program that: A. has, as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; B. teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; C. teaches that abstinence from sexual activity is the only certain way to avoid outofwedlock pregnancy, sexually transmitted diseases, and other associated health problems; D. teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; E. teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;

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F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; G. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and H. teaches the importance of attaining self-sufficiency before engaging in sexual activity. Source: Social Security Act, § 510(b)(2) (codified at 42 U.S.C. § 710(b)(2)).

The Community-Based Program, which is also administered by ACF, is focused on funding public and private entities that provide abstinenceuntilmarriage education for adolescents from 12 to 18 years old. The CommunityBased Program provides grants for school-based programs, adult and peer mentoring, and parent education groups. For fiscal year 2007, 59 grants were awarded to organizations and other entities. Grantees are required to report to ACF, on a semiannual basis, on the performance of their programs.

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The AFL Program also supports programs that provide abstinence-untilmarriage education.8 Under the AFL Program, OPA awards competitive grants to public or private nonprofit organizations or agencies, including community-based and faith-based organizations, to facilitate abstinenceuntil-marriage education in a variety of settings, including schools and community centers. In fiscal year 2007, OPA awarded funding to 36 grantees. Grantees are required to conduct evaluations of certain aspects of their programs and report annually on their performance. Five organizational units located within HHS—ACF, OPA, CDC, ASPE, and NIH—have responsibilities related to abstinence-until-marriage education. ACF and OPA administer the three main federal abstinence-until-marriage education programs. CDC supports abstinence-until-marriage education at the national, state, and local levels. CDC, ASPE, and NIH are sponsoring research on the effectiveness of abstinence-until-marriage programs.

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FEDERAL AND STATE EFFORTS TO ASSESS THE SCIENTIFIC ACCURACY OF MATERIALS USED IN ABSTINENCEUNTIL-MARRIAGE EDUCATION PROGRAMS HAVE BEEN LIMITED In October 2006 we reported that efforts by HHS and states to assess the scientific accuracy of materials used in abstinence-until-marriage education programs had been limited.9 ACF—whose grants to the State and CommunityBased Programs accounted for the largest portion of federal spending on abstinence-until-marriage education—did not review its grantees’ education materials for scientific accuracy and did not require grantees of either program to review their own materials for scientific accuracy. In addition, not all states funded through the State Program chose to review their program materials for scientific accuracy. In contrast to ACF, OPA reviewed the scientific accuracy of

8

See 42 U.S.C. § 300z et seq. In this statement, when we use the term AFL Program, we are referring only to the abstinence-until-marriage component of the AFL Program. The AFL Program also supports other projects for pregnant and parenting adolescents, their infants, male partners, and family members. The purpose of these projects is to improve the outcomes of early childbearing for teen parents, their infants, and their families. 9 See GAO-07-87.

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grantees’ proposed educational materials and corrected inaccuracies in these materials.

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ACF Neither Reviewed Nor Required Grantees to Review Program Materials for Scientific Accuracy, Although Some State Grantees had Conducted Such Reviews As of October 2006, there had been limited efforts to review the scientific accuracy of educational materials used in ACF’s State and Community- Based Programs—the two programs that accounted for the largest portion of federal spending on abstinence-until-marriage education. ACF did not review materials for scientific accuracy in either reviewing grant applications or in overseeing grantees’ performance. Prior to fiscal year 2006, State Program and CommunityBased Program applicants were not required to submit copies of their proposed educational materials with their applications. While ACF required grantees of the Community-Based Program—but not the State Program—to submit their educational materials with their fiscal year 2006 applications, ACF officials told us that grantee applications and materials were only reviewed to ensure that they addressed all aspects of the scope of the Community-Based Program, such as the A-H definition of abstinence education.10 Further, documents provided to us by ACF indicated that the agency did not review grantees’ educational materials for scientific accuracy as a routine part of its oversight activities. In addition, ACF also did not require its grantees to review their own materials for scientific accuracy. While not all grantees of the State Program had chosen to review the scientific accuracy of their educational materials, officials from 5 of the 10 states in our review reported that their states chose to do so. These five states used a variety of approaches in their reviews. For example, some states contracted with medical professionals—such as nurses, gynecologists, and pediatricians—to serve as medical advisors who review program materials and use their expertise to determine what is and is not scientifically accurate. One of the states required that all statistics or scientific statements cited in a program’s materials be sourced to CDC or a peer-reviewed medical journal. Officials from this state told us that if 10

HHS officials told us that if ACF finds inaccurate statements during this more general review process or if inaccuracies are brought to their attention at any time during the grant period, ACF officials work with the grantees to take corrective action.

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statements in these materials could not be attributed to these sources, the statements were required to be removed until citations were provided and materials were approved. As a result of their reviews, officials from two of the five states reported that they had found inaccuracies. One state official cited an instance where materials incorrectly suggested that HIV can pass through condoms because the latex used in condoms is porous. State officials who have identified inaccuracies told us that they informed their grantees of inaccuracies so that they could make corrections in their individual programs. Some of the educational materials that states reviewed were materials that were commonly used in the Community–Based Program. While there had been limited review of materials used in the State and Community-Based Programs, grantees of these programs had received some technical assistance designed to improve the scientific accuracy of their materials. For example, ACF officials reported that the agency provided a conference for grantees of the Community-Based Program in February 2006 that included a presentation focused on medical accuracy.

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OPA Reviewed Materials Used by AFL Program Grantees for Scientific Accuracy As of 2006, in contrast to ACF, OPA reviewed for scientific accuracy the educational materials used by AFL Program grantees, and it did so before those materials were used. OPA officials said that after grants were awarded, a medical education specialist (in consultation with several part- time medical experts) reviewed the grantees’ printed materials and other educational media, such as videos. OPA officials explained that the medical education specialist must approve all proposed materials before they are used. On many occasions, OPA grantees had proposed using— and therefore OPA has reviewed—materials commonly used in the Community-Based Program. For example, an OPA official told us that the agency had reviewed three of the Community-Based Program’s commonly used curricula and was also currently reviewing another curriculum commonly used by Community-Based Program grantees. OPA officials stated that the medical education specialist had occasionally found and addressed inaccuracies in grantees’ proposed educational materials. OPA officials stated that these inaccuracies were often the result of information being out of date because, for example, medical and statistical information on STDs changes frequently. OPA addressed these inaccuracies by either not approving the materials in which they appeared or correcting the materials through discussions with the grantees and, in some cases, the authors of the materials. In fiscal year 2005, OPA disapproved

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of a grantee using a specific pamphlet about STDs because the pamphlet contained statements about STD prevention and HIV transmission that were considered incomplete or inaccurate. For example, the pamphlet stated that there was no cure for hepatitis B, but the medical education specialist required the grantee to add that there was a preventive vaccine for hepatitis B. In addition, OPA required that a grantee correct several statements in a true/false quiz—including statements about STDs and condom use—in order for the quiz to be approved for use. For example, the medical education specialist changed a sentence from “The only 100% effective way of avoiding STDs or unwanted pregnancies is to not have sexual intercourse.” to “The only 100% effective way of avoiding STDs or unwanted pregnancies is to not have sexual intercourse and engage in other risky behaviors.” While OPA and some states had reviewed their grantees’ abstinence-untilmarriage education materials for scientific accuracy, these types of reviews have the potential to affect abstinence-until-marriage education providers more broadly, perhaps creating an incentive for the authors of such materials to ensure they are accurate. As of October 2006, the company that produced one of the most widely used curricula used by grantees of the Community-Based Program had updated its curriculum. A representative from that company stated that this had been done, in part, in response to a congressional review that found inaccuracies in its abstinence-until-marriage materials. To address concerns about the scientific accuracy of materials used in abstinence-until-marriage education programs, we recommended that the Secretary of HHS develop procedures to help assure the accuracy of such materials used in the State and Community-Based Programs.11 We recommended that in order to provide such assurance, the Secretary could consider alternatives such as (1) extending the approach currently used by OPA to review the scientific accuracy of the factual statements included in abstinence-until-marriage education to materials used by grantees of ACF’s Community-Based Program and requiring grantees of ACF’s State Program to conduct such reviews or (2) requiring grantees of both programs to sign written assurances in their grant applications that the materials they propose using are accurate. In its written comments on a draft of our report, HHS stated that it would consider requiring grantees of both ACF programs to sign such written assurances to the accuracy of their materials. In April 2008, an ACF official reported that, in response to our recommendation, ACF began requiring in fiscal year 2007 that community-based grantees sign written assurances that the materials they propose using are accurate. This official also reported that, starting in fiscal 11

See GAO-07-87.

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year 2008, grantees of the State Program will also be required to sign these written assurances. In addition, this official reported that ACF is implementing a process to review the accuracy of the proposed curricula of fiscal year 2007 Community-based grantees. The ACF official reported that the curricula will be reviewed by a research analyst to ensure that all statements are referenced to source documents, and then by a healthcare professional who will compare the information in the curricula to information in the source documents. The official also reported that, in the future, ACF will require states to provide the agency with descriptions of their strategies for reviewing the accuracy of their abstinence-untilmarriage education programs.

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A VARIETY OF EFFORTS WERE MADE TO ASSESS THE EFFECTIVENESS OF ABSTINENCE-UNTIL-MARRIAGE EDUCATION PROGRAMS, BUT A NUMBER OF FACTORS LIMIT THE CONCLUSIONS THAT CAN BE DRAWN HHS, states, and researchers have made a variety of efforts to assess the effectiveness of abstinence-until-marriage education programs; however, a number of factors limit the conclusions that can be drawn. ACF and OPA have required their grantees to report on various outcomes used to measure the effectiveness of grantees’ abstinence-until-marriage education programs. To assess the effectiveness of the State and Community-Based Programs, ACF has analyzed national data on adolescent birth rates and the proportion of adolescents who report having had sexual intercourse. As of October 2006, other organizational units within HHS were funding studies designed to assess the effectiveness of abstinence-until-marriage education programs in delaying sexual initiation, reducing pregnancy and STD rates, and reducing the frequency of sexual activity. Despite these efforts, several factors limit the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. Most of the efforts to evaluate the effectiveness of abstinence-untilmarriage education programs that we reviewed have not met certain minimum criteria that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid, in part because such designs can be expensive and time-consuming to carry out. In addition, the results of some efforts that meet the criteria of a scientifically valid assessment have varied.

