[DRAFT – May 20, 1999]

Prepared by the

Strategic Planning Work Group

Of the

Task Force on Teen Pregnancy Prevention

Charlottesville and Albemarle County, Virginia

JUNE 1999 (?)

Martha Jefferson Hospital graciously provided a meeting room and lunches for the dozens of noontime sessions at which the Small Group fought over the ideas, the structure, and the words in the Strategic Plan. The University of Virginia Teen Health Center sent out announcements and agendas to alert members of both working groups about meetings; it also reproduced preliminary drafts of the Plan and distributed them to the scores of participants in the development process. The Council on Adolescent Pregnancy Prevention (CAPP) provided technical assistance in word processing. Susan McLeod, Thomas Jefferson Health Department, provided data and perspective on STDs among local teens. Karen Dame, of Technical Editing, gave us her exceptional editorial services for the final version of the document.

The printing and distribution of the last draft, and of this final version, was made possible by the Martha Jefferson Hospital and the University of Virginia Health Sciences Center.

A number of people and agencies outside our community also encouraged the plan with ideas and information. Kathy LaMotte, the Teen Pregnancy Prevention Coordinator in Roanoke in 1997, spoke to us candidly about her city’s experience in developing a strategic plan. Barbara Huberman from the national organization Advocates for Youth gave us encouragement and useful supporting documents, and we frequently consulted the invaluable publications from the National Campaign to Prevent Teen Pregnancy.

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . .(not yet drafted). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Purpose of this strategic plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. The need to prevent teen pregnancy and sexually transmitted diseases . . . . 4

1. The statistical picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. The human situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1. Lessons from national research on teen pregnancy prevention programs . . . 14

1. Roots of the teen pregnancy/STD problems: Risk factors . . . . . . . . . . . . . . 14
2. Findings from program evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

III. Overarching issues and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1. Setting the tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2. Adjusting the mix of programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

4. Issues and recommendations by sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

A. Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

B. Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

C. Community Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

D. Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

E. Religious Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

F. Business Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

A. Costs of current and proposed programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

B. Economic benefits of current and proposed programs . . . . . . . . . . . . . . . . . 50

C. Administrative support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

VI. Evaluating local efforts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

VII. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

1. Members of the Strategic Planning Work Group
2. The Strategic Planning Process
3. Teen female population by age, Charlottesville and Albemarle County, 1990
4. Number of pregnancies among girls aged 10-19 and 10-17 years, Charlottesville and Albemarle County, by year, 1988-1997
5. Calculating teen pregnancy rates
6. Pregnancy rates for girls age 15-19, Charlottesville and Albemarle County, by year, 1990-1997
7. Number of teen pregnancies by age group, Charlottesville and Albemarle County, 1997
8. Pregnancy, birth, and abortion rates for females aged 15-19, by race, Charlottesville and Albemarle County, 1996
9. Percentage of teen pregnancies ending in abortion, Charlottesville and Albemarle County, by year, 1990-1997
10. Percentage of public high school students in Virginia who have had sexual intercourse, 1992
11. Percentage of students nationally who have had sexual intercourse, by age, 1995
12. Summary descriptions of local programs, projects, and organizations involved with teen pregnancy/STD prevention
13. Calculating the economic benefits of current and proposed programs

Figure 1: Pregnancy rates for girls aged 15-19 in 1997, Albemarle County,

Charlottesville, Virginia, and the USA . . . . . . . . . . . . . . . . . . . . . . . 4

Figure 2: Outcome of all 250 pregnancies in 1997, Charlottesville and

Albemarle County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Figure 3: Birth rates for girls aged 15-19 in 1996, Albemarle County,

Charlottesville, Virginia, the USA, and France . . . . . . . . . . . . . . . . 7

Figure 4: Graph representing hypothetical distribution of local teens’

Motivations to avoid becoming a teen parent . . . . . . . . . . . . . . . . . . . 66

Table 1: Costs and estimated benefits for current teen pregnancy/STD

prevention programs and proposed expansions . . . . . . . . . . . . . . 49

Table 2:

To guide the development of a community strategic plan for preventing teen pregnancies and sexually transmitted diseases, the Strategic Planning Work Group of the Task Force on Teen Pregnancy Prevention adopted the following mission statement:

The Charlottesville/Albemarle County community has long been concerned about pregnancies and sexually transmitted diseases (STDs) among our adolescents, despite the virtual absence of public policy on the issue. During the last 40 or 50 years we have increasingly perceived teen pregnancies with misgivings, in large part because the personal, social, and economic costs have grown. The teen pregnancy rate today is about the same as in the 1950s, but now a much smaller percentage of teens get married when they get pregnant. Single-parenting teens too often drop out of school, qualify only for low-paying jobs, and not infrequently end up on welfare. Moreover, since the 1950’s the abortion rate among teens has increased, and, with the spread of AIDS since the 1980’s, alarm about STDs among teens has grown.

Parents' apprehensions about teen pregnancy and STDs have been paralleled by disquiet expressed by many sectors of the society: schools, local civic and youth-serving organizations, health care providers, religious groups, the media, etc. The concern, however, has been manifest in only a handful of local programs that reach only a small proportion of the youth who need them; the following chapters will discuss these efforts. With a few laudable exceptions, our community's ventures into teen pregnancy/STD prevention programs that have demonstrable impacts have been limited by inadequate funding and/or paralyzed by fear of controversy.

Both of these problems -- the inability to find resources to sustain needed programs, and the unwillingness to initiate a program that may provoke challenges from some sector of the community -- are linked to a third problem: the absence of a common community vision that articulates what we will do about teen pregnancies and STDs, and what our priorities are.

The strategic plan outlined in the following pages attempts to fill this gap in our community vision. It is intended:

1. to raise awareness about the need to deal more effectively with teen pregnancies and sexually transmitted diseases in our community;
2. to provide a broad perspective that helps coordination of efforts and cooperation among agencies;
3. to review the strengths and weaknesses of our current efforts;
4. to advance specific recommendations for meeting current needs, and to suggest priorities;
5. to propose institutional responsibilities for implementing, or for monitoring the implementation of, the proposed tasks; and
6. to stimulate discussion that may lead to new policies and programs in the public, nonprofit, and private sectors.

This report contains hundreds of implicit and explicit ideas for improving our community’s teen pregnancy prevention efforts. From among the many ideas, over fifty specific recommendations emerged using three criteria:

• the probability that the program/activity/policy will have an effect in reducing teen pregnancy and STD rates in our community, based on reliable evaluations of experience elsewhere;

• the cost, in terms of money, people, and time; and

• the cultural and political acceptability in our community at this time: is the activity consonant with overall community values?

Because local teen pregnancy rates have shown a modest drop during the 1990’s, paralleling a national trend (see I.B., below), there is a risk that we as a community will relax our efforts to deal with the problem. Such complacency would be ill-advised. American teen pregnancy and teen birth rates are by far the highest in the industrialized world; the small recent declines do not change this picture. Moreover, every year in Charlottesville and Albemarle County unintended teen pregnancies number in the hundreds; each represents personal anguish and social costs that might have been avoided. We have a continuing responsibility to devote to this issue the attention it deserves.

The need for strategic planning for teen pregnancy and STD prevention in our area has been evident for some time. In the 1990’s alone, three major efforts were launched to identify overall needs in the Charlottesville/Albemarle community, and to develop projects and programs in the context of the "big picture".

During 1993-1994 the Charlottesville/Albemarle Children and Youth (CACY) Commission – now evolved into the Commission on Children and Families --convened a series of forums and working groups with over 50 local citizens to develop a "Community Action Plan". The plan, presented to the community at a March 1995 "Roundtable Discussion," identified three top-priority issues: character education in elementary schools, greater parent involvement in teen pregnancy prevention, and focussed programs aimed at small groups of high-risk children aged 8-11. Though working groups met to deal with all three issues, only the third topic led to tangible results. The group developed and obtained initial funding for the "Beating the Odds" program at the Monticello Area Community Action Agency (MACAA), currently serving 32 children in the city and county (described in Chapter IV.C. and Appendix L).

In 1995, a needs assessment report by the Council on Adolescent Pregnancy Prevention (CAPP) reviewed strengths and weaknesses in local teen pregnancy/STD prevention activities. One of CAPP’s conclusions was that until a systematic strategic plan was developed by the community, teen pregnancy/STD efforts would continue to be fragmented and inadequate. As a result, scarce resources were unlikely to be allocated optimally.

On May 30, 1997 a town meeting on "Partners in Teen Pregnancy and STD Prevention" was sponsored by a consortium of local organizations (see Appendix B). The 60 concerned citizens who participated reviewed the community's present approach to teen pregnancy prevention and suggested the next steps for concerted effort. Participants urged that four topics be addressed immediately: parents' communication with their children about sexuality and other subjects (echoing a theme from the 1995 Roundtable Discussion); after-school activities for teens; expansion into more public schools of existing teen pregnancy prevention projects; and strategic planning. A working group was established to deal with each issue.

The strategic plan presented in this document was created in direct response to the Town Meeting consensus recommendation. The Strategic Planning Work Group began meeting in the summer of 1997, and over the next two years a small group collected data, reviewed literature, and drafted sections of the Plan. These drafts were then critically reviewed by a larger group more representative of the community’s diversity. The Strategic Planning Working Group’s membership and its operations are detailed in Appendices A and B.

Approximately 4 in 10 girls in the United States become pregnant at least once before turning 20 years old (National Campaign to Prevent Teen Pregnancy, 1997b, p. 3).

A million teenage girls in America got pregnant in 1997. Of that number, our share was 128 girls in Albemarle County and 122 in Charlottesville (Virginia Center for Health Statistics, 1998). Over the past ten years local figures on teen pregnancies have varied somewhat; Appendix D graphs the data for all teens (i.e. age 10-19) and for teens age 10-17.

The meaning of these numbers is easier to understand when translated into rates, representing the number of pregnancies per thousand teen girls (see Appendix E for steps in calculating a rate). Rates can be compared among different groups or show changes over time.

For example, Figure 1 shows that the pregnancy rate for girls aged 15-19 in

Albemarle County is lower than the rate for all teen girls in the state of Virginia;

the pregnancy rate for Charlottesville teen girls is higher than the state average. Focussing on 15-19 year old girls, who are responsible for 98% of teen pregnancies, both the city and county rates show a modest and irregular drop over the past eight years (see Appendix F) that parallels a state and national trend.