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HHS, States, and Researchers Have Made a Variety of Efforts to Assess the Effectiveness of Abstinence-Until-Marriage Education Programs ACF has made efforts to assess the effectiveness of abstinence-untilmarriage education programs funded by the State Program and the Community-Based Program. One of ACF’s efforts has been to require grantees of both programs to report data on outcomes, though the two programs have different requirements for the outcomes grantees must report.12 As of fiscal year 2006, State Program grantees were required to report annually on four measures of the prevalence of adolescent sexual behavior in their states, such as the rate of pregnancy among adolescents aged 15 to 17 years, and compare these data to program targets over 5 years. States also were required to develop and report on two additional performance measures that were related to the goals of their programs.13 Also as of fiscal year 2006, ACF required Community-Based Program grantees to develop and report on outcome measures designed to demonstrate the extent to which grantees’ community-based abstinenceuntil-marriage education programs were accomplishing their program goals.14 In addition to outcome reporting, ACF required grantees of the Community-Based Program to report on program “outputs,” which measure the quantity of program activities and other deliverables, such as the number of participants who are served by the abstinenceuntilmarriage education programs. As of October 2006, OPA also had made efforts to assess the effectiveness of the AFL Program. Specifically, OPA required grantees of the AFL Program to develop and report on outcome measures, such as participants’ knowledge of the 12

This reporting is a part of ACF’s efforts to collect evaluative information about these programs. These efforts include both performance measurement—the ongoing monitoring and reporting of program accomplishments toward pre-established goals—and program evaluation—individual systematic studies to assess how well a program is working. 13 For example, in fiscal year 2002, state grantees developed such measures as the percentage of teens surveyed who show an increase in participating in structured activities after school hours; the percentage of live births to women younger than 18, fathered by men age 20 and older; the percentage of program participants proficient in refusal skills; the percentage of high school students who reported using drugs or alcohol before intercourse; and the percentage of high school students who had sexual intercourse for the first time before age 13. 14 The fiscal year 2006 program announcement for the Community-Based Program provided examples of outcome measures that grantees could use, including increased knowledge of the benefits of abstinence, the number of youths who commit to abstaining from premarital sexual activity, and increased knowledge of how to avoid high-risk situations and risk behaviors.

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benefits of abstinence and their reported intentions to abstain from sexual activity, that were used to help demonstrate the extent to which grantees’ programs were having an effect on program participants. To collect data on outcome measures, OPA required grantees to administer, at a minimum, a standardized questionnaire to their program participants, both when participants begin an abstinence-only education program and after the program’s completion. OPA officials told us that they were planning to aggregate information from certain questions in the standardized set of questionnaires in order to report on certain performance measures as part of the agency’s annual performance reports; the agency expected to begin receiving data from grantees that were using these questionnaires in January 2007. To help grantees measure the effectiveness of their programs, both ACF and OPA required that grantees use independent evaluators and have provided assistance to grantees in support of their program evaluation efforts. ACF and OPA required their grantees to contract with third-party evaluators, such as university researchers or private research firms, who were responsible for helping grantees develop the outcome measures they were required to report on and monitoring grantee performance against those measures. Unlike ACF, OPA required that these third-party evaluations incorporate specific methodological characteristics, such as control groups of individuals that did not receive the program and sufficient sample sizes to ensure that any observed differences between the groups were statistically valid. Both ACF and OPA have provided technical assistance and training to their grantees in order to support grantees’ own program evaluation efforts. ACF also analyzed trends in adolescent behavior, as reflected in national data on birth rates among teens and the proportion of surveyed high school students reporting that they have had sexual intercourse.15 ACF used these national data as a measure of the overall effectiveness of its State and Community-Based Programs, comparing the national data to program targets. In its annual performance reports, the agency has summarized the progress being made toward lowering the rate of births to unmarried teenage girls and the proportion of students (grades 9-12) who report having ever had sexual intercourse.

15

Data on teen birth rates and adolescents’ reported sexual behavior are contained in the National Vital Statistics System and the Youth Risk Behavior Surveillance System, respectively. The former is a national data set of public health statistics reported by states to CDC, and the latter is a national data set based on nationwide surveys administered to high school students by CDC.

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Some states have made additional efforts to assess the effectiveness of abstinence-until-marriage education programs. Specifically, we found that 6 of the 10 states in our review that received funding through ACF’s State Program had made efforts to conduct evaluations of selected abstinenceuntil-marriage programs in their state. All 6 of the states worked with third-party evaluators, such as university researchers or private research firms, to perform the evaluations, which in general measured self-reported changes in program participants’ behavior and attitudes related to sex and abstinence as indicators of program effectiveness. Four of these states had completed third-party evaluations as of February 2006, and the results of these studies varied.16 Among those 4 states, 3 states required the abstinence programs in their state to measure reported changes in participants’ behavior as an indicator of program effectiveness—both at the start of the program and after its completion. The 3 states required their programs to track participants’ reported incidence of sexual intercourse. Additionally, 2 of the 4 states required their programs to track biological outcomes, such as pregnancies, births, or STDs. In addition, 6 of the 10 states in our review required their programs to track participants’ attitudes about abstinence and sex, such as the number of participants who make pledges to remain abstinent. Besides ACF and OPA, other organizational units within HHS have made efforts to assess the effectiveness of abstinence-until-marriage education programs. As of 2006, ASPE was sponsoring a study of the Community- Based Program and a study of the State Program. The study of the State Program was conducted by Mathematica Policy Research, Inc. (Mathematica) and completed in 2007. It examined the impact of five programs funded through the State Program on participants’ attitudes and behaviors related to abstinence and sex.17 Like ASPE, CDC has made its own effort to assess the effectiveness of abstinenceuntil-marriage education by sponsoring a study to evaluate the effectiveness of two middle school curricula—one that complies with abstinence-untilmarriage 16

17

See, for example, LeCroy & Milligan Associates, Inc., Abstinence Only Education Program: Fifth Year Evaluation Report, a report prepared for the Arizona Department of Health Services (2003); Patricia Goodson et al., Abstinence Education Evaluation: Phase 6, a report prepared for the Texas Department of State Health Services (2005); MGT of America, Evaluation of Georgia Abstinence Education Programs Funded Under Title V, Section 510, a report prepared for the Georgia Department of Human Resources (2005); Thomas E. Smith, It’s Great to Wait: An Interim Evaluation, a report prepared for the Florida Department of Health (2001). The five abstinence-until-marriage education programs studied were My Choice, My Future! in Powhatan, Virginia; ReCapturing the Vision in Miami, Florida; Teens in Control in Clarksdale, Mississippi; Families United to Prevent Teen Pregnancy in Milwaukee, Wisconsin; and Heritage Keepers in Edgefield, South Carolina.

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education program requirements and one that teaches a combination of abstinence and contraceptive information and skills. The agency expects to complete the study in 2009. Likewise, NIH has funded studies comparing the effectiveness of education programs that focus only on abstinence with the effectiveness of sex education programs that teach both abstinence and information about contraception. As of October 2006, NIH was funding five studies, which in general were comparing the effects of these two types of programs on the sexual behavior and related attitudes among groups of either middle school or high school students. In addition to the efforts of researchers working on behalf of HHS and states, other researchers—such as those affiliated with universities and various advocacy groups—have made efforts to study the effectiveness of abstinence-until-marriage education programs. This work includes studies of the outcomes of individual programs and reviews of other studies on the effectiveness of individual abstinence-until-marriage education programs. In general, research studies on the effectiveness of individual programs have examined the extent to which they changed participants’ demonstrated knowledge of concepts taught in the programs, declared intentions to abstain from sex until marriage, and reported behavior related to sexual activity and abstinence. As of October 2006, the efforts to study and build a body of research on the effectiveness of most abstinenceuntil-marriage education programs had been under way for only a few years, in part because grants under the two programs that account for the largest portion of federal spending on abstinence-untilmarriage education—the State Program and the Community-Based Program—were not awarded until 1998 and 2001, respectively.

Several Factors Limit the Conclusions That Can Be Drawn about the Effectiveness of Abstinence-Until-Marriage Education Programs Most of the efforts of HHS, states, and other researchers to evaluate the effectiveness of abstinence-until-marriage education programs included in our review have not met certain minimum criteria that experts have concluded are necessary in order for assessments of program effectiveness to be scientifically valid. In an effort to better assess the merits of the studies that have been conducted on the effectiveness of sexual health programs—including abstinenceuntil-marriage education programs—scientific experts have developed criteria that

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can be used to gauge the scientific rigor of these evaluations. The reports of two panels of experts,18,19 as well as the experts we interviewed in the course of our previous work, generally agreed that scientifically valid studies of a program’s effectiveness should include the following characteristics: •

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•

An experimental design that randomly assigns individuals or schools to either an intervention group or control group, or a quasi-experimental design that uses nonrandomly assigned but well-matched comparison groups. According to the panel of scientific experts convened by the National Campaign to Prevent Teen Pregnancy, experimental designs or quasi-experimental designs with well-matched comparison groups have at least three important strengths that are typically not found in other studies, such as those that use aggregated data: they evaluate specific programs with known characteristics, they can clearly distinguish between participants who did and did not receive an intervention, and they control for other factors that may affect study outcomes. According to scientific experts, studies that include experimental or quasiexperimental designs should also collect follow-up data for a minimum number of months after subjects receive an intervention. In addition, experts have reported that studies should have a sample size of at least 100 individuals for study results to be considered scientifically valid. Studies should assess or measure changes in biological outcomes or reported behaviors instead of attitudes or intentions. According to scientific experts, biological outcomes—such as pregnancy rates, birth rates, and STD rates—and reported behaviors—such as reported initiation and frequency of sexual activity—are better measures of the effectiveness of abstinence-until-marriage programs, because adolescent attitudes and intentions may or may not be indicative of actual behavior.