Though the overall numbers and rates help describe the situation, they tend to obscure the fact that each teen pregnancy is unique. So, of course, are the impacts on the teens and their families. The age at which a teen pregnancy occurs, for example, can make a tremendous difference. In both the city and the county, three of the pregnancies in 1997 were to girls aged 14 or below – still in junior high – but most (of the pregnancies were to 18 and 19 year olds, some in college (see Appendix G). A small proportion of the girls were married (18% in Albemarle, 11% in Charlottesville); most were not.

There are also differences in teen pregnancy rates by race, which may be primarily a function of the overall socio-economic disparity in our community between blacks and whites. As Appendix H shows, in Charlottesville the 1996 pregnancy rate for black teens aged 15-19 was more than twice that of white teens, and the birth rate of black teens was nearly four times higher. In Albemarle County these differences are considerably less apparent, and the rates for both black and white teens far lower.

Figure 2 shows the outcome of the teen pregnancies in 1997. Most now result in live births, and nearly all teen mothers choose to keep their children rather than

Charlottesville Albemarle County

put them up for adoption. Until 1995 the majority of adolescent pregnancies ended in abortions and miscarriages. The change in the proportion of teen pregnancies that end in abortion over the last eight years is illustrated in Appendix I.

Teen birth rates, rather than teen pregnancy rates, have in recent years become preferred by many authorities as a useful way to measure adolescent reproductive health and behavior. This is mainly because data on teen births are far more reliable (some teen pregnancies, particularly those ending in an early miscarriage, are unreported), and because a birth is more likely than a pregnancy to be a life-changing event for a teen.

The current pattern of teen birth rates, shown in Figure 3, is similar to that of teen pregnancy rates – except that the Charlottesville rate is greater than the USA rate. For teens age 15-19 in 1996, the birth rate in Charlottesville is nearly three times that of Albemarle County, and about 30% higher than the state. To provide a sense of perspective, Figure 3 includes the comparable teen birth rate for France: it is about a third that of Albemarle County.

The birth rate among American teenagers aged 15-19 has declined for the sixth consecutive year, for a total decrease of 16 percent from its peak in 1991 (Havemann 1999). Local birth rates, analyzed by the Strategic Planning Work Group for this report, have fluctuated over the same six-year period because of our relatively small population. When these normal variations are smoothed out with a regression line, the result reveal that birth rates for 15-19-year-old teens in our community declined at an even faster rate from 1991 to 1997. In Charlottesville, the drop in the teen birth rate was 21%; in Albemarle County, 24%.

A look at all 150 teens who gave birth in 1990 in Charlottesville and Albemarle County revealed that 29 gave birth to their second child and 8 gave birth to their third or fourth child (Kars-Marshall and Marshall, 1992). These figures show that one in four (24.7%) already had at least one birth. Since the number of live births and the number of abortions for teens were about the same in that year, probably another quarter had been pregnant but ended the pregnancy with an abortion. This suggests that roughly half the teens in our community who get pregnant have already been pregnant once before.

Data on teen sexuality – knowledge, attitudes, or behavior -- are not available for our community, an absence that makes it much more difficult to identify local needs and to tailor our own solutions for preventing pregnancy and STDs. As a proxy, we can look at studies of the state and national levels to suggest the situation in the Charlottesville/Albemarle community. One important item of information, for example, is that the average age of puberty for American girls is now under 13, and the average age of marriage is 26.

Though parents may not wish to believe it, roughly half the teens in high school are sexually active, i.e., have had sexual intercourse. In a 1992 study of public-school students in Virginia, half of all ninth and tenth graders – both boys and girls -- reported already having had sexual intercourse (Department of Education, 1992). Among eleventh and twelfth graders, 70% of the females and 74% of the males reported having had sexual intercourse (see Appendix J).

Roughly the same pattern was revealed in a national survey in 1995 (Moore et al. 1998; see Appendix K). More than half of 15- to19-year-old males and females said they were sexually experienced. Two-thirds of the teenage women used a condom the first time they had intercourse; they were more likely to do so if their partner was the same age or younger. Overall, fewer than half the sexually active teenage men used a condom every time they had sex; between the ages of 16 and 19, the level of consistent use drops from 70% to 36%.

This research also found that the probability that a sexually active young woman had given birth increased steadily from 3% of 15-year-olds to 28% among those aged 19. At each age, girls who did not use a contraceptive method at first intercourse were about twice as likely to give birth as those who used a method.

A more recent major study, with a nationwide sample of more than 16,000 high school students, indicates that the proportion of teens (grades 9 through 12) engaging in sex, after rising in the 1970’s and 80’s, dropped from 54.1% in 1991 to 48.4% in 1997 (Centers for Disease Control and Prevention 1998). The proportion of 1997 students who had had sexual intercourse ranged from 38% of ninth graders to 61% of twelfth graders.

The same research shows that among sexually active high school students in 1997, nearly 57% had used a condom the last time they had intercourse – compared to about 46% in 1991. Moreover, during the same period, the number of teens reporting that they had had four or more sexual partners over their lifetime decreased from nearly 19% to 16%; most had no more than one partner in the past year.

Though at least one third of the teen population does not use condoms or other contraceptives the first time they have intercourse, use of contraception by teens has increased in the past eight years. Indeed, the Vice President for Research of the Alan Guttmacher Institute links this trend to the drop in teen pregnancy:

Risky sexual behavior, in addition to being linked with pregnancy and STDs, also appears to be associated with a wide range of other adolescent problem behaviors including delinquency, alcohol and drug use, and academic difficulties (Jessor and Jessor 1977; Donovan and Jessor 1985).

We know less about STDs among teens – particularly among local teens – than about teen pregnancy. National statistics show, however, that 3 million American teens become infected each year with an STD – three times more than the number who get pregnant. Teens are at particular risk of STDs because of their low rate of condom use and because the physiology of the adolescent woman’s cervix makes it more susceptible to some of the STDs.

Two very common viral STDs – genital herpes and genital warts – are not routinely reportable, nor is there an easy screening test available. Thus reliable data on their prevalence, particularly among teens, is not available. The cause of genital warts is the human papilloma virus or HPV. Cell changes detected in a cervical pap smear, though not a diagnostic certainty, strongly suggest the disease. Locally, the Teen Health Center reports that over 20% of their female patients have abnormal pap smears with changes that may be caused by HPV (Aretakis 1999). Some studies based on pap smears have estimated that half of sexually active young women are infected. For both genital herpes and genital warts, treatment can be given to deal with the immediate problem but it cannot remove the virus from the body. A major concern is that some HPV infections lead to cervical cancer.

Two bacteria-caused STDs – chlamydia and gonorrhea -- are more commonly known and more reliably reported because of the availability of simple, commonly used screening tests. Untreated infections can lead to pelvic inflammatory disease and permanent scarring, which can impair fertility in men or, more commonly, women. As with viral STDs, both these bacterial infections may be silent, causing few or no symptoms (particularly among women). A national study of 3,200 sexually active girls aged 12-19 found that more than 24% of the girls making their first clinic visit were infected with chlamydia (Burstein et al. 1998). In Virginia in 1997, 43% of the reported chlamydia cases were in the age group 15 to 19. For gonorrhea, 60% of the cases at the state level in 1997 were in the age group between 15 and 24, and equally distributed between males and females.

Syphilis tends to be diagnosed in older groups, with only 11% of the Virginia cases reported in 1997 under age 19. As with gonorrhea, reported cases of syphillis declined significantly during the 1990’s; none has been reported among local teens in recent years.

The most feared STD today is the human immunodeficiency virus/autoimmune disease syndrome (HIV/AIDS). Although at a national level reported cases have decreased in recent years, AIDS is nevertheless more of a risk to teens than it was a decade ago because the pool of infected partners has increased (Vobejda 1998). Though half of HIV infections in this country occur among people under 25 years of age, no teens in Charlottesville or Albemarle County have been reported to the Thomas Jefferson Health Department with HIV or AIDS. However, there is very little local testing among teens, and a positive test would be attributed to the location of the screening. It is assumed that some local teens are becoming infected but they are not being identified until they are in their twenties (McLeod 1998). The delay between acquiring the infection, and having either symptoms or other cause to be tested, makes it likely that many teen cases of HIV go undetected.

Teens’ ignorance about STDs and unrealistically low appraisal of their risk of STDs are impressive. Though we have no local studies to pinpoint problems and help develop education strategies, national research probably reflect the local situation. In one of the most recent investigations,

Many sexually active teen girls have accepted the message that they should protect themselves from pregnancy, so they use the pill or Depo-Provera for contraception. But, despite their fear of AIDS and the admonitions of health clinic staff, the girls do not think consistently about the need for abstinence or condoms for STD prevention (McLeod 1998). Most STDs are silent, especially in women, so they can be passed on and do permanent damage without being recognized unless screened as part of a routine exam. Such exams are important elements of the services provided to adolescent females by local clinics, and are now recommended for sexually active teens every 6 months (Burstein et al. 1998).

How many – and more importantly, which -- of the 14,000 boys and girls ages 10-19 in Charlottesville and Albemarle County are "at risk" of getting pregnant or contracting an STD? Some experts argue that the whole adolescent and pre-adolescent population is theoretically at risk, since there is virtually no certainty that any individual teen will avoid an STD or unwanted pregnancy before age 20. Other experts propose ways to define the "at risk" population, noting that -- based on past experience – there is tremendous variation in the probabilities that various subgroups of the 14,000 teens will get pregnant or contract an STD (see Chapter 2., Section A.).

The national data showing fewer teen pregnancies in the past few years and a decline in teen births, coupled with the surveys indicating that sexually active teens are more inclined in recent years to use condoms and have fewer partners, point to encouraging changes in risk behavior. Though the precise causes of these recent trends are uncertain, experts tentatively attribute the changes to (a) the growing barrage of messages from schools, community groups, churches, and families urging teens to delay sex and protect themselves against AIDS, (b) teens’ fear of getting sick and dying from AIDS, (c) greater accessibility to condoms and other contraceptives, (d) successful efforts to strengthen teens' decision-making and refusal skills, and (e) social, cultural, and economic trends that have led to the broad general decline in a range of youth problem behaviors nationally (e.g. criminal behavior, drug use, etc.).

Whether out of compassion for the people often put at insurmountable disadvantage because a teen gets pregnant or contracts a STD, or out of a dispassionate dollars-and-cents calculation, there are compelling reasons for our community to devote fiscal and human resources to preventing the problems.

Each unintended pregnancy forces upon the young woman – often with little support from her partner, her family, or others she can trust – a decision between the option of abortion or carrying the pregnancy to term. If the outcome of the pregnancy is a birth, another choice must be made by the mother: to keep the baby or put it up for adoption.

In the roughly 60% of local teen pregnancies that end in a birth (see Figure 2), there are likely to be physical, social, psychological, and economic effects on the infant, the teen mother and the father, and the parents of the teen mother -- as well as economic impacts on the larger community. Most teen mothers or fathers have had no training to take care of an infant; it is frequently the baby’s maternal grandparent(s) who becomes the primary care giver. Often a teen, especially if she is a single mother, will drop out of school and/or quit a job after the birth of their child. Neither the mother nor the father may know how to obtain maternal and child health care, daycare for the baby, welfare or child support, continuing education, or a job consistent with newly changed circumstances. Fathers may be unaware of their legal and financial responsibilities for the child.

Although the consensus of the research community is not settled on the total impact of adolescent parenting (Hoffman 1998), some effects seem pretty certain. Studies (summarized in Hayes 1987) suggest that teen mothers have higher rates of birth complications; higher school dropout rates, with lower education attainment or greater delays in completing school; poorer jobs, with lower incomes and lower occupational prestige; increased chances of welfare dependency; greater chances of single parenthood and marital instability. Not surprisingly, teen parents are significantly less likely to function well as parents than are older parents.

For children born to teen mothers, research indicates that they are more likely to show deficits in social, emotional, and cognitive functioning that can be seen years after their birth. They have more chance of child abuse and neglect; a greater risk of long-term health and developmental problems; poorer adaptation to school and poorer intellectual achievement, with a higher chance to be a school dropout and have troubles with police; and a tendency to become teen parents themselves.

The economic burden of caring for a child – in whatever ways the costs may be shared by the teen mother, the father, the parent(s) of the teen mother, or society in general -- represents money that could be going for other purposes. Estimating the costs of teenage pregnancies is not an exact science, and a range of estimates for the costs of teen pregnancy exists. However, even choosing from the lower cost projections yields an estimated annual cost for the nation as a whole of $6.9 billion to taxpayers from lost tax revenues, increased spending on public assistance, health care for children, foster care, and the criminal justice system. Recent evidence suggests that these financial estimates may understate the problem by overlooking effects on the young offspring of teen parents (Maynard, 1996).

The economic costs of STDs are roughly of the same magnitude, according to Helene Gayle, director of the Centers for Disease Control’s program for HIV, STD and tuberculosis prevention:

3. STDs, not including HIV, cost about $8 billion annually to diagnose and treat – largely preventable expenses (cited in Stepp, 1999).

No direct data exist on the local economic costs of teen pregnancies, though it is possible to estimate our share of the national cost. The $6.9 billion cost was based on a total of 185,000 teen births, or a cost in today’s taxpayer dollars of $37,000 for each birth over the lifetime of the mother and child. For 82 teen births in Albemarle County in 1997, then, the costs to taxpayers (not including the costs to the teen or her parents) would be $3 million; for the 69 teen births in Charlottesville, $2.5 million.

Recent research has aimed at a better understanding of the variables linked with teen pregnancy, giving us some idea of which teens might have a higher risk getting pregnant. The clearest finding to emerge from our review of the research is that teen pregnancy is not the result of any single problem. There appear to be three general categories of factors that increase the risks for teen pregnancy (Kirby 1997):

(a) Biological factors such as higher levels of testosterone in males that influence

2. Social/environmental factors such as poverty, parental unemployment, family

marital disruption, parental lack of education, family history of teenage parenthood, poor childrearing practices, and being a sexual abuse victim.

3. Individual factors such as drug and alcohol use, poor educational performance and low educational expectations, low general expectations for the future, an external locus of control, aggressiveness, and lack of religious affiliation (Vincent et al., 1987; Koo et al., 1994).

Although these general risk factors have been linked to teenage pregnancy, in each case the documented relationship is a very slight one.

In addition, researchers have identified more specific predictors of risky sexual activity. These include teenagers’ beliefs and values about sexual behavior, pregnancy, and childbearing, as well as their perception of the beliefs and values of others in their communities, and their own specific plans/goals regarding their sexual behavior. In brief, those who see risky sexual behavior and pregnancy as completely unacceptable have a lower risk of becoming pregnant than those who are less disturbed by these possible outcomes.

We draw two main conclusions from the national research.

First, there is no single factor that "marks" those most at-risk for teen pregnancy, in part because so many adolescents are at substantial risk. Given that 25% of female adolescents become pregnant before reaching age 18 (Alan Guttmacher Institute, 1994), a far higher percentage are likely to be putting themselves at risk of pregnancy and avoiding it only through luck. It is hard to identify clear risk factors predicting teen pregnancy in part because the population that risks teen pregnancy may easily comprise half of all of the adolescents in our communities.

Second, most of the risk factors listed above support the proposition that the risk of teen pregnancy is highest for those teens living in unsupportive environments who are struggling to adapt to the expectations our society holds of adolescents in areas such as academic success, avoiding delinquency, etc. Although pregnancy rates for adolescent females are high enough that one could reasonably argue that all teens are "at-risk", we will use the term "high-risk" to refer to teens who face a combination of the risk factors listed at the outset of this section (e.g. poor educational performance, family history of teenage parenthood, high levels of drug or alcohol use).

Conversely, adolescents who are thriving in their communities and have enough support that they can envision continuing to thrive as adults, appear best situated to avoid teen pregnancy. In this respect, the succinct summary of the research literature by Marion Wright Edelman, President of the Children’s Defense Fund, appears quite germane: "The best contraceptive is a future you believe in."

Virtually all operating programs that target teen pregnancy make at least some claim that theirs is an effective approach to prevention. To sort among these claims we reviewed programs that have been rigorously and objectively evaluated, meaning programs that have: a) utilized both program groups and well-matched comparison or control groups; b) looked at actual changes in sexual behavior or in pregnancy rates; and c) had their results subjected to peer review by scientists who have no vested interest in the programs. We used this approach because we wanted to identify programs that would stand up to careful scrutiny, regardless of how much enthusiasm they may have aroused among their proponents.

The programs demonstrating the strongest evidence of effectiveness are described below, presented in descending order of efficacy:

• Sex and HIV/AIDS Education Programs combined with skills training - Programs that link education about the dangers of risky sexual behavior (particularly those that focus on HIV/AIDS risk) and are combined with social skills-training programs, have shown some evidence of reduction of teen pregnancy rates and risky sexual behavior. Social skills-training programs typically focus on topics such as assertiveness training and effective decision-making and use techniques such as role-playing to allow teens to practice skills they are learning. Many such programs have been evaluated to date with some showing signs of efficacy and others not. Somewhat better results have been obtained with HIV/AIDS education programs than with basic sex education programs in this context (perhaps because fear of contracting a potentially fatal illness is a more powerful motivator than fear of pregnancy)(Kirby 1997).

• Multi-Component Programs - These programs combine disparate elements such as community mobilization, media campaigns, installation of condom vending machines, peer educational programs and classroom instruction. At least one community that has adopted this approach reports significant decreases in pregnancy rates relative to surrounding communities, a result that other communities are now working to replicate (Koo et al., 1994; Vincent et al., 1987).

Two popular approaches for preventing teen pregnancy and/or STDs show only weak or equivocal evidence of effectiveness:

• Improved Access to Contraception (e.g., school-based clinics providing contraceptives) - Although early research suggested that improving access to contraceptives, by itself, was a quite promising approach to reducing teen pregnancy, more rigorous recent research has been far less likely to find positive effects.

• Curriculum-based Sex Education Programs in Isolation - These have generally been quite thoroughly and rigorously evaluated and have consistently found to neither reduce pregnancy rates nor to decrease (or increase) adolescent sexual behavior. It appears that simply presenting information to adolescents, without helping young people cope with the challenges of adolescence (e.g., decision-making, finding a role for themselves in the community, etc.) has little impact, positive or negative, on teens’ behavior.

It should be noted that abstinence-based programs, though extensively publicized, have yet to be rigorously evaluated. However, unlike some of the other approaches above, abstinence-based approaches are new enough that this lack of positive data may merely reflect the fact that good research is difficult and time consuming; possibly abstinence-based approaches have not yet received sufficient scrutiny to allow conclusions about them to be drawn. Thus, while these approaches have not demonstrated that they are effective, neither has evidence accrued to allow one to draw the conclusion that they are not effective.

The evaluations in recent years help us understand not only what is likely to occur as a program intervenes on the life of a teenager, but what is not likely to occur. In particular, the results indicate that teaching students about sex and safe-sex practices does not result in an increase in promiscuity, as some critics feared.

Several conclusions can be drawn from the review of program evaluation literature. After years of program development, the list of successful approaches to preventing pregnancy is sobering in its brevity but nevertheless offers a basis for optimism. Although most teen pregnancy prevention programs have fallen short of expectations, some of the programs have reduced pregnancy rates by 50% under real-world conditions.

The principles embodied in successful programs seem to coalesce around the idea of focusing on the adolescent as a whole person. Successful programs help adolescents develop as social and emotional beings. Somewhat surprisingly, they may or may not even concentrate on sexuality, but they all focus on helping the overall process of adolescent development with approaches ranging from teaching decision-making skills to encouraging youth involvement in their community through volunteer service. Such programs, recent research suggests, have an ameliorating effect not just on teen pregnancies, but on a number of other adolescent problems including violence and drug use.

Proposals for dealing more effectively with teen pregnancy and STDs can be divided into those that tend to be particularly relevant for a "sector" (i.e., a division of the whole community such as schools, religious organizations, health care providers), and those that transcend a single sector. In this chapter we discuss the broader "overarching" issues and recommendations for teen pregnancy/STD prevention, grouped in three categories: (a) those that set the tone in the community, (b) those that guide the mix of programs in the community, and (c) those that help determine the appropriate level of effort.

core beliefs – honesty, for example -- are held in common. Shared values – reaffirmed by parents, schools, religions, etc. – are part of the social glue that allows us to live and work together in relative harmony. In a positive way, a broadly similar system of beliefs provides a society common goals and visions. Conversely, by inducing shame, guilt and/or social sanctions, the framework of values discourages inappropriate behavior that may threaten the smooth functioning of the family and other social units.