Many of the efforts by HHS, states, and other researchers that we identified in our review lack at least one of the characteristics of a scientifically valid study of program effectiveness. Most of the efforts to assess the effectiveness of these 18

See Kirby. This panel included experts from NIH, the Medical Institute for Sexual Health, the Alan Guttmacher Institute, the Institute for Research and Evaluation, and various universities. 19 See Satcher. This panel included experts from a variety of organizations, including the Medical Institute for Sexual Health, the Alan Guttmacher Institute, and the American Academy of Pediatrics.

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programs have not used experimental or quasi-experimental designs with sufficient follow-up periods and sample sizes. For example, ACF used, according to ACF officials, grantee reporting on outcomes in order to monitor grantees’ performance, target training and technical assistance, and help grantees improve service delivery. However, because the outcomes reported by grantees have not been produced through experimentally or quasi-experimentally designed studies, such information cannot be causally attributed to any particular abstinence-untilmarriage education program. Further, none of the state evaluations we reviewed that had been completed included randomly assigned control groups. Similarly, some of the journal articles that we reviewed described studies to assess the effectiveness of abstinence-untilmarriage programs that also lacked at least one of the characteristics of a scientifically valid study of program effectiveness. In these studies, researchers administered questionnaires to study participants before and after they completed an abstinence-until-marriage education program and assessed the extent to which the responses of participants changed.20 These studies did not compare the responses of study participants with a group that did not participate in an abstinence-until-marriage education program. Like the lack of an experimental or quasi-experimental design, not measuring changes in behavioral or biological outcomes among participants limits the conclusions that can be drawn about the effectiveness of abstinence-untilmarriage education programs. Most of the efforts we identified in our review used reported intentions and attitudes in order to assess the effectiveness of abstinenceuntil-marriage programs. For example, as of 2006, neither ACF’s communitybased grantees nor OPA’s AFL grantees were required to report on behavioral or biological outcomes, such as rates of intercourse or pregnancy. Similarly, the journal articles we reviewed were more likely to use reported attitudes and intentions—such as study participants’ reported attitudes about premarital sexual activity or their reported intentions to remain abstinent until marriage—rather than their reported behaviors or biological outcomes to assess the effectiveness of abstinence-until-marriage programs. According to scientific experts, HHS, states, and other researchers face a number of challenges in applying either of these criteria. According to these experts, experimental or quasi-experimental studies can be expensive and time20

See, for example, S. M. Fitzgerald et al., “Effectiveness of the Responsible Social Values Program for 6th Grade Students in One Rural School District,” Psychological Reports, vol. 91 (2002), and J. E. Barnett and C. S. Hurst, “Abstinence Education for Rural Youth: An Evaluation of the Life’s Walk Program,” The Journal of School Health, vol. 73, no. 7 (2003).

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consuming to carry out, and many grantees of abstinence-until-marriage education programs have insufficient time and funding to support these types of studies. Moreover, it can be difficult for researchers assessing abstinence-until-marriage education programs to convince school districts to participate in randomized intervention and control groups, in part because of sensitivities to surveying attitudes, intentions, and behaviors related to abstinence and sex. Similarly, experts, as well as state and HHS officials, have reported that it can be difficult to obtain scientifically valid information on biological outcomes and sexual behaviors. For example, experts have reported that when measuring a program’s effect on biological outcomes—such as reducing pregnancy rates or birth rates—it is necessary to have large sample sizes in order to determine whether a small change in such outcomes is the result of an abstinence-until-marriage education program. Among the assessment efforts we identified are some studies that meet the criteria of a scientifically valid effectiveness study. However, results of these studies varied, and this limits the conclusions that can be drawn about the effectiveness of abstinence-until-marriage education programs. Some researchers have reported that abstinence-until-marriage education programs have resulted in adolescents reporting having less frequent sexual intercourse or fewer sexual partners.21 For example, in one study of middle school students, participants in an abstinence-until-marriage education program who had sexual intercourse during the follow-up period were 50 percent less likely to report having two or more sexual partners when compared with their nonparticipant peers.22 In contrast, other studies have reported that abstinence-until-marriage education programs did not affect the reported frequency of sexual intercourse or number of sexual partners.23 For example, one study of middle school students found that participants of an abstinence-until-marriage program were not less likely than nonparticipants at the 1 year follow-up to report less frequent sexual intercourse 21

See E. A. Borawski et al., “Effectiveness of Abstinence-only Intervention in Middle School Teens,” American Journal of Health Behavior, vol. 29, no. 5 (2005). See also T. L. St. Pierre et al., “A 27-Month Evaluation of a Sexual Activity Prevention Program in Boys & Girls Clubs Across the Nation,” Family Relations, vol. 44, no. 1 (1995). 22 See Borawski et al., “Effectiveness of Abstinence-only Intervention in Middle School Teens,”. 23 See N. G. Harrington et al., “Evaluation of the All Stars Character Education and Problem Behavior Prevention Program: Effects on Mediator and Outcome Variables for Middle School Students,” Health Education & Behavior, vol. 28, no. 5 (2001). See also J. B. Jemmott III, L. S. Jemmott, and G. T. Fong, “Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents: A Randomized Controlled Trial,” Journal of the American Medical Association, vol. 279, no. 19 (1998).

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or fewer sexual partners.24 Experts with whom we spoke emphasized that there were still too few scientifically valid studies completed as of 2006 that could be used to determine conclusively which, if any, abstinence-until-marriage programs are effective. We identified two key studies that experts anticipated would meet the criteria of a scientifically valid effectiveness study. Experts and federal officials we interviewed stated that they expected the results of these two federally funded studies to add substantively to the body of research on the effectiveness of abstinence-until-marriage education programs. One of these key studies—the final Mathematica report, contracted by ASPE, on the State Program—has been completed.25 In this report, the researchers found that youth who participated in the abstinence-until-marriage education programs were no more likely than control group youth to have abstained from sex, and among those who reported having had sex, they had similar numbers of sexual partners and had initiated sex at the same average age. The youth in abstinence-until-marriage education programs also were no more likely to have engaged in unprotected sex than control group youth. The second key study we identified is CDC’s research on middle school programs, which is still ongoing. In addition, since October 2006, a third key report was released, presenting the 2007 analysis of the National Campaign to Prevent Teen and Unplanned Pregnancy of the available research on abstinence-until-marriage education programs. This report stated that studies of abstinence programs have not produced sufficient evidence of effectiveness, and that efforts should be directed toward further evaluation of these programs.26

24

25

26

See Harrington et al., “Evaluation of the All Stars Character Education and Problem Behavior Prevention Program: Effects on Mediator and Outcome Variables for Middle School Students.” See Trenholm at al., Impacts of Four Title V, Section 510 Abstinence Education Programs: Final Report, a report prepared for ASPE, 2007. According to several scientific experts, Mathematica’s study is an important one, in part because of its sound design: the study randomly assigns and compares control groups with groups receiving abstinenceuntil-marriage education and uses surveys to follow up with program participants for several months after their completion of a program. See Douglas Kirby, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases (Washington D.C.: National Campaign to Prevent Teen and Unplanned Pregnancy, 2007).

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STATUTORY REQUIREMENT TO INCLUDE INFORMATION ON CONDOM EFFECTIVENESS WOULD APPLY TO CERTAIN ABSTINENCE-UNTIL-MARRIAGE EDUCATION MATERIALS During the course of our work on abstinence-until-marriage education, we identified a federal statutory provision—section 317P(c)(2) of the Public Health Service Act—relevant to the grants provided by HHS’s State Program, Community-Based Program, and AFL Program.27 This provision requires that educational materials prepared by HHS’s grantees, among others, that are specifically designed to address STDs, contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the diseases the materials are designed to address. At the time of our review, an ACF official reported that materials prepared by abstinence-until-marriage education grantees were not subject to section 317P(c)(2). However, we concluded that this requirement would apply to abstinence-until-marriage education materials prepared by and used by federal grant recipients, depending upon the substantive content of those materials. In other words, in materials specifically designed to address STDs, HHS’s grantees are required to include information on condom effectiveness, and that information must be medically accurate. Therefore, we recommended in a letter dated October 18, 2006, that HHS reexamine its position and adopt measures to ensure that, where applicable, abstinence education materials comply with this requirement.28 In a letter to us dated January 16, 2007, ACF responded that it would take steps to “make it clear to grantees that when they mass produce materials that as a primary purpose are specifically about STDs those materials are required by section 317P(c)(2) of the Public Health Service Act to contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the sexually transmitted disease the materials are designed to address.” The fiscal year 2007 Community- Based Program announcement states that mass 27

42 U.S.C. § 247b-17(c)(2). Section 317P(c)(2) states that “. . . educational and prevention materials prepared and printed . . . for the public and health care providers by the Secretary (including materials prepared through the Food and Drug Administration, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration) or by contractors, grantees, or subgrantees thereof, that are specifically designed to address STDs . . . shall contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the STD the materials are designed to address. Such requirement only applies to materials mass produced for the public and health care providers, and not to routine communications.” 28 See GAO, B-308128, Oct. 18, 2006.

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produced materials that as their primary purpose are specifically about STDs are subject to this requirement. The announcement also states that mass produced materials are considered to be specifically designed to address STDs if more than 50 percent of the content is related to STDs. An ACF official also told us that future State and Community-Based Program announcements would include this language.29 Mr. Chairman, this completes my prepared remarks. I will be happy to answer questions you or other Committee Members may have.

CONTACT AND ACKNOWLEDGMENTS For further information regarding this testimony, please contact Marcia Crosse at (202) 512-7114 or [email protected]. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Major contributors to this report were Kristi Peterson, Assistant Director; Kelly DeMots; Cathleen Hamann; Helen Desaulniers; and Julian Klazkin.