Some values, though widely held, enjoy only rare or inconsistent public affirmation, a situation that reduces their influence on behavior. For example, there is probably widespread consensus in our community that teens tend to be poorly equipped with the skills necessary for parenting. Most of us probably also share the sentiment expressed in the mission statement for this strategic plan (see page iii):

Nevertheless, these important community values are not forcefully and consistently stated, and thus their impact on adolescents’ behavior is diminished. The timidity and ambivalence with which our community expresses the value that "Teen girls should not get pregnant; boys should not get girls pregnant; and neither should get STDs" are doubtless perceived by teens themselves.

Recently an expert team examined the reasons teen pregnancy and STD rates in France, Germany, and the Netherlands are significantly lower than those in the USA. The team’s report notes, among many other things, that governments in these countries support massive, consistent, and long-term public education campaigns which use television, radio, billboards, discos, pharmacies, and doctors (Berne and Huberman, 1999).

2. Public policy: Neither of the local governments has articulated community goals for teen pregnancy/STD reduction. Public policy can encourage and guide deliberate programmatic (and budgetary) changes. The absence of any such policy regarding pregnancy/STD prevention is in itself a de facto policy implying an acceptance of the current situation and a reluctance to encourage schools and public youth-serving agencies take even the most timid steps.

As Rhode (1993-94, p. 657) has said so bluntly about America:

This reluctance – prudishness – makes it difficult to disseminate clear, accurate information about contraception, which in turn doubtless limits contraceptive use.

In Charlottesville and Albemarle County, as in other American communities, most people find it difficult to speak candidly about teen sexuality, including teen pregnancy and STD prevention. The constraint is spawned by any of a number of issues: simple embarrassment about the perceived indelicacy of the topics; ignorance of the subject matter; awkwardness about how to initiate a discussion; apprehension that initiating a discussion about adolescent reproductive health will lead to repercussions from outsiders; the (mistaken) belief that talking about teen sexual behavior somehow encourages it.

For many, it is even more difficult to talk about STDs than pregnancy prevention. STD information is complicated to master even for adults, and youth are often constrained by social stigma. In a discussion with a group of young people in Northern Virginia, no one they knew, including their parents, wanted to talk about genital warts and other so-called "skanky" diseases (Stepp, 1999).

It is not coincidental that industrialized countries with the lowest teen pregnancy rates (e.g. France, Germany, and the Netherlands) also have the least inhibited communication about teen sexuality and pregnancy/STD prevention. In these nations, unlike the USA, open, honest and consistent communication about sexuality occurs between adults and teens through schools, families, and health providers, and has not resulted in earlier sexual activity (Berne and Huberman 1999). The role of the media in creating an atmosphere of open communication cannot be overemphazized:

In our discussions with community members as we prepared to write this strategic planning document, many spoke about their reluctance to talk in everyday contexts about teen pregnancy and STD prevention. This recurrent theme was voiced by parents (who said they were inhibited about talking with their children because of embarrassment and inadequacy), teachers – even some FLE teachers (who expressed hesitancy to talk about reproductive health and pregnancy prevention because of fear of recrimination by parents or supervisors), religious leaders (unwilling to risk offending segments of their congregations), and leaders in youth-serving agencies (fearing repercussions from outraged parents).

4. Balancing (a) core broad-based programs aimed at youth with unspecified risks

of teen pregnancy/STDs, and (b) special programs targeted for high-risk youth: Limited resources force a community to make hard choices about the kinds of public-service programs that can be supported, and about who receives such services. Some argue that, since all teens are theoretically at risk of pregnancy and STDs, a community has the responsibility to provide prevention programs for everyone. This can be done through efforts aimed at virtually all teens (e.g., FLE, or training to improve parent-child communication), as well as smaller programs intended for youth of indeterminate risk who are served by the provider organization (e.g., programs offered through religious communities or scouts).

Others contend that the greater need is to fund programs designed for adolescents with a higher-than-average chance of getting pregnant or contracting an STD (e.g. Beating the Odds, Camp Horizon, Steppin’ Up, and Reach, described in Appendix L). Not only do such narrower efforts concentrate resources where the need is presumably greatest, but – in terms of teen births averted – programs directed at this audience are more cost effective (see Chapter V).

At this time we simply do not know the distribution of risk among our community’s teens, and no research-based guidelines exist to suggest the ideal distribution of resources in a community.

5. Building programs on others’ lessons: Communities all over America -- and in other countries -- are exploring ways to tackle teen pregnancy and teen STD problems. A bewildering array of programs, projects, messages, and tactics has been developed. Many of these efforts, including some of the most popular, are untested and based more on ideological hopes and beliefs than proven efficacy. On occasion, residents in our community have – with some success -- vigorously opposed proposed pregnancy/STD prevention programs or elements of programs, and advocated others – all with little reliable data to support their claims.

Only in the last five years have reliable and objective evaluations begun to be available; we can now design our own teen pregnancy/STD prevention strategies based on the tested experience of others. Programs of proven effectiveness have widely varying natures, but they tend to share one or more common themes: emphasis on responsible behavior (including abstinence), building self-esteem, skill training to resist peer pressure, encouraging an interest in planning for the future, and building teens’ community involvement.

6. Leaving room for innovation: Notwithstanding recommendation #5, above, research has yet to provide definitive answers about how to best reduce teen pregnancy and STDs. The community should encourage diversity of ideas and new approaches; experimentation has value when it is accompanied by reliable evaluation.

7. No magic bullets; the cumulative effect of diverse efforts: Reviewing the results of program evaluations can be discouraging in that no single approach eliminates teen pregnancy and STDs. We need to encourage various types of programs to meet the many-sided needs of our teenagers. In a community that shares the aim of reducing teen pregnancy and unsafe sexual activity, all participants who debate tactics for achieving the common goal need to be flexible and open-minded.

Local governments cannot fund all needed teen pregnancy/STD prevention activities. Private and non-profit organizations can supplement public sector resources, particularly for innovative projects. By promoting all activities that have a reasonable chance of helping with teen pregnancy/STD prevention, the community increases the cumulative effect.

8. Continuum of services: Few at-risk boys and girls have access to programs directly related to teen pregnancy prevention. For example, Beating the Odds (described in Appendix L), a successful local program for 8- to 11-year-olds, handles only 32 city and county children from an available pool of hundreds. Thus a program may be effective for youth who receive the services, while the overall effect on area teen pregnancy rates is small.

Moreover, a child who "graduates" from an age-based program may not find entry into another appropriate program as he or she grows older. Our community is far from providing a seamless "continuum of services" to ensure that all at-risk youth have access over time to teen pregnancy and STD prevention programs. Missing (with a few exceptions) is direct pregnancy/STD prevention programming for boys, for example, and programming for anyone in those neighborhoods not served presently by the MACAA and Teensight programs.

Significantly more funding is needed than currently available to achieve the goal of a continuum, and to meet the needs of both high-risk youth and the much larger number of teens and pre-teens at normal risk.

9. Focus on each adolescent as a whole person: Evaluation research indicates

that teen pregnancy has been lowered the most where programs are designed to deal simultaneously with a range of adolescent needs. The greatest impact on high-risk teens occurs when the interventions involve parents and other family members, help with school work, provide sports, boost self confidence, monitor physical health, offer after-school activities, and provide reproductive health information and services. Such efforts are labor-intensive and expensive. But they work.

In addition, teen pregnancy/STD prevention programs aimed at the whole adolescent, in a well-rounded intensive way, have benefits in addition to reducing pregnancy/STD rates. In the absence of a single multi-faceted program with integrated activities (dealing with support for schoolwork, health care, sports, job training, etc.), many of the same advantages would likely occur if teens were involved simultaneously in several extra-curricular activities. For example, Teens Give, a program of volunteer service for adolescents identified through the court system (described in Appendix L), shows results in better performance in school and lower rates of trouble with the law. ArtReach at FOCUS and the Music Resource Center (described in Appendix L) both aim at strengthening self-esteem of high-risk youth through self-expression. Though the impacts on participants in these two local programs – and of participants in organized sports, or other local youth activities -- has not yet been assessed, it is probable that we would see positive effects on a range of risk behaviors.

10. Focus on boys vs. girls: How should limited resources for teen pregnancy

prevention programs be allocated between girls and boys? On the one hand, programs for girls are important because girls incur the major costs of pregnancy (other than the babies themselves) and have the most incentive to change behavior. One the other hand, since there are a somewhat smaller number of boys responsible for most of the teen pregnancies, a program effective at identifying such boys and changing their behavior would have large effects.

At present, it has not been demonstrated whether programs aimed either at boys or at girls are more effective in reducing the number of teen pregnancies. It is apparent, though, that efforts directed at boys are less common, despite several promising new approaches. For example, MACAA and Teensight at FOCUS have recently launched "Young Guys of Distinction", a primary pregnancy prevention program for 10-15-year-old boys in Charlottesville. At a national level, "Wise Guys", a program promoting abstinence and sexual responsibility for 10-19-year-old young men, has been selected as a "Best Practice Model" by North Carolina’s Adolescent Pregnancy Prevention Coalition.

Families -- especially parents -- are children's first and best teachers about love, values, and sex, and research confirms that parents and family are important influences on teens' sexual behavior and pregnancy risk (Miller 1998). Parent/child connectedness (i.e., support, closeness, warmth) is related to lower adolescent pregnancy risk. So, too, are parental attitudes and values disapproving of adolescent sexual intercourse and (in most studies) parental supervision/regulation. On the other hand, abused children are at high risk for teen pregnancy and other problems.

Studies linking direct parent/child communication with teen pregnancy risk, however, are inconclusive, though the willingness and ability of parents to talk knowledgeably with their children increases the probability that the children will make informed and responsible decisions.

Parents can positively influence (though never absolutely determine) whether adolescents have sex, use contraceptives, contract STDs or become pregnant. The success in risk reduction depends on, among other things, adults having fundamental parenting skills and knowledge, including the ability to listen constructively, to articulate their own values, to maintain communication with teachers and others who have contact with their children, and to serve as role models. Parents also need to be able to strengthen children's self-esteem, confidence, and refusal skills, and to use examples from real life (e.g., TV news) to stimulate constructive discussions about responsible behavior.

To help train and support parents for these responsibilities, a range of community organizations -- churches, schools, civic/neighborhood groups, health-care centers, etc. -- would ideally offer courses and workshops that strengthen knowledge and skills, and establish networks of adults that provide needed encouragement and guidance. Parents/responsible adults would be actively involved in school curriculum decisions and knowledgeable about the content of FLE courses; they would also participate in parent-teacher conferences and other opportunities to learn about their child by seeing him/her through others' eyes.

No studies reveal how Charlottesville/Albemarle parents, in particular, deal with their children regarding pregnancy/STD risk reduction. If we are like other communities where survey research has been conducted, however, some parents are deeply involved in helping their children learn appropriate values, knowledge, and behavior regarding sexuality. The majority of parents, though, report that they have little meaningful communication with their adolescent children, and feel insecure about their abilities to educate their children about sex and reproductive health, because of embarrassment, lack of skills to meet their children at an appropriate level, and uncertainty about relevant age-appropriate information. Often parents of sexually active teens lack basic knowledge about available contraceptive options, including their safety, effectiveness, cost and accessibility; their grasp of STDs is rarely more proficient.

The social institutions in our community are not well designed to strengthen parents' capability to influence their children's risk of adolescent pregnancy or STDs. In schools, according to our discussions with teachers, counselors, and parents, parent-teacher conferences are poorly attended, especially as children get older, and the weakest parent-teacher links are with parents of high-risk kids. The location and timing of Parent-Teacher Organization (PTO) sessions are often awkward for working and single parents, and the sessions ordinarily avoid sensitive topics such as the adults' role in teen pregnancy prevention. Few parents voice policy preferences for libraries or FLE classes. A laudable example of a school’s effort to increase parental involvement is Burnley-Moran Elementary School’s program of sending buses into the Westhaven public housing area to help parents attend PTO sessions.

Our discussions with local health care providers suggest that, with few exceptions, this sector of our community also does less than it could to help parents. Family physicians have limited time and interest – and not always the expertise -- to focus on parent-child interaction, especially regarding sexuality and reproductive health. The Teen Health Center, the Health Department, and Planned Parenthood of the Blue Ridge, though prepared to discuss teen pregnancy with individual parents or groups (e.g., PTO's; parents at churches), report that they are rarely asked to do so. Pamphlets and booklets are available to help improve parent/child communication, but miss large segments of the appropriate audiences.

Only a handful of local churches devote attention to teen sexuality and pregnancy prevention, and even these churches provide little guidance or support to parents (see section E, below).

Several community agencies offer help to parents: Parents Anonymous, affiliated with Region X, is a support group for and by parents with a special mission to prevent abuse and neglect; MACAA provides some parent education classes; Teensight at FOCUS helps teen parents learn parenting skills; Youth and Family Services gives individual family counseling to families in crisis; Planned Parent of the Blue Ridge offers parent group workshops on talking with one’s children about sexuality issues.

Public schools in the city and county educate roughly 16,000 students; private schools handle an additional 4,000. Though the Charlottesville and Albemarle County public school divisions are separate and distinct, there are elements in common.

Schools’ main direct effort to deal with teen pregnancy and STD is through Family Life Education (FLE). Currently, both public school divisions teach FLE from kindergarten through tenth grade. Students in middle and high schools (though not in grades eleven or twelve) are exposed to FLE from 10 to 15 hours per year. In some FLE classes, however, science replaces the sexuality education component, especially when a teacher is less than comfortable with the topic.

Contrary to widespread belief, only a small proportion of the subject matter of FLE deals with sexuality. In ninth and tenth grades, for example, from roughly 50% to 90% of the short FLE module is devoted to such issues as household budgeting, family violence, breastfeeding, and parenting. In discussions with teens to develop this strategic plan, most reported that the modest age-appropriate information on sexuality and reproductive health is boring. Little effort is made in local schools to integrate FLE issues into other classroom topics (e.g. biology, English). More importantly, FLE curricula do not supplement didactic teaching with substantial efforts to enhance adolescents’ life skills by, for example, engaging them in role plays, decision-making practice, or values clarification exercises. Yet it is only when these supplemental activities are included that FLE courses have been shown to have measurable effects on teen pregnancy prevention (Kirby, 1997).

Various community agencies (e.g. the Health Department, Teen Health Center, Sexual Assault Resource Agency (SARA)) have been approved as resources, and staff from these agencies occasionally play a role in FLE courses. FLE curricula and the list of resources are reviewed irregularly; for all new FLE resources, School Board approval is needed. In neither school division are refresher courses for FLE teachers a regular feature, and supervision is reported to be minimal. Despite the limitations, teachers who handle FLE inform us that they are generally satisfied with the curriculum, class activities, and assignments.

School officials acknowledge the importance of preparing students for the real world through teaching FLE. The demands on the school systems to reach the state-mandated Standards of Learning (SOL’s), however, do not allow much time for FLE or much flexibility in the FLE curricula – and FLE is not part of the SOL requirements. Moreover, there is reluctance to devote greater time or effort on the FLE curricula at a time when researchers are just beginning to publish reliable evaluations at a national level (no local assessments have been attempted; see Chapter II). Most school officials see FLE as a potentially volatile topic, and to avoid a public outcry prefer to quietly and unaggressively continue present activities.

In both Charlottesville and Albemarle County schools, following state guidelines when FLE was mandated, parents who do not wish their children to be exposed to FLE opt out of the program by sending a letter to the school.

Local private schools vary in the degree to which they have developed FLE courses and teen pregnancy/STD prevention classes. This diversity ranges from no formal mention of prevention issues (at Tandem Friends School), to planned but not yet fully implemented FLE teaching units for K-through-12 grades (at St. Anne’s Belfield).

The expense for providing FLE is modest. In the whole Albemarle public school system – kindergarten through tenth grade – we calculate the annual cost of FLE staff time to be $59,000. In the Charlottesville system the cost of staff time is $39,600. Though we do not know the precise effects of FLE, if it succeeds in averting three teen births each year (assumed conservatively to cost taxpayers $37,000, not including the costs to the teen or her parents; see chapter I.C.2. and Chapter V) it will have paid for itself.

In addition to FLE, local schools contribute significantly to teen pregnancy/STD prevention in other direct and indirect ways:

• School counseling professionals are available in most schools, though often on a part-time basis, to help students with personal, as well as academic, problems. In the county, responding to the recognition that schools are being overwhelmed by all they are being asked to do to help families under pressure, a new Family Support Program is placing trained, experienced social workers in all 15 elementary schools where they can respond directly to the needs of parents and children.

• Most schools have some kind of health care provider, ranging from uncertified health clinicians to certified registered nurses, and working on a part- or full-time basis. These specialists can help with reproductive health problems or refer students to appropriate professionals.

• "Character education" provides a consistent set of expectations that students respond to, and allows teachers to incorporate the value education into their lessons as they see fit. At Henley Middle School in Albemarle County, the Character Counts programs emphasizes the six qualities of trustworthiness, respect, responsibility, fairness, caring , and citizenship (Nonte, 1999).

• A number of schools in the city and the county collaborate on small-scale teen pregnancy prevention programs, concentrating on high-risk youth, implemented by community organizations (MACAA and Teensight at FOCUS; see Table 1 in Chapter V).

• Extra-curricular sports and interest groups occupy students after classroom hours, encouraging involvement in constructive activities, helping to build decision-making skills, and boosting self-confidence.

It becomes clear that schools play an important role in preparing youth to avoid pregnancy and STDs. An examination of the research literature, however, also makes it apparent that in many other American communities schools are making greater efforts than ours to introduce programs shown to lead to reductions in youth risk behavior.

• Our local schools do not yet have peer education programs, using selected and trained teens to provide other students with accurate information about pregnancy and STD prevention. Lessons might be learned from peer education being used elsewhere in the community: The AIDS Services Group (ASG) has developed a peer education program focussing on HIV awareness, recruiting and training students from St. Annes Belfield; SARA has implemented the VIVA peer education program; and UVA’s Madison House has experimented with this technique.

• Systematic efforts to introduce youth volunteer programs have, until now, been tried only in one of the local private schools. Monticello High School, working with United Way, is moving toward the establishment of a volunteer program for students.

• Neither public school division has school-based health centers (i.e. fixed clinics on school grounds that provide primary health care services to students) or even school-linked health centers (i.e. clinics not on school grounds with special relationships to the pupils from one or more schools). Though there is not convincing evidence that they prevent teen pregnancy, such clinics have the potential to make important contributions to children’s health.

Public and private schools in Charlottesville and Albemarle County can clearly do more to provide students with information and skills that are likely to reduce teen pregnancy/STI at-risk behavior, both for students at ordinary risk of teen pregnancy and those at high risk.

A number of organizations in the community are either directly or indirectly involved with preventing teenage pregnancy and STDs, and an even larger number have the potential, not yet fully utilized, to be involved. The organizations directly involved are MACAA through its Beating the Odds, Camp Horizon, and Steppin’ Up programs; and FOCUS through its Teensight and Reach programs. The MACAA and Reach programs are designed for small numbers of high-risk youth and aimed at primary prevention, that is, the main goal is pregnancy/STD prevention. Teensight provides teen mothers with the skills and support system to stay in school, get and keep a job, and strengthen parenting abilities; a secondary aim is to help these adolescents avoid a subsequent pregnancy. There is strong evidence that Camp Horizon and Teensight are very effective, based on participants’ comparatively few pregnancies. The other programs are too new to evaluate yet.

Planned Parenthood of the Blue Ridge provides technical support for these community teen pregnancy/STD prevention programs, as it does for FLE in public and private schools and for some church-based teen sexuality training programs. For selected components of the programs’ curricula, Planned Parenthood makes specialists available to talk with youth (or their parents), and offers audio-visual and other supplementary educational material (e.g. pamphlets, posters, "Baby Think It Over" dolls) from its open library of resources. A community educator is available to lead workshops and professional training for groups.

The Council on Adolescent Pregnancy Prevention (CAPP) does not provide direct services to teens, except for distributing a "Teen Help Card" (listing telephone numbers of community services) and a flyer describing local family planning services for teens, and paying for needy teens’ taxi fare to family planning clinic appointments. CAPP’s primary function is as a support network and information clearinghouse for local professionals and others interested in pregnancy prevention; it also works to strengthen community policies and programs regarding teen pregnancy/STD prevention, and organizes an annual public awareness campaign.