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GAO’S MISSION The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed 29

OPA reported that, as a matter of policy, it has required since 1993 that AFL Program materials that include information regarding STDs contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the STDs addressed in the materials. Further, OPA reported that, since November 2006, OPA has taken additional steps to inform grantees about OPA’s policy and the need to be compliant with the requirements of Section 317P(c)(2) of the Public Health Service Act.

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CONGRESSIONAL RELATIONS Ralph Dawn, Managing Director, [email protected], (202) 512-4400 U.S. Government Accountability Office, 441 G Street NW, Room 7125 Washington, DC 20548

PUBLIC AFFAIRS

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Chuck Young, Managing Director, [email protected], (202) 512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, DC 20548.

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Chapter 3

TESTIMONY ON DHHS ABSTINENCE EDCUCATION PROGRAMS BEFORE HOUSE COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM *

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Statement by Charles Keckner WEDNESDAY, APRIL 23, 2008 Mr. Chairman and Members of the Committee, thank you for providing me with the opportunity to discuss the abstinence education programs administered by the Department of Health and Human Services. The Administration continues to support abstinence education programs, as one among several methods used by educators to address the continuing problems created by adolescent sexual activity, the result of which includes unacceptably high rates of non-marital childbearing and sexually transmitted diseases among America’s youth. Remarkable progress has occurred in this area over the last 15-20 years. Teenage pregnancy among 15-17 year-old girls declined over 20% since the early 1990s, although it remains substantially above the rates recorded for other industrialized nations. Teenage sexual activity and *

This is an edited, reformatted and augmented version of remarks delivered as Testimony given before House Committee on Oversight and Government Reform, by Charles Keckner, Acting Deputy Assistant Secretary ACF on April 23, 2008.

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non-marital childbearing have serious consequences for teens, their families, their communities and our society. The two greatest risk factors for teen pregnancy and transmission of STDs are the age at first onset, and the number of partners. In other words, if a teen delays the onset of sexual activity and reduces the number of partners, they are much less likely to become pregnant or get someone pregnant compared to those who don’t. By definition, abstinence education programs aim to do just that. Abstinence is the only 100 percent effective method to prevent pregnancy and sexually transmitted diseases. Through education, mentoring, counseling and peer support, abstinence education services help teens delay the onset of sexual activity and reduce the number of sexual partners they have. The ideal of abstinence programs is to encourage individuals to wait to experience sexual relations within the context of a healthy marriage. Abstaining until you get married also has another beneficiary. There is a wide body of social science literature showing more positive outcomes across a variety of measures for children raised in 2-parent married households when compared to their peers in unmarried households. In addition to the serious risks of disease, early childbearing very often limits later opportunities for both the parents and the children involved, creating greatly enhanced risks of a fragile family structure, poverty and welfare dependence. The State Abstinence Education Program and the Community-Based Abstinence Education (CBAE) Program of the Administration for Children and Families, together with the Adolescent and Family Life Program from the Office of Population Affairs, provide useful tools to help parents, schools, communities and States guide our Nation’s youth away from these devastating outcomes. As requested by the Committee, my testimony will provide background on these programs and discuss what we know and what we are seeking to learn about their effectiveness. I also would like to take this opportunity to discuss recent steps we have taken to improve administration of the programs and increase our knowledge of their operation. However, before I describe the abstinence education programs, evaluation efforts, and efforts to improve program administration, I will first provide some background on HHS’ comprehensive strategy to combat teen pregnancy and sexuallytransmitted diseases.

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Background: HHS’ Comprehensive Strategy HHS’ abstinence education programs are part of a broader strategy to combat teen pregnancy and STDs. Over the last five years, the Department estimates that it has expended billions of dollars towards this effort. HHS funds a variety of interventions, both primary models which include a risk-avoidance message provided through abstinence education programs, as well as secondary models, which include a risk- reduction message. These interventions provide information about the risks of sexual activity and the ways to eliminate or reduce these risks, with the goal of altering adolescent attitudes and behaviors in ways that lead to healthier outcomes. Other interventions can provide direct health services to adolescents, including administering contraception and providing information about its proper use. Beyond abstinence education, the Department provides at least $300 million annually to administer a variety of pregnancy prevention or STD/HIV prevention and awareness programs. Some of these programs may include information about abstinence or encouraging delayed sexual activity, but are not subject to the Title V, Section 510 A-H definition of abstinence education in the Social Security Act. Curriculum often called “abstinence- plus” or “comprehensive sex education” could be supported under these funding streams. Additionally, the Department provides hundreds of millions annually in family planning services to adolescents through a variety of programs. Of the total federal resources devoted to combating teen pregnancy and STD prevention, abstinence education accounts for a fraction. The majority of departmental funding devoted to this effort includes family planning services, pregnancy prevention activities, and other STD or HIV prevention and awareness activities for adolescents. Abstinence education, unlike a comprehensive sex education message, has been given a detailed statutory definition by Congress in Title V of the Social Security Act, as part of the Personal Responsibility and Work Opportunity Reconciliation Act enacted in 1996 during the Administration of President Clinton. However, because comprehensive sex education curricula may include information about abstinence, although to varying degrees, these approaches in practice exist along a continuum of approaches rather than as two completely distinct approaches. The main difference is that comprehensive sex education programs, in addition to abstinence education, also provide instruction about the use of various forms of contraceptive devices. In other words, abstinence education programs do not provide detailed instructions on how to use contraceptive devices, although some provide information about the relative effectiveness of contraceptive devices in preventing pregnancy and disease. This

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is because the statute requires using federal funds for the “exclusive purpose” of teaching abstinence. In epidemiological terms, both interventions are oriented toward risk prevention; abstinence education is fully focused on risk prevention using a primary public health intervention. Comprehensive sex education mixes the risk-prevention message with a risk-reduction component, using a secondary public health model. By contrast, a pure risk-reduction program could, for example, involve simply distributing contraceptives to adolescents and demonstrating their proper use.

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Background: Abstinence Education Programs HHS’ Administration for Children and Families is responsible for administering the State Abstinence Education program. This program was first authorized in 1998 to provide up to $50 million per year in grants to States by Title V of the Social Security Act. Funds are allocated to States and territories according to a pro-rata method based on the ratio of the number of low-income children in each State to the total number of low-income children in all States. States must match every four dollars they receive in federal abstinence education funds with three non-federal dollars. In FY 2007, approximately $39 million dollars was awarded to 40 States, the District of Columbia, and three territories. The Administration for Children and Families also administers the Community-Based Abstinence Education (CBAE) program. This program was first funded in FY 2001 to support public and private entities for implementation of abstinence education programs for adolescents ages 12 through 18. Annual appropriations language also references the statutory definition of abstinence education program in Title V, Section 510 of the Social Security Act for administering CBAE. These programs are focused on educating young people and creating an environment within communities that supports adolescent decisions to postpone sexual activity until marriage. Grantees include public and private entities such as community-based and faith-based organizations, hospitals, health centers, school systems and other youth services agencies. In FY 2008, Congress appropriated $113 million for the CBAE program. These funds will be used to support approximately 188 new start and continuation grants, as well as fund technical assistance, evaluation, research, and public education campaign. The FY 2009 Budget requests an increase of $28 million for CBAE. The final abstinence education program administered by HHS is the Adolescent Family Life (AFL) program. This program is administered by the Office of Population Affairs within the Office of Public Health and Science and supports two types of demonstration

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grants: (1) Prevention (abstinence education) that promotes and evaluates abstinence from sexual activity among adolescents; and (2) care demonstration grants that provide and evaluate comprehensive health and social services for pregnant and parenting adolescents. The prevention demonstrations are abstinence education projects that have been tied by legislative language in the annual appropriation bill to the statutory definition of abstinence education program in Title V, Section 510 of the Social Security Act. These demonstrations aim to find effective means of reaching preadolescents and adolescents before they become sexually active and to encourage them to abstain from sexual activity and other risky behaviors. The care demonstrations attempt to identify ways to minimize the consequences of this sexual activity by supporting projects for pregnant and parenting teens, their infants, their partners and their families. The abstinence education component of AFL is funded in FY 2008 at $13 million and supports 37 competitively awarded grants to public or private organizations. The FY 2009 Budget continues to request $13 million for this program. Together, the three abstinence education programs reach more than two million youth every year. Countless other youth and families are reached through a national media campaign. The Parents Speak Up National Media Campaign, developed through a partnership with the Office of Public Health and Science, provides public service announcements encouraging parents to talk to their preteens and teens about waiting to have sex, and to share their values and expectations for their children’s future. The campaign has developed and distributed media messages, established a website, and developed strategies for targeting Hispanic, African American and Native American communities. Abstinence education is an important preventive component of an overarching federal strategy designed to protect youth from the physical, psychological and economic consequences associated with teenage sexual activity and non-marital childbearing. Teenage pregnancy among 15-17 year-old girls declined over 20% since the early 1990s, although it remains substantially above the rates recorded for other industrialized nations. This decline in teenage pregnancy has been driven by both declines in early sexual activity and by more consistent use of contraception among teens, although there is an on-going debate in the research community about the relative contribution of these trends.