There are also a number of related youth-serving organizations either that affect the risk behavior that leads to teen pregnancy (e.g., Teens Give) or that have underutilized potential to affect such behavior (e.g., Boys and Girls Club, Girl Scouts, Piedmont Family YMCA). For the most part, the programs with untapped potential have a captive audience of children of the relevant ages and backgrounds, and an established teen pregnancy prevention program developed by the national office of the organization. Many of the local organizations do not implement the available national model, either because of different local priorities or concern about the sensitive nature of the subject.

Discussions about coordination among existing programs, and even possible consolidation, have recently been stimulated as our community teen prevention programs sought local funding. While there is obvious value in coordination, in this situation the expectations for increased efficiency may have been overrated. The two main community-based pregnancy prevention efforts (i.e. the MACAA and Teensight at FOCUS programs) have communicated and coordinated much more in the last few years than ever before. But because both programs are so small and deliberately focus on quite different populations of youth, the increased coordination did not appear to lead to any significant gain in program efficiency.

A current proposal for city, county, and United Way funding of community-based teen pregnancy/STD prevention programs would provide a lump sum of money that MACAA and Teensight at FOCUS would decide how to allocate. Such an arrangement would demand an improbable level of cooperation by historically independent agencies, essentially demanding that they operate as a single entity. The two agencies, in the interest of promoting peaceful relations, would agree to compromises on funding that have little to do with optimal allocations. Optimal allocation requires hard choices that competing agencies are usually not in a position to jointly make. The proposed allocation rule also takes the public, as it is represented by local governing bodies, out of the process of allocating public funds. A much better process would have the local governments making decisions with significant input from other interested parties including the agencies running the programs and the public.

Youth volunteer programs, current evaluation research suggests, appear to be among the most effective ways to reduce the risk behavior that leads to teen pregnancy (and many other adolescent problems). There is hope that, in our community, by encouraging far more youth to be involved in volunteer activities and providing them with the opportunities to do so, we can have a significant impact on a high proportion of youth at relatively low cost. Teens Give estimates that initial monetary costs for such a venture would be $100,000. Presently, United Way is making significant progress in expanding youth volunteer activities by encouraging agencies who might use youth volunteers, organizing brokerage activities, and working with some of the local high schools to set up youth volunteer programs. We applaud and support these efforts.

Youth volunteer programs require adult intervention to a) supervise the youth, b) create volunteer activities, and c) help youth reflect on the value of the activities. In the long run, some of these activities might be performed by high school students themselves in a model similar to Madison House (which operates for college students). But a Madison House for high school youth will not happen without significant resources, and unless adult volunteer coordinators accept the idea of sharing administrative tasks with teenage volunteers – much as Martha Jefferson Hospital does with the Reach program. That change requires many confidence-building steps along the lines developed by staff at successful youth volunteer agencies such as Teens Give and the Miller School's volunteer program. Both programs, relying on adult supervision of the high school students, have built a reputation of providing reliable youth volunteers. Despite significant startup costs, this approach seems very promising given the history of success by groups such as Teens Give and the national research showing large and statistically significant effects of such programs.

IV. D. Health Care Services

During adolescence the greatest risks for morbidity and mortality are behavioral, ranging from the risky consequences of driving or using drugs and alcohol, to engaging in unprotected sex. Health care for teens needs to be continuous and preventive, aimed at modifying behavior. Instead, in large part because of money and time constraints within the system, health care tends instead to be -- as it is for adults -- episodic and curative. One result of the inadequate focus on preventive care for adolescents is that teens delay seeking family planning services for an average of 18 months from their sexual debut (first intercourse). Consequently when teens do seek contraceptives, they are often already pregnant. A parallel problem is that sexually transmitted diseases among teens are often identified so late that they require emergency room treatment and/or hospitalization.

Most physicians have little training about adolescent reproductive health. The specialized health-care clinicians who work with children and adolescents, whether in private practice providing comprehensive care or in public clinical settings offering episodic treatment, are well positioned to provide not just curative care but anticipatory guidance (e.g., about prevention of pregnancy and STDs) to their young patients and their parents. To help clinicians refocus their attention on preventive health services for adolescents, guidelines developed by the American Medical Association include recommendations for:

• an annual preventive services visit from the ages of 11 to 21 at which time biomedical and psychosocial aspects of health are addressed;

• a complete physical examination at least three times during these years (with annual pap smears for sexually active teen women);

• an established office policy regarding confidential care for adolescents that is clear to both adolescent and parent(s);

• health guidance annually regarding responsible sexual behaviors, including abstinence, together with the availability of condoms and birth control methods.

This ideal situation has yet to be widely implemented, and we rarely see parents guided by their child’s health-care provider to deal with sexuality issues in an environment of clarity, respect, and honesty. It is not surprising that evaluation research shows little or no beneficial effect on pregnancy or STD prevention from an adolescent’s random and brief encounter with a health care professional, though two studies show an increase in contraceptive use (Kirby 1998).

The Charlottesville/Albemarle community has several hundred medical professionals who have the opportunity to provide local youth with health-care services to reduce the risk of early sexual activity, pregnancy, and STDs. These include physicians (pediatricians, family practitioners, obstetricians/gynecologists, others), pediatric and family nurse practitioners, and certified nurse midwives.

In addition to private practices, the area is fortunate to have four specialized clinics to which teens can turn for reproductive health care. All provide contraceptive counseling (including information about abstinence and methods available at drug stores), pregnancy testing, pregnancy counseling (options for prenatal care, abortions, and adoptions) and referral if appropriate, Pap smears and breast exams, and STD testing and treatment for both males and females. Contraceptives available at all four clinics include condoms, birth control pills, Depo-provera (three-month injection), Norplant (five-year implant under the skin; not available at the UVA Student Health Center), and emergency contraception (the morning-after pill).

• Thomas Jefferson District Health Department (1138 Rose Hill Drive, Charlottesville), covering Charlottesville, Albemarle, Fluvanna, Green, Louisa, and Nelson Counties, is part of the state-tax-supported health system. Fees on are on a sliding scale based on ability to pay; a pregnancy test is $11.00, contraceptives (choice) are $1.00, and exams are free.

• Planned Parenthood of the Blue Ridge (1928 Arlington Blvd., Charlottesville) is a non-profit organization offering professional reproductive health-care educational (see previous section) and clinical services. A pregnancy test costs $10.00, with other services on a sliding scale depending on income.

• The Teen Health Center (1400 W. Main Street, Charlottesville) is a specialized clinic of the Woman's Place at the University of Virginia. Fees on are on a sliding scale based on ability to pay, with a maximum of $32.00 plus lab tests.

• Elson Student Health Center at The University of Virginia (corner of Jefferson Park Avenue and Brandon Avenue, Charlottesville) serves only UVA students (no partners). Costs for clients are included in the student health fee paid each semester, though lab and prescription costs are extra.

In addition to these sources of reproductive health care, there are a number of agencies that provide education, counseling, and referral to specialized medical care. One of the more prominent ones is The Charlottesville Pregnancy Center which provides free pregnancy testing, relationship counseling, and information on all options (though in the context of its anti-abortion mission).

Significantly, staff at the four clinical facilities report that their reproductive health services are underutilized by teens. This observation is confirmed by a rough comparison of the number of female teens in the community – approximately 4,300 in the 15-19 year-old group (see Appendix C) – with the number of females in that age group who visit one of the clinics at least once – estimated very approximately at fewer than 1000. Further, national data shows that only about half of sexually active high school students used a condom or other contraceptive the last time they had sexual intercourse, and far fewer sexually active teens have tests for STDs (see Chapter I.C.1).

A small survey of the local health-care providers to whom teens turn, conducted in preparation for writing this strategic plan, suggests that all discuss information about sexuality, but that the range of topics and depth of detail was limited by the (often brief) time made available. All clinicians reported that the youths’ confidentiality was respected in these discussions. Few of the clinicians had (or took advantage of) an opportunity to talk with parents about teens’ reproductive health issues.

Optimally, local health-care providers would see more teens and would spend more time with them; their attention would shift from primarily "problem" visits on rare occasions to regular sessions where preventive care became the chief concern. One local physician noted that the community, and more importantly the managed care companies, did not see the value of preventive health-care visits during adolescence. Only a few health care professionals currently talk to teens about community values regarding early sexual activity and/or parenthood, or – for sexually active teens – fully discuss contraceptive options. Emergency contraception, though legal for over twenty years, remains relatively unknown among sexually active adolescents – as well as adults.

Clearly not all local health-care professionals are trained adequately to provide the wide range of educational, counseling, and medical services required to meet the needs of today’s adolescent clients – and to work constructively with the teens’ parents. Local professional organizations of health care providers – where possible using guidelines prepared by national groups – should offer training and support.

Regrettably, the economic status of a teen affects the type and quality of health care services that are accessible. Though reproductive health care is widely available and affordable at the clinics identified above, for the poor it is hard to obtain comprehensive care with one provider with whom a young person can develop a relationship. Private practices only see teens with insurance, including Medicaid. Given the long-term societal costs of unwanted teen pregnancies and STDs, greater efforts should be made to ensure that all youth have access to high-quality reproductive health care.

IV. E. Religious Communities

Religious communities stand out as the only grassroots social organizations that serve individuals and families from cradle to grave. People choose faith communities based on deep and fundamental beliefs; religious leaders have immense power to influence followers, and edicts carry weight with congregation members and sometimes within the larger community.

Despite this, our survey for this strategic plan indicates that most religious communities are not active participants in teen pregnancy prevention efforts, or in the provision of rigorously evaluated sexuality education. In the Charlottesville/Albemarle community, efforts by CAPP in the past several years to reach and educate religious community leaders have been met with little enthusiasm.

At the national level, virtually all mainstream religious denominations have developed, and make available to individual congregations, sexuality education curricula. Locally, only a handful of churches or synagogues has adopted such denominational, scriptures-based sexuality education programs. Within the religious communities in our area, five general categories of programs dealing with youth sexuality education/teen pregnancy can be distinguished:

Implementation of sexuality education curricula relies on strong pastoral and congregational consensus, education, and volunteer support. Leaders in the faith communities also point out that they are constrained by teachers’ discomfort with sexuality issues, inadequate resources, and lack of teacher training (recalling that most are volunteers).

Because religious communities serve members through the lifespan, most provide rites of passage for youth. Traditionally these rites of passage include such events as bar and bat mitzvah, confirmation, and youth baptism – all reinforcing community values and teaching responsible behavior. Some religious communities recognize that the rites of passage which occur during adolescence provide an opportunity to expose youth to denominationally-appropriate sexuality education. Recent example of churches’ efforts to build teen pregnancy prevention education on scriptural teaching include the "True Love Waits" pledge ceremony, or a program like "Journey to Adulthood" that spans fifth through twelfth grades and is implemented in several Protestant denominations.

Although a few local faith communities are implementing some noteworthy and comprehensive programs that include elements believed to prevent premature sexual activity (e.g. volunteer work and developing and practicing new behavioral skills), most religious communities are not taking full advantage of their unique position in the larger community.

Local business plays an important role in the provision of health and human services in the Charlottesville/Albemarle area. In addition to making direct financial and in-kind contributions to local community organizations, many firms free employees for volunteer help with public-sector and non-profit groups (assisting in the delivery of services; participating on working committees; serving on governing boards; etc.). The private sector also gives direct financial support to the local United Way, which in turn funds community teen pregnancy prevention programs.

Businesses recognize that it is in their best interests to support efforts to prevent teen pregnancies and STDs. When employees’ teenage children have babies who demand time and attention from the new grandparents, for example, productivity can be affected. Also, teens who become parents are less likely to obtain the education and training necessary to be productive in the labor force, contributing instead to the increase in numbers of unskilled workers. And the overall economic costs of teen pregnancy and STDs, estimated conservatively at over $5 million each year just in Charlottesville and Albemarle County (see section I.C.2.), is reflected in the tax burden for businesses as well as individuals.

The potential for greater business participation in teen pregnancy/STD activities is great, through more active involvement with on-going community programs, more liberal direct funding, and more imaginative in-house programs. The March of Dimes, for instance, has available for businesses a "workplace education" program focussing on teen pregnancy prevention (including a module on "parenting your teen"). This program would be a valuable "on the job" resource for local employees. More businesses could participate in the United Way "Day of Caring", as way of showing residents how easy it is to spend a little time with a community agency and the difference their involvement could make.

In gathering information for this Strategic Report, we were told that some businesses shy away from direct financial support of teen pregnancy/STD prevention activities because the controversial nature of some programs might alienate customers. This protestation ignores the many non-controversial interventions – youth volunteer programs, for example, or mentoring programs – which recent research suggests are among the most effective in preventing teen pregnancy and STDs.

Table 1 summarizes the economic costs of the community’s programs that have significant direct effects on teen pregnancy. These programs, also discussed in Chapter IV.C., consist of Beating the Odds, Camp Horizon, Reach, Steppin’ Up, Teensight t FOCUS, Young Guys of Distinction, and Teens Give.

The unshaded rows in Table 1 represent the current six programs, whose total annual cost is $455,700. Of this, ??? comes from city and county public funds, ??? from third-sector grants [Steve will fill in the blanks].

The proposed extensions of teen pregnancy prevention programs, as suggested by the agencies, are indicated by the shaded rows in Table 1. In brief, they consist of expansions of the current activities into additional city and county youth populations of high-risk children, and total an additional $$382,500. For example, Beating the Odds presently exists in four neighborhoods (identified in the table) at a cost of $46,000 per year. To expand Beating the Odds into the rest of the city elementary schools would cost $46,700 more per year, and to expand it into four more elementary schools in the county, another $52,000.

Direct teen pregnancy and STD prevention programs in our community now consume almost half a million dollars per year, and this Strategic Plan proposes increasing the amount to more than one million dollars. Is it worth the money?

In short, the answer is a resounding yes. The measurable economic benefits of the current direct teen pregnancy prevention programs in our community, though the estimates are rough, can be calculated conservatively at one and

Table 1: Costs of current teen pregnancy prevention programs and proposed

a half times the costs of the programs. A more realistic estimate yields benefits three times the programs’ costs. It should be emphasized that these figures include only pregnancy-related benefits; they do not take into account the likely

Table 2: Total costs and estimated benefits of current teen pregnancy prevention

sizable benefits in preventing STDs, or the other collateral beneficial effects of the programs (for example, volunteer-service programs have as large an effect on school dropout rates as they do on teen pregnancy rates). Nor does this calculation include the benefits to the mother or child – only to society.

Our method of calculating a program’s economic benefits consists of first identifying the impact of the program in terms of averting teen pregnancies, and then assigning an economic value to that impact (ignoring, for this analysis, other impacts).

To measure a program’s success, if any, in averting teen births, we compare (a) the pregnancy rate of teens in a program with (b) the pregnancy rate of comparable teens not in the program. In the following paragraphs we illustrate our approach with respect to Camp Horizon. Full details of our assumptions in assessing each of the other programs listed in Table 1 appears in Appendix M.

From data provided by the program, we know that, at most, 3% of Camp Horizon participants become pregnant by the age at which they should finish high school. On average, 2/3 of pregnancies lead to births in Charlottesville. So we estimate that 2% of Camp Horizon participants give birth by the age at which they should finish high school.

For the birth rate of comparable high-risk teens not in the program, we have to rely on estimates since there is no data. For our estimate, we simply use the birth rates for girls in Charlottesville as an extremely conservative estimate of the rate for high risk girls, and, for a more realistic estimate, we double the Charlottesville rate.

The annual teen birth rate for all 10-14 year old girls in Charlottesville is 2 (per thousand) and for 15-17 year old girls it is 60.3 (per thousand). A 12 year old Camp Horizon participant would have had a .998 chance (1- .002) of not giving birth between ages 12 and 13, another .998 chance between ages 13 and 14, another .998 chance between ages 14 and 15, a .9397 chance between ages 15 and 16, another .9397 chance between ages 16 and 17, and another .9397 chance between ages 17 and 18. The chance of not giving birth by age 18 is the product of these probabilities: .998 x .998 x .998 x .9397 x .9397 x .9397 = .825. This implies that a 12-year-old Camp Horizon participant would have had a 17.5% chance (1 - .825) of giving birth had she not participated in Camp Horizon. On the other hand, she has a 2% chance given that she did participate. Thus, the effect of the program on birth rates is 17.5% - 2% = 15.5%.

The estimated cost of a birth in today’s dollars over the lifetime of the mother and child is $37,000 (see Chapter I.C.2.). Some of the costs of the birth occur immediately; others take years to occur. The costs that occur in years after the birth need to be discounted. The idea is that a dollar in a year from now is not worth as much as a dollar today because we could take a dollar today, put it in a bank and have more than a dollar in a year from now. Similarly a cost in the future is not as expensive as the same cost today.

Typically, we deal with this by discounting future costs to put all costs in terms of costs today. If we add up these discounted costs over time, then the total discounted cost of a birth is estimated to be $37,000. We also need to discount costs even more because they occur in years after program costs; the goal is to put all costs and benefits in terms of dollars at the time of the program.

Next, we need to adjust for program participation over many years. We make the most conservative assumption that, once in a program, the child participates as long as possible. Thus we divide benefits by the number of years of program participation to get savings per new child participating. We conservatively discount birth costs by five years using a 5% annual discount rate. Thus, a birth at age 17 costing $37,000 is worth only .95 x .95 x .95 x .95 x .95 x $37,000 = $28,630. This implies that the conservative estimate of the cost savings for one Camp Horizon participant is the difference in birth probabilities, (.175 - .02), times the cost of a birth, $37,000, times the discount factor, 0.774, divided by 2 years of participation = $2219. Since there are 60 participants per year, the total cost savings is $133,167. If we use the more reasonable estimates of high risk birth rates, the total cost savings becomes (.350 - .02) x $37,000 x .774 x 60/2 = $283,516.

We perform similar calculations for Camp Horizon expansions by adjusting program size. We assume that the proposed expansion of Camp Horizon will result in benefits proportional to its size. This leads to added estimated conservative benefits of $88,800 and more realistic benefits of $189,000.

Note that the total benefits to the programs are about 73% of the total teen pregnancy costs discussed in the earlier chapter. This is because those numbers were annual costs, and the numbers in this table represent total benefits over many years of reducing teen pregnancy. Even taking this into account, our estimates suggest that complete expansion would reduce teen pregnancy rates by about one-quarter. This is a reasonable expectation given these program’s success at targeting high risk youth and dramatically changing their behavior.

In any case, it is clear that Camp Horizon, Teensight, and Teens Give are very worthwhile programs. Even ignoring benefits to the participants in the program, the programs more than pay for themselves in terms of reduced costs to society associated with lower pregnancy rates. If the newer programs (Beating the Odds, Reach, Young Guys of Distinction) have similar results, they will also be cost effective.

Given this analysis, it is clearly cost-effective to devote more funding to programs aimed at directly preventing teen pregnancies.

The programs listed in Table 1 could count on funding only for the initial two or three years of their operation. Even as the new staff launched their programs, the directors had to spend time seeking future support to maintain the activities. The absence of an assurance of reliable long-term funding for community teen pregnancy/STD programs hinders staffing, weakens planning, increases time spent in grant-writing (at the expense of programmatic effort), and lowers morale.

A centralized teen pregnancy/STD prevention coordinator (or coordinating body), whose tasks and limited authority are ratified by local governments and program administrators, is currently an essential element in the prevention programs of many communities. A teen pregnancy/STD prevention coordinator can serve:

Regarding this last suggested function of a coordinator, it may be instructive to note that the Task Force on Teen Pregnancy Prevention (the group of which our Strategic Planning Work Group is a part) recently hired a consultant to seek funding for maintenance and expansion of the programs by Teensight at FOCUS and MACAA. Using about $13,000 in seed money from the state Partners in Prevention program, during the year ending September 1998 the consultant helped the Task Force write 16 grant proposals for a total of $520,000. The result was disappointing: Teensight received a $5,000 grant from an outside source (the Seay Foundation) and a large grant ($65,000) from the local Perry Foundation. MACAA received no funds.

Two problems were evident as this effort progressed:

1. It was difficult to divide the needs for new programs into innovative, discrete packages that fell under the modest limits ($5,000) of most of the appropriate funding agencies.
2. Most foundations were not interested in providing funds for the maintenance of small existing programs.