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Evaluation of Abstinence Education Programs Increasing abstinence among early adolescents cannot be wholly or directly attributed to health education interventions, including abstinence education. The current research questions surrounding the effectiveness of abstinence education programs are largely focused on the following: Are abstinence education programs equally or more effective in promoting abstinence than comprehensive sex education programs and does the absence of an explicit risk-reduction element in abstinence education cause participants to be less likely to use contraception if they engage in intercourse? As a general matter, health education interventions have a record of mixed success. While the majority of studies have shown a limited impact on sexual behavior, some programs have shown evidence for effectiveness. Increasingly evident during the 1990s, studies showed certain programs had some effect on delaying the age at first intercourse, and in reducing the frequency of sexual activity or the number of partners involved. The use of abstinence education curricula, as such, has a shorter history of evaluation, but the results have been similar. Some peerreviewed research has shown a significant effect in delaying intercourse among program participants. Other studies have shown some effect on partner number even if intercourse is not delayed. We are using the results of these studies to identify the characteristics that distinguish effective from ineffective implementations. There is no strong evidence for a decline in the use of contraception as a consequence of these programs. Recently, the Department reported the final results of a years-long longitudinal study by Mathematica Policy Research of five projects among the first group of abstinence education programs created by Title V and overseen by the State grantees. Some of these projects were effective in increasing participants’ knowledge of sexually- transmitted diseases, and in the short-term, increasing pro-abstinence attitudes and the support of an individual’s peers for abstinence. Both of these psychosocial traits were predictive of later abstinence; but the positive effects created by the intervention eroded rapidly in the intervening teen years. By the time of the last data collection four to six years later, behavioral and biological outcomes such as rates of sexual activity and pregnancy were not statistically distinct from a control population that had received the usual services available in that area. An important additional result of the study was that there was no additional risk of unprotected sex among abstinence

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education participants, contrary to the concern that lack of a contraception instruction component could create additional risk in this regard. From a policy perspective, a key question is whether the relevant biological and behavioral outcomes differ systematically between abstinence education and comprehensive sex education programs, where both are available. Put simply, when we have the option to provide either type of curricula, is it possible to show that one is better than another in preventing disease transmission and teen pregnancy? This question was not addressed in the recent Mathematica research, nor has such a comparison ever been made in any other major abstinence or comprehensive sex education evaluation to date. Currently, the Department is funding a long-term study in collaboration with the University of Texas Health Sciences Center that has randomly assigned students to the two different types of treatments, or to a control group. This type of experimental study design should provide us important new evidence that allows direct comparison between the two types of treatments. Data collection from this study, funded primarily by the Centers for Disease Control and Prevention and also ACF, is expected to be complete in May, 2010. At the current time, there is no reason to believe that programs involving abstinence education cannot be designed to be more effective with the available curricular alternatives in encouraging delays or reductions in adolescent sexual activity, and such programs do not appear to cause any decrease in the use of contraception by participants who choose not to abstain. The Administration believes that the abstinence education program sends the healthiest message as it is the only certain way to avoid out-ofwedlock pregnancy, and sexually transmitted diseases. The great majority of American parents agree: a 2007 poll conducted by the National Campaign to Prevent Teen Pregnancy found that 90 percent of teens aged 12-19 and 93 percent of adults agree that it is important for teens to be given a strong message that they should not have sex until they are at least out of high school. Also, the Health Education Guidelines used by many States and local school districts require use of abstinence education curricula. Likewise, many current grantee organizations would likely no longer apply to participate in providing health education programs if they were required to give instruction in contraceptive techniques. These jurisdictions and grantees have such constraints for a variety of reasons. For instance, some have concerns that comprehensive sex education curricula do not fulfill

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their stated goal of making abstinence the primary message. Because abstinence education curricula must comply with Congress’s statutory criteria, they represent a safe harbor for those agencies and entities seeking assurance that the curricula they choose comports with their requirements. Consequently, the abstinence education service option expands the range of possible providers, as well as the populations they can serve.

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Progress in Administration of Abstinence Education Programs In October 2006, the Government Accountability Office released a report on assessing the accuracy and effectiveness of federally funded abstinence education programs. Since this report was released, HHS has taken steps to improve the administration of abstinence education programs. Specifically, HHS’ efforts have focused on heightened program oversight and strengthened expectations of our grantees. HHS requires abstinence education grantees to comply fully with Section 317P of the Public Health Service Act. Section 317P requires mass-produced educational materials that are specifically designed to address sexually transmitted diseases to contain medically accurate information about condom effectiveness. Although abstinence education grantees do not always use materials that are subject to Section 317P's requirements, when they do, they are required to adhere to Section 317P by discussing condom effectiveness or ineffectiveness in the disease transmission context in a medically accurate way. Compliance with 317P is part of HHS’s broader commitment to scientific accuracy in abstinence education, a concern that has been expressed by the GAO and the Committee, and which the Department fully shares. First, in FY 2007 ACF implemented GAO’s recommendation to require Community-Based Abstinence Education and State Abstinence Education grantees to sign a written assurance in their grant applications stating that education materials are factually accurate. Additionally, ACF attached a special condition requiring that each grantee correct any medical inaccuracies identified by ACF in the proposed curriculum. Failure to provide satisfactory resolution to all medical accuracy issues raised by ACF will result in the withholding of funds and/or termination of the project, or both. Also as recommended by GAO, curricula used by grantees in the Community-Based Abstinence Education program are now reviewed by an

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independent panel of medical professionals. When considering CBAE grantee plans, the proposed curriculum is reviewed by a research analyst who notes any statements of fact that are not referenced and obtains source documents, when available, of all references that are given. The curriculum is then reviewed by a medical professional (a doctor or nurse in the field of obstetrics and gynecology) to compare the information in the curriculum to the information in the sources, which are themselves assessed for scientific validity. In tandem with these efforts, ACF also requires States to provide their strategies for ensuring accuracy of medical and scientific information in the State Abstinence Education program. In addition to increasing assurance of accuracy, the Department is also committed to making the changes necessary to increase program effectiveness. CBAE grantees are required to spend a minimum of 15 percent of funds on evaluation of their programs, and there is now an increased emphasis on standardized evaluations that will allow us to aggregate data from multiple grantees to conduct program-wide analyses with large sample sizes. This will also greatly increase our ability to compare grantees with one another by identifying best practices in efficiency and effectiveness as well as those grantees that are underperforming. For example, grantees are required to report quantitative data on the number of youth served, the hours of service per youth, and the proportion of youth that complete the program. We are also requiring a new standardized survey that will be administered by CBAE grantees to all youth served both before and after service delivery, and a follow-up survey 6-12 months upon the completion of the intervention. The questions will measure initiation and discontinuation of sexual intercourse as well as evidence-based predictors of age at first intercourse, such as sexual attitudes and behavioral intentions. Combined, these data sources will help us to track how grantees are using their funds, and which ones are efficiently achieving meaningful change in adolescent sexual behavior. In its report, GAO also expressed the expectation that certain ongoing research projects such as the Mathematica evaluation, when completed, should provide direction to our efforts in abstinence education. I am pleased to report that the final results of the Mathematica research study, released in April and August 2007, have already begun to be incorporated into programmatic changes as part of the Department’s emphasis on evidence-based policy development. The results of the Mathematica study indicate that targeting abstinence education to youth only in their early adolescent years may not be sufficient, and the programs may be more

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effective if interventions occur more closely in time to heightened risks of sexual activity in the high school years or are at least sustained up until that time. Based on these findings, preferences will be given to grant applications that show their programs include high school aged youth. The Mathematica study also indicated that the programs heighten proabstinence attitudes and friends’ support for abstinence and are significant predictors of future abstinence, but that both frequently erode over the years following the intervention. We now have specific criteria that encourage grantees to focus on developing and sustaining peer networks among adolescent participants, which is expected to create mutual support for abstinence education and to increase the probability of favorable biological and behavioral outcomes in the long-term. The Administration appreciates the opportunity to update the Committee on the progress we are making in this important area of adolescent health and remains committed to providing accurate information that effectively assists young people to make healthy and responsible choices as they mature towards adulthood. I would be pleased to answer any questions that you have.

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Chapter 4

REPORT RELEASED ON FOUR TITLE V ABSTINENCE EDUCATION PROGRAMS *

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United States Department of Health and Human Services The Office of the Assistant Secretary for Planning and Evaluation today released findings from a multiyear evaluation of four Title V, Section 510 abstinence education programs. Begun in 1999, the study was conducted by Mathematica Policy Research, Inc.

BACKGROUND Title V, Section 510 programs were among the first abstinence programs to be implemented under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Nationwide, more than 700 Title V, Section 510 programs receive up to $50 million in federal funds annually for programs that teach abstinence from sexual activity outside of marriage. Since the 1996 legislation, the number of abstinence education programs operating nationwide has increased. There are now hundreds of additional *

This is an edited, reformatted and augmented version of a U.S. Deparatment of Health and Human Services Report, HHS Fact Sheet, dated April 13, 2007.

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programs outside the Title V, Section 510 program which receive support from the federal government or the private sector. There is considerable variation in the range of approaches that are being used by different abstinence programs, the specific populations served and the strategies for engaging youth, parents and community stakeholders. Abstinence education programs outside Title V were not evaluated as part of this study. This new report evaluates behavioral outcomes as well as knowledge of risks associated with teen sexual activity by participants in four Title V, Section 510 programs. The programs selected for this study offered a range of implementation and program strategies. All four programs served youth in elementary and middle school located in: Powhatan, VA; Miami, FL; Milwaukee, WI; and Clarksdale, MS. The study followed up with youth four to six years after they received the intervention in an elementary or middle school program. It compared youth who participated in a Title V, Section 510 abstinence education program with peers in a control group that received “services as usual” provided by their school. Youth in the program group were eligible to receive Title V abstinence education program services, while those in the control group received only the usual health, family life, and sex education services available in the school and community.

SUMMARY OF MAJOR FINDINGS Findings indicate that youth who were assigned to the Title V abstinence education “program group” were no more likely than youth who were assigned to the “services as usual” control group to have abstained from sex. Those who reported having sex had similar numbers of sexual partners and had initiated sex at the same mean age. Contrary to concerns raised by critics of abstinence education, program group youth were no more likely to have engaged in unprotected sex than control group youth. The programs improved identification of sexually transmitted diseases (STDs) though had no overall impact on knowledge of unprotected sex risks and the consequences of STDs. Both program and control group youth had a good understanding of the risks of pregnancy but a less clear understanding of STDs and their health consequences.

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IMPLICATIONS FOR ABSTINENCE EDUCATION This study presents findings from a selected group of abstinence education programs that were among the first of the programs funded when the program was authorized in 1996. Since then, many programs have been developed that incorporate building peer support and providing abstinence education to high school students. In addition, HHS recently encouraged states to focus on young people most likely to bear children out-of-wedlock instead of directing their programs to pre-teens only. The field has continued to evolve, and the lessons learned from this study will help shape future programming efforts. This new study has several implications for planning and strengthening abstinence education programs overall: •

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•

Targeting youth solely at young ages may not be sufficient. These programs were targeted solely at middle school youth, and did not continue to serve youth as they entered high school. This study suggests that delivering abstinence education programs in middle school may not be enough to sustain changes in attitudes and behaviors. Peer support for abstinence may be protective in middle school, but erodes sharply during the teen years. Friends’ support for abstinence is a significant predictor of future sexual abstinence. This finding suggests that promoting support for abstinence among peer networks into the high school years should be an important feature of future abstinence programs.

Findings from this study of four Title V, Section 510 programs highlight the need for continued rigorous research on programs for preventing teen pregnancy and risk-taking behavior. HHS is committed to understanding how best to encourage youth to make healthy choices.

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Chapter 5

SCIENTIFIC EVALUATIONS OF APPROACHES TO PREVENT TEEN PREGNANCY *

Congressional Research Service

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SUMMARY The long-awaited experimentally designed evaluation of abstinenceonly education programs, commissioned by Congress in 1997, indicates that young persons who participated in the U.S. Department of Health and Human Services’ Title V Abstinence Education block grant program were no more likely than other young persons to abstain from sex. The evaluation conducted by Mathematica Policy, Inc. found that program participants had just as many sexual partners as nonparticipants, had sex at the same median age as nonparticipants, and were just as likely to use contraception as participants. For many analysts and researchers, the study confirms that a comprehensive sex education curriculum with an abstinence message and information about contraceptives and decision-making skills is a better approach to preventing teen pregnancy. Others maintain that the evaluation examined only four programs for elementary and middle school students, and is thereby inconclusive. Separate experimentally designed evaluations of comprehensive sexual education programs found that some comprehensive programs, including contraception information, decision- making skills, and peer pressure strategies, were successful in delaying sexual activity, improving

*

This is an edited, reformatted and augmented version of a Congressional Research Service Report RS22656, dated May 1, 2007.

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Congressional Research Service contraceptive use, and/or preventing teen pregnancy. This report will not be updated.

INTRODUCTION For many years, there have been divergent views with regard to sex and young persons. Many argue that sexual activity in and of itself is wrong if the persons are not married. Others agree that it is better for teenagers to abstain from sex, but are primarily concerned about the negative consequences of sexual activity, namely unintended pregnancy and sexually transmitted diseases (STDs). These two viewpoints are reflected in two teen pregnancy prevention approaches. The abstinence-only education approach centers on the abstinence-only message and exclusively funds programs that adhere solely to bolstering that message. The Title V Abstinence Education block grant administered by the Department of Health and Human Services (HHS) supports this approach. The comprehensive sexual education approach provides funding (through many other federal programs) for both prevention programs (that often include an abstinence message) and programs that provide medical and social services to pregnant or parenting teens.

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BACKGROUND Since 1991, teen pregnancy, abortion, and birth rates have all fallen considerably. In 2002 (the latest available data), the overall pregnancy rate for teens aged 15-19 was 75.4 per 1,000 females aged 15-19, down 35% from the 1991 level of 115.3. The 2002 teen pregnancy rate is the lowest recorded since 1973, when this series was initiated.1 However, it still is higher than the teen pregnancy rates of most industrialized nations. After increasing sharply during the late 1980s, the teen birth rate for females aged 15-19 declined every year from 1991 to 2005.2 The 2005 teenage birth rate of 40.4 per 1,000 women aged 15-19 is the lowest recorded birth rate for U.S.

1 The Alan Guttmacher Institute, U.S. Teenage Pregnancy Statistics: National and State Trends and Trends by Race and Ethnicity, updated September 2006, p. 5. 2 In 1970, the teen birth rate was 68.3 births per 1,000 women aged 15-19. The birth rate dropped to 50.2 in 1986 and rose back to 61.8 in 1991. Since 1991, the teen birth rate for women aged 15-19 has decreased each year, declining almost 35% during the 14-year period from 1991 to 2005 (from 61.8 births per 1,000 women aged 15-19 in 1991 to 40.4 births per 1,000 women aged 15-19 in 2005).

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teenagers. In 2005, the number of births to teens was 421,123 (10.2% of the 4.1 million births in the U.S.), of which 6,717 births were to girls under age 15.3 Nearly 23% of all nonmarital births were to teens in 2005. Although birth rates for U.S. teens have dropped in recent years, they remain higher than the teenage birth rates of most industrialized nations. According to a recent report on children and youth, in 2005, 34% of ninth graders reported that they had experienced sexual intercourse. The corresponding statistics for older teens were 43% for tenth graders, 51% for eleventh graders, and 63% for twelfth graders.4 About 30% of female teens who have had sexual intercourse become pregnant before they reach age 20.5 An October 2006 study by the National Campaign to Prevent Teen Pregnancy estimated that, in 2004, adolescent childbearing cost U.S. taxpayers about $9 billion per year. Research indicates that teens who give birth are less likely to complete high school and go on to college, thereby reducing their potential for economic self-sufficiency. The research also indicates that the children of teens are more likely than children of older parents to experience problems in school and drop out of high school, and as adults are more likely to repeat the cycle of teenage pregnancy and poverty. The 2006 report contends that if the teen birth rate had not declined between 1991 and 2004, the annual costs associated with teen childbearing would have been almost $16 billion (instead of $9 billion).6 In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of teen pregnancy is a major national goal.

SCIENTIFIC EVALUATION OF TEEN PREGNANCY PREVENTION APPROACHES While a number of different techniques are available to evaluate the impact of policy changes, there is widespread consensus that well-designed and well3 National Center for Health Statistics, Births: Preliminary Data for 2005, by Brady E. Hamilton, Joyce A. Martin, and Stephanie J. Ventura, National Vital Statistics Reports, Vol. 55, No. 11. December 28, 2006. 4 Centers for Disease Control and Prevention, MMWR, vol. 55, no. SS-05, Youth Risk Behavior Surveillance: United States, 2005, June 9, 2006, available at [http://www.cdc.gov/mmwr/ preview/mmwrhtml/ss5505a1 .htm]. 5 The National Campaign to Prevent Teen Pregnancy, How is the 34% Statistic Calculated? Fact Sheet. February 2004. 6 The National Campaign to Prevent Teen Pregnancy, By the Numbers: The Public Cost of Teen Childbearing, by Saul D. Hoffman. October 2006.

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implemented studies that require random assignment to experimental and control groups provide more reliable, valid, and objective information than other types of approaches. Random assignment experimental studies generally assign potential participants to two groups. Individuals assigned to a control group are subject to current policies or practices (no policy change); individuals assigned to the experimental or treatment group are subject to a different policy initiative (i.e., intervention), such as abstinence-only education. Individuals are randomly assigned to these two groups, and any differences between the experimental and control group are attributed to the policy initiative being examined. The random assignment experimental approach attempts to estimate a program’s impact on an outcome of interest. It measures the average difference between the experimental group and the control group. For a policy to have an impact, it must be determined that the impact did not just occur by chance. In other words, the difference must be determined to be “statistically significant.” Differences between experimental and control groups that pass statistical significance tests are reported as policy impacts.7 The random assignment experimental approach generally is considered to provide the most valid estimate of an intervention’s impact, and thereby provides useful information on whether, and the extent to which, on average, an intervention causes favorable impacts for a large group of subjects. (For information about some of the problems with the experimental approach, see CRS Report RL3 3301, Congress and Program Evaluation: An Overview of Randomized Controlled Trials (RCTs) and Related Issues.) Abstinence-Only Education. P.L. 105-33, the Balanced Budget Act of 1997, included funding for a scientific evaluation of the Title V Abstinence-Only Education block grant program (Title 510 of the Social Security Act), originally authorized by P.L. 104-193, the 1996 welfare reform law. Mathematica Policy Research, Inc. won the contract for the evaluation.8 7 U.S. House of Representatives. Committee on Ways and Means. 2004 Green Book: Background Material and Data on the Programs Within the Jurisdiction of the Committee on Ways and Means. WMCP: 108-6. On p. Appendix L-31. March 2004. 8 The Title V Abstinence Education block grant program to states was originally provided $250 million in federal funds ($50 million per year for five years, from FY1998 to FY2002). Funds must be requested by states when they solicit Title V Maternal and Child Health (MCH) block grant funds, and must be used exclusively for teaching abstinence. To receive federal funds, a state must match every $4 in federal funds with $3 in state funds. This means that funding for abstinence education must total at least $87.5 million annually. Although the Title V abstinence- only education block grant has not yet been reauthorized,

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Two other programs — the Community-Based Abstinence Education (CBAE) program funded via HHS appropriations and the “prevention” component of the Adolescent Family Life (AFL) program — include the eight statutory elements of the T i t l e V A b s t i n e n c e - O n l y Education block grant program (see Text Box at right). For FY2007, total abstinenceonly education funding amounted to $177 million: $50 million for the Title V abstinence program; $13 million for the AFL abstinence education projects; $109 million for the CBAE program (up to $10 million of which may be used for a national abstinence education campaign); and $4.5 million for an evaluation of the CBAE program.

A Title V Abstinence Education program (1) has, as its exclusive purpose, teaching the social, psychological, and health gains of abstaining from sexual activity; (2) teaching abstinence from sexual activity outside of marriage as the expected standard for all school-age children; (3) teaching that abstinence is the only certain way to avoid out-ofwedlock pregnancy, STDs, and associated health problems; (4) teaching that a mutually faithful monogamous relationship within marriage is the expected standard of human sexual activity; (5) teaching that sexual activity outside of marriage is likely to have harmful psychological and physical effects; (6) teaching that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (7) teaching young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (8) teaching the importance of attaining self-sufficiency before engaging in sex. Source: Section 510 of the Social Security Act. [Title 42 U.S. C. Section 710]

Mathematica’s April 2007 report presents the final results from a multiyear, experimentally based impact study on several abstinence-only block grant programs. The report focuses on four selected Title V abstinence education programs for elementary and middle school students: (1) My Choice, My Future!, in Powhatan, Virginia; (2) ReCapturing the Vision, in Miami, Florida; (3) Families United to Prevent Teen Pregnancy (FUPTP), in the latest extension, contained in P.L. 109-432 (the Tax Relief and Health Care Act of 2006), continues funding for the block grant through June 30, 2007. According to Mathematica, more than 700 Title V abstinence programs have been funded.

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Milwaukee, Wisconsin; and (4) Teens in Control, in Clarksdale, Mississippi. Based on follow-up data collected from youth (aged 10 to 14) four to six years after study enrollment, the report, among other things, presents the estimated program impacts on sexual abstinence and risks of pregnancy and STDs.

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ACCORDING TO THE REPORT Findings indicate that youth in the program group were no more likely than control group youth to have abstained from sex and, among those who reported having had sex, they had similar numbers of sexual partners and had initiated sex at the same mean age. ... Program and control group youth did not differ in their rates of unprotected sex, either at first intercourse or over the last 12 months. ... Overall, the programs improved identification of STDs but had no overall impact on knowledge of unprotected sex risks and the consequences of STDs. Both program and control group youth had a good understanding of the risks of pregnancy but a less clear understanding of STDs and their health consequences.9 In response to the report, HHS has stated that the Mathematica study showcased programs that were among the first funded by the 1996 welfare reform law. It stated that its recent directives to states have encouraged states to focus abstinence-only education programs on youth most likely to bear children outside of marriage, i.e., high school students, rather than elementary or middle- school students. It also mentioned that programs need to extend the peer support for abstinence from the pre-teen years through the high school years.10

9 Mathematica Policy Research, Inc., Impacts of Four Title V, Section 510 Abstinence Education Programs, by Christopher Trenholm, Barbara Devaney, Ken Fortson, Lisa Quay, Justin Wheeler, and Melissa Clark. Final Report. April 2007. Contract No.: HHS 100-98-00 10. [http://aspe.hhs. gov/hsp/abstinence07/]. 10 U.S. Department of Health and Human Services (HHS), Report Released on Four Title V Abstinence Education Programs. HHS Press Office. April 13, 2007. [http://aspe.hhs.gov /hsp/ abstinence07/factsheet.shtml].

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EXPERIMENTALLY DESIGNED STUDIES OF EFFECTIVE COMPREHENSIVE SEXUAL EDUCATION PREGNANCY PREVENTION PROGRAMS 1. Aban Aya Youth Project — Chicago, Illinois: The study found that 78% of boys in the program/ intervention group used condoms compared to 65% of boys in the control group. There were no significant findings for the girls. 2. Children’s Aid Society (CAS) Carrera Program — NY, MD, FL, TX, OR, and WA: The study found that the girls in the program group were 18% less likely to have had sex than girls in the control group; were 55% less likely to become pregnant; and were 80% more likely to use dual methods of contraception at last sexual encounter. There were no significant findings for the boys. 3. Draw the Line/Respect the Line — Northern California: At the three-year follow-up, 19% of the boys in the program group had engaged in sexual activity compared to 27% of boys in the control group. There were no significant findings for the girls. 4. Postponing Sexual Involvement, Human Sexuality, and Health Screening Curriculum — Washington, D.C.: Several months after the intervention, girls in the program were twice as likely as girls in the control group to delay sex; and girls in the program group were three to seven times more likely than girls in the control group to have used contraception at last sexual encounter. There were no significant findings for the boys. 5. Safer Choices — Texas and California: At the 31- month follow-up, sexually active program participants (boys and girls) were 1.5 times more likely than control group participants to use a condom; and program participants were 1.5 times more likely than the control group to use a second method of birth control. Source: The National Campaign to Prevent Teen Pregnancy. Putting What Works To Work: Curriculum-

• •

Convince teens that not having sex or that using contraception consistently and carefully is the right thing to do. Last a sufficient length of time.

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Are operated by leaders who believe in their programs and who are adequately trained. Actively engage participants and personalize the program information. address peer pressure. Teach communication skills. Reflect the age, sexual experience, and culture of young persons in the programs.

Although there have been numerous evaluations of teen pregnancy prevention programs, there are many reasons why programs are not considered successful. In some cases the evaluation studies are limited by methodological problems or constraints because the approach taken is so multilayered that researchers have had difficulty disentangling the effects of multiple components of a program. In other cases, the approach may have worked for boys but not for girls, or vice versa. In some cases the programs are very small, and thereby it is harder to obtain significant results. In other cases, different personnel may affect the outcomes of similar programs.

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AN ABSTINENCE-ONLY INTERVENTION VERSUS AN ABSTINENCE MESSAGE There is a significant difference between abstinence as a message and abstinence- only interventions. While the Bush Administration continues to support an abstinence- only program intervention (with some modifications), others argue that an abstinence message integrated into a comprehensive sex education program that includes information on the use of contraceptives and that enhances decision-making skills is a more effective method to prevent teen pregnancy. A recent nationally representative survey found that 90% of adults and teens agree that young people should get a strong message that they should not have sex until they are at least out of high school, and that a majority of adults (73%) and teens (56%) want teens to get more information about both abstinence and contraception.11 The American public — both adults and teens — supports encouraging teens to delay sexual activity and providing young people with

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information about contraception. (For additional information on teen pregnancy prevention, see CRS Report RS20301, Teenage Pregnancy Prevention: Statistics and Programs, and CRS Report RS20873, Reducing Teen Pregnancy: Adolescent Family Life and Abstinence Education Programs, both by Carmen Solomon-Fears.)

11 The National Campaign to Prevent Teen Pregnancy, With One Voice 2007 — America’s Adults and Teens Sound Off About Teen Pregnancy, by Bill Albert. February 2007, p. 2. [http://www.teenpregnancy.org/ resources/ data/pdf/WOV2007 _fulltext.pdf].

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INDEX

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A access, 11 accountability, 54, 80 accounting, 6, 60 accuracy, 1, 2, 5, 7, 9, 17, 18, 19, 20, 21, 22, 43, 44, 45, 48, 49, 50, 57, 58, 59, 60, 61, 62, 66, 67, 68, 69, 90, 91 achievement, 33 acquisitions, 52 adolescent behavior, 8, 24, 30, 38, 63, 72 adolescents, 4, 5, 6, 8, 10, 12, 13, 16, 17, 23, 24, 25, 27, 29, 30, 31, 34, 36, 37, 41, 52, 53, 58, 59, 61, 63, 65, 66, 70, 71, 77, 85, 86, 88 adulthood, 10, 64, 92 adults, 89, 99, 104 advocacy, 34, 74 afternoon, 54, 81 age, vii, 10, 24, 26, 33, 48, 65, 71, 78, 84, 88, 91, 94, 97, 99, 101, 102, 104 alcohol, 10, 24, 26, 27, 33, 48, 65, 71, 101 alcohol use, 33 alternatives, 9, 44, 69, 89 anatomy, 5 appendix, 5, 46 assessment, 3, 9, 23, 28, 35, 41, 42, 43, 45, 50, 52, 60, 70, 77 assignment, 100

attitudes, 28, 31, 32, 33, 34, 35, 37, 39, 40, 41, 53, 73, 75, 76, 77, 85, 88, 91, 92, 95 auditing, 7, 61 avoidance, 85 awareness, 85

B behavior, iv, 25, 31, 32, 35, 37, 41, 73, 74, 75, 95 behavioral intentions, 53, 91 beliefs, 27, 34 bias, 37 birth, 4, 8, 23, 24, 30, 31, 37, 38, 40, 58, 63, 70, 72, 75, 77, 98, 99, 103 birth control, 103 birth rate, 4, 8, 23, 24, 30, 31, 37, 38, 40, 58, 63, 70, 72, 75, 77, 98, 99 births, 24, 25, 26, 30, 32, 71, 72, 73, 98, 99 boys, 103, 104

C campaigns, 53 children, 4, 10, 11, 12, 15, 16, 17, 48, 64, 65, 84, 86, 95, 99, 101, 102 chlamydia, 10, 64 chronic diseases, 16 classroom, 19 collaboration, 16, 29, 89

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Index

colleges, 28 communication, 104 communication skills, 104 community, 11, 13, 25, 27, 30, 40, 62, 66, 69, 71, 76, 86, 87, 94 competition, 49 competitive advantage, 51 competitive process, 13 compliance, 17, 44, 48 components, 104 confidentiality, 39 conflict, 48, 51, 52 conflict of interest, 48, 51, 52 Congress, 54, 80, 85, 86, 97, 100 consensus, 99 consent, 41 consultants, 18, 30 contraceptives, 45, 86, 97, 104 control, 16, 28, 34, 36, 38, 39, 42, 72, 75, 76, 77, 78, 88, 89, 94, 100, 102, 103 control group, 28, 34, 36, 38, 39, 42, 72, 75, 76, 77, 78, 89, 94, 100, 102, 103 costs, 50, 99 counseling, vii, 12, 84 credibility, 37 culture, 104 curriculum, 8, 21, 22, 44, 52, 53, 68, 69, 90, 91, 97

D data collection, 28, 29, 88 data set, 30, 38, 72 database, 52 decisions, 13, 23, 29, 54, 81, 86 definition, vii, 11, 17, 18, 64, 67, 84, 85, 86 delivery, 23, 25, 28, 38, 49, 76, 91 Department of Health and Human Services, v, 1, 3, 4, 50, 57, 59, 83, 97, 98, 102 directives, 102 distribution, 16, 46, 48 District of Columbia, 12, 64, 65, 86 draft, 9, 44, 45, 69 drug use, 10, 26, 27, 48, 65, 101 drugs, 24, 26, 71

E ears, 92, 95 Education, i, ii, iii, v, vii, 4, 5, 10, 11, 14, 15, 17, 19, 23, 24, 32, 33, 35, 39, 40, 42, 45, 47, 53, 57, 59, 60, 64, 65, 66, 70, 71, 73, 74, 76, 77, 78, 79, 84, 86, 88, 89, 90, 93, 95, 97, 98, 100, 101, 102, 103, 105 enrollment, 102 environment, 13, 86 evidence-based policy, 91 exercise, 52 expenditures, 50 experimental design, 35, 36, 37, 38, 43, 53, 75, 76 expertise, 19, 50, 67

F failure, 5, 45 faith, 4, 11, 13, 20, 59, 66, 86 family, 4, 11, 13, 16, 64, 66, 84, 85, 94 family members, 13, 66 family planning, 11, 16, 85 federal funds, 14, 86, 93, 100 females, 98 financial resources, 49 firms, 31, 72, 73 funding, 1, 2, 6, 7, 8, 11, 12, 13, 14, 15, 16, 23, 24, 29, 31, 32, 33, 34, 39, 44, 54, 57, 58, 60, 61, 62, 64, 65, 66, 70, 73, 74, 77, 81, 85, 89, 98, 100, 101 funds, 4, 11, 12, 15, 21, 28, 45, 54, 59, 80, 85, 86, 90, 91, 98, 100

G Georgia, 6, 32, 60, 73 girls, 4, 83, 87, 99, 103, 104 goals, 4, 6, 11, 14, 17, 23, 24, 25, 26, 28, 29, 61, 64, 71 government, 7, 49, 51, 54, 61, 80, 94 grades, 30, 72

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Index grants, 1, 2, 7, 11, 12, 13, 14, 15, 16, 17, 21, 26, 28, 32, 35, 44, 49, 58, 64, 65, 66, 68, 74, 79, 86 groups, 4, 10, 13, 14, 20, 28, 34, 36, 39, 42, 65, 72, 74, 75, 78, 100 guidance, 19, 48, 61 guidelines, 18

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H health, 4, 5, 6, 10, 11, 16, 20, 27, 28, 34, 36, 48, 61, 64, 65, 79, 85, 86, 88, 89, 92, 94, 101, 102 health care, 79 health education, 16, 36, 88, 89 health problems, 4, 6, 10, 48, 61, 65, 101 health services, 85 hepatitis, 22, 69 high school, 8, 10, 24, 26, 30, 34, 38, 40, 53, 63, 64, 71, 72, 74, 89, 92, 95, 99, 102, 104 HIV, 2, 3, 5, 8, 16, 18, 19, 21, 22, 62, 68, 69, 77, 85 hospitals, 86 House, v, 5, 33, 46, 47, 83, 100 households, 84 human immunodeficiency virus, 3

I identification, 94, 102 implementation, 27, 48, 86, 88, 94 incidence, 1, 4, 11, 25, 30, 32, 57, 59, 64, 73 inclusion, 9, 53 income, 11, 12, 64, 86 indicators, 31, 73 ineffectiveness, 90 infants, 13, 66, 87 infection, 10, 19, 64 initiation, 5, 23, 33, 37, 39, 42, 53, 70, 75, 91 institutions, 6, 61 instruction, 18, 85, 89 instruments, 28, 29, 30 integrity, 54, 81 intensity, 34

intentions, 27, 35, 37, 39, 40, 72, 74, 75, 76, 77 interactions, 53 intervention, 28, 36, 38, 39, 75, 77, 86, 88, 91, 92, 94, 100, 103, 104

J judgment, 52 justification, 41, 50

L labor, 50 language, 63, 80, 86 laws, 18 legislation, 93 legislative proposals, 20 likelihood, 10, 40 litigation, 21 location, 13 longitudinal study, 88 Louisiana, 6, 60

M management, 26, 49, 50 marketing, 26 marriage, 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 48, 49, 52, 53, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 69, 70, 71, 73, 74, 75, 76, 77, 78, 79, 84, 86, 93, 101, 102 measurement, 23, 71 measures, 8, 24, 25, 26, 27, 29, 30, 33, 37, 53, 59, 60, 63, 71, 72, 75, 79, 84, 100 media, 21, 53, 68, 87 media messages, 87 median, 15, 97 men, 24, 71 mentoring, vii, 12, 13, 65, 84

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Index

Miami, 33, 73, 94, 101 models, 85 money, 12, 14, 54, 64, 81

N National Institutes of Health, 3, 6, 7, 61 negative consequences, 98 nurses, 19, 67

O objectivity, 51 observations, 19 Office of Management and Budget, 3, 29 organizations, 1, 4, 6, 11, 12, 13, 16, 36, 57, 59, 61, 65, 66, 75, 86, 89 oversight, 1, 5, 15, 16, 18, 54, 57, 59, 67, 81, 90

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P parental involvement, 27, 29 parenting, 13, 16, 66, 87, 98 parents, vii, 10, 13, 41, 48, 65, 66, 84, 87, 89, 94, 99, 101 partnership, 87 peer support, vii, 84, 95, 102 peers, 41, 77, 84, 88, 94 permit, 50 physiology, 5 planning, 72, 85, 95 policy initiative, 100 population, 13, 31, 88 poverty, 84, 99 preadolescents, 13, 87 predictors, 91, 92 pregnancy, vii, 4, 8, 10, 16, 20, 23, 24, 25, 27, 31, 33, 36, 37, 40, 48, 52, 63, 64, 65, 70, 71, 75, 76, 77, 83, 84, 85, 87, 88, 89, 94, 95, 97, 98, 99, 101, 102, 104 President Clinton, 85 pressure, 97, 104

prevention, 16, 21, 22, 33, 52, 69, 79, 85, 86, 87, 98, 99, 101, 104, 105 private sector, 94 probability, 92 administration, 84 program outcomes, 25, 33 programming, 95 public education, 86 public health, 4, 18, 30, 32, 72, 86 public service, 87

R random assignment, 3, 8, 63, 100 range, 16, 49, 50, 51, 90, 94 ratings, 50 recognition, 99 recruiting, 33 reduction, 26, 33, 85, 86, 88 regulation, 52 regulations, 52 relationship, 4, 10, 48, 65, 101 relationships, 51 reliability, 42, 54, 81 resolution, 90 resources, 20, 85, 105 risk, vii, 10, 25, 26, 27, 33, 34, 64, 71, 84, 85, 86, 88, 95 risk factors, vii, 84 risk-taking, 95

S sample, 3, 9, 28, 37, 40, 63, 72, 75, 76, 77, 91 school, vii, 4, 10, 13, 16, 18, 21, 24, 26, 33, 34, 36, 39, 41, 42, 48, 53, 59, 64, 65, 66, 71, 73, 75, 77, 78, 84, 86, 89, 92, 94, 95, 97, 99, 101, 102 scores, 50 search, 52 searches, 52 selecting, 36 Senate, 47 series, 98

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Index sex, 18, 31, 32, 33, 34, 35, 37, 39, 46, 73, 74, 77, 78, 85, 87, 88, 89, 94, 97, 98, 101, 102, 103, 104 sexual activity, vii, 4, 6, 10, 12, 13, 23, 25, 27, 28, 31, 33, 35, 37, 38, 39, 40, 48, 61, 65, 70, 71, 72, 74, 75, 76, 83, 84, 85, 86, 87, 88, 89, 92, 93, 94, 97, 98, 101, 103, 104 sexual behavior, 8, 10, 24, 30, 34, 35, 38, 40, 63, 64, 71, 72, 74, 77, 88, 91 sexual health, 35, 74 sexually transmitted diseases, vii, 1, 4, 10, 48, 57, 59, 65, 83, 84, 89, 90, 94, 98 shape, 95 shares, 90 sign, 9, 18, 44, 58, 62, 69, 90 skills, 24, 27, 34, 49, 71, 74, 97, 104 Social Security, 11, 13, 48, 65, 85, 86, 100, 101 social services, 87, 98 stability, 11, 64 stakeholders, 94 standards, 7, 9, 44, 61 statistics, 10, 19, 30, 38, 67, 72, 99 strategies, 58, 62, 70, 87, 91, 94, 97 students, 8, 10, 19, 24, 26, 30, 34, 38, 39, 41, 53, 63, 64, 71, 72, 74, 77, 89, 95, 97, 101, 102 summaries, 21, 53 supervision, 12 systems, 52, 86

T targets, 24, 30, 71, 72 teaching, iv, 4, 6, 10, 48, 61, 65, 86, 100, 101 technical assistance, 5, 7, 14, 15, 16, 18, 20, 25, 29, 32, 38, 45, 68, 72, 76, 86 teenage girls, 30, 72 teenagers, 25, 40, 98, 99 teens, vii, 8, 16, 24, 30, 31, 63, 71, 72, 84, 87, 89, 95, 98, 99, 103, 104 textbooks, 4

threats, 4, 11, 64 time, 3, 9, 18, 21, 23, 24, 26, 37, 39, 43, 45, 63, 64, 67, 68, 70, 71, 76, 79, 88, 89, 92, 103 tobacco, 26 tracking, 26 training, 7, 15, 16, 18, 20, 25, 29, 38, 48, 49, 72, 76 traits, 88 transmission, vii, 20, 22, 69, 84, 89, 90 true/false, 8, 22, 69

U United States, iv, v, 1, 4, 5, 10, 47, 53, 64, 93, 99 universities, 6, 28, 34, 36, 61, 74, 75

V vaccine, 22, 69 validity, 91 values, 54, 81, 87 variables, 53 variation, 94 voting, 50 vulnerability, 10, 48, 65, 101

W welfare, 84, 100, 102 welfare reform, 100, 102 women, 24, 71, 98 writing, 50

Y young adults, 4, 10, 52, 53

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