The Task Force also looked into seeking funds for large research-oriented projects,

but learned that our needs did not meet the criteria of most funding agencies (e.g., emphasis on abstinence programs to the exclusion of other approaches; preference for projects in economically depressed cities).

The experience suggests that outside fundraising requires long-term help from an experienced person, and that it is unlikely for outside foundations to provide a significant proportion of support for our local needs. A coordinator can provide the long-term grant-writing skills. The community, however, must make a financial commitment to reducing teen pregnancy with or without a coordinator.

To the argument that the dollars for maintaining such a coordination post could be better spent on front-line programs for teens, some experienced specialists reply that a good community coordinator provides overall benefits (in terms of program impact and new program support) that far outweigh his or her costs.

Measuring objectively the success of teen pregnancy/STD prevention programs helps policymakers and program staff make decisions

• to improve its practices and procedures, perhaps by adding or dropping specific program strategies and techniques;

• to institute similar programs elsewhere;

• to allocate resources among competing programs; and

• to accept or reject a program approach or theory (Weiss 1972:16).

The keys to doing good evaluations of local programs are (a) to build in data collection as an integral part of the program, and (b) to match the size, scope, and nature of the evaluation research to the characteristics of the program being evaluated. Matching the evaluation to the programmatic effort is tricky: extensive, rigorous, and systematic program outcome research can be tremendously valuable, but also logistically demanding and extremely expensive – in some cases more than the cost of actually running the program. Such an intensive effort is appropriate only in those unusual cases in which a completely new programmatic approach has been developed, implemented, tentatively evaluated, and has achieved sufficient national attention to permit independent funding of evaluation efforts. A major evaluation is simply not appropriate or feasible – primarily because of the cost -- for most small local programs.

Indeed, if an agency or organization in our community adopts a program (or element of a program) that has been rigorously and objectively evaluated elsewhere, there is little need to replicate the entire assessment. Rather, an appropriate goal, at least initially, would be to ensure that the local implementation accurately reflects the tested model.

In the past year or two our local governments, together with United Way, have articulated policies reflecting a new seriousness being given to assessment issues. Until recently, public service programs in our community (including those addressing teen pregnancy/STD prevention) received only the most cursory evaluation – often little more than the earnest assurance of the program administrator that all was going well. Now local governments and United Way jointly are reviewing past evaluation reports from grant recipients to determine how reliably progress can be measured, revising questions on progress reports to better measure outcomes, and developing a new program evaluation model.

To help determine how to match an evaluation exercise with the local teen pregnancy/STD prevention effort it examines – and to increase the probability that comparable programs collect comparable data -- funding and administrative agencies should consider three distinct but not mutually exclusive categories of data:

• Description of the client population: Responsible teen pregnancy prevention programs continuously collect at least rudimentary data on the people they actually (not ideally) serve. This information helps ensure that (a) program administrators know if they are reaching their intended audience, and (b) the program can be coordinated with other service providers to fill gaps and avoid overlaps. At the least, records are kept on each client/participant’s age, gender, race/ethnicity, and residence location; depending on need and feasibility, more detailed information is sometimes gathered on whether the teen is sexually active, contraceptive history, pregnancy history, socio-economic status, etc. Ideally, all community programs would cooperate to identify the client variables to be described, with the result that standardized data would be made available for each program – without violating confidentiality.

• Outcome evaluation: To determine whether a teen pregnancy/STD prevention effort is having its intended impact, one measures, before and after the intervention(s), a parameter the program aimed to change. These hoped-for "outcomes" could include: greater awareness or knowledge about something (e.g., the disadvantages of early parenthood, or how contraceptives work), modified attitudes (e.g., more respect for abstinence), better skills to make and enforce responsible decision-making (e.g., how to say "no"), or alterations in behavior (e.g., delayed age at first sexual intercourse, or greater use of effective contraceptives for sexually active adolescents). Ultimately, of course, the programs – if successful – should result in reductions in teen pregnancy and/or STD rates.

Some programs – particularly those intended to enhance the development of the whole person -- have incidental benefits other than those related to pregnancy and STD prevention. To the degree those impacts can be anticipated, data should be collected on those outcomes as well.

In addition to (or sometimes instead of) measuring the selected outcome variable(s) before and after the program intervention, some programs evaluate their impact by comparing the outcomes of those who participate in the program against a matched group of individuals who do NOT participate. If the program is effective, there should be a significant difference in the two groups. It should be noted that using a comparison group effectively can be difficult because of problems inherent in identifying accurately matched groups.

Because some adults in our community object to "personal" questions being asked of youth, it is sometimes impossible for evaluators to get reliable data to show whether a teen pregnancy/STD prevention program has had an impact on sexual behavior or pregnancy histories; this is true particularly for broadly-targeted, school-based programs. Though no outcome evaluation of our local FLE curricula has yet been attempted (and thus no objections voiced to any questions), decisions were made in Charlottesville and Albemarle County, for reasons that had nothing to do with science, to omit questions on sexual activity from the 1992 Virginia Youth Risk Survey.

Other (non-evaluation) Research: Research other than evaluation of programs in progress can be of tremendous value in helping a community identify needs and define programs that meet those needs. We in the Charlottesville-Albemarle area have virtually no reliable information about our teens’ attitudes and values, their hopes and preferences, their knowledge and behavior regarding sex and reproductive health. No data exist on local parents’ knowledge and attitudes about their children’s sexuality, or their ability to talk with children about such issues. We know little about the ability and willingness of local youth-serving professionals – health care workers, religious leaders, education specialists, etc. – to help our children avoid pregnancies and STDs. This dearth of data is in sharp contrast to a comparable university community, Chapel Hill, North Carolina, where a rich database helps planners to identify priority problems and design appropriate programs.

By identifying children’s or parents’ areas of ignorance or misinformation, communities can tailor educational programs to local needs. Training teachers and up-grading courses for FLE can also be more effective, and public awareness campaigns can target local needs when appropriate are available. Local and state decision-makers in North Carolina were better able to represent their constituents’ wishes when opinion polls revealed that over 75% of respondents throughout the state felt FLE was a good thing.

In several ways our review of the teen pregnancy/STD situation in Charlottesville and Albemarle County offers encouragement. The rates of teen pregnancies and teen births in both the city and county show modest declines in the past eight years, and the rates in Albemarle County are significantly below the state and national averages. Clinical services for teens seeking reproductive health care – including contraceptives – are very good. Both city and county public school systems have Family Life Education courses that reach nearly all students. The community boasts a few good pregnancy prevention programs aimed at small groups of high-risk children; some of these programs have recently expanded. We should also be encouraged to know that local teen pregnancy and STD rates can be lowered further, as our review of the research literature shows, and the examples of European countries should give us hope.

Often, though, the picture painted in these pages is disturbing. In 1997 – a fairly typical year – 250 Charlottesville and Albemarle County teens got pregnant. Of these, 90 ended with induced abortions and 151 in live births. Albemarle County’s teen birth rate is approximately three times greater than that of western European countries, and the Charlottesville rate is three times higher than the county’s. Most sexually active teens do not take advantage of local clinical services. Only about 15% of pregnant teen girls are married, and more than 80% of teen pregnancies are unintended. Every year about 1 in 4 sexually experienced teens acquires an STD, three times the number of teens who get pregnant. The teen pregnancy prevention programs in our community simply do not have the resources to deal with the needs of ordinary adolescent boys and girls, much less the needs of all high-risk children. A number of youth-serving organizations with access to many children avoid direct involvement in pregnancy or STD prevention.

For some readers, the most unpleasant element in this document may be the observation that many teens in the community – our children – are sexually active. We know they have had sexual intercourse because the youth themselves tell us, in national and statewide surveys, and because their statements are confirmed by the patterns of reported abortions, miscarriages, and births among girls aged 10-19.

The positive side of this disclosure is that most youth before age 17 are NOT sexually active; 8 in 10 girls and 7 in 10 boys are virgins at age 15. This fact suggests one of the most important strategic goals for our community teen pregnancy and STD prevention effort:

Of 15-19 year-olds, however, more than half of both males and females are sexually active, a proportion that rises to three-quarters of 18- and 19-year olds.

The 250 teens each year who get pregnant constitute a third group that deserves special attention. Whether the pregnant teen (with or without her mate) decides for abortion, adoption, or parenthood, she may feel that just when she is the most vulnerable, she has the least access to a network of caring and counseling.

Though this document deals with pregnancy and STD prevention, it is likely to be parenthood, more than pregnancy, which provokes the most critical life changes. For this reason a fourth category of teens deserves attention:

Each of the four strategic goals proposed above focuses on a subgroup of the adolescent population; a fifth needs to be added. This last strategic goal encompasses all teens – indeed, all pre-teens as well. It builds on the recognition that (a) all children will, as part of normal healthy development at some later point in life, become sexually active, and (b) whenever that point comes, many are unprepared and unprotected against STDs and pregnancy.

These five broad strategic goals provide a comprehensive vision for teen pregnancy/STD prevention in our community.

As we seek realistic strategies for reaching these goals, it is important to remind ourselves that tremendous variation exists within the population of adolescents. Of particular relevance for this discussion, teens differ in their motivation to avoid becoming a parent while still a teen. It is interesting to imagine a continuum of this motivation, along which any adolescent could be placed.

At one end would be a teen who has a powerful, paramount, desire to keep from giving birth and becoming a parent. She or he is likely to be abstaining from sex, or, if sexually active, using effective contraceptives, and in the event of an unintended pregnancy, would consider an abortion.

Very high Neutral Very Low

At the other extreme would be an adolescent who wants to get pregnant (or cause a pregnancy) and become a parent. Many teens exist in a world that offers little hope: hope of a worthwhile education, for example, or a satisfying job, a stable and loving family, affordable housing and health care. Without hope, teen parenthood is not seen as an obstacle to achieving future goals, as it is among more advantaged adolescents. Instead, for many youth with few other life options, pregnancy appears a realistic way to satisfy basic needs for recognition, status, nurturance, respect, prestige, and independence.

If we could somehow measure each teen in our community, we could distribute the entire population of local youth along this continuum according to his or her motivation to avoid giving birth and become a parent while still a teen. An entirely hypothetical distribution, based on speculation, is suggested in Figure 4.

Most teens in the Charlottesville/Albemarle area would probably cluster at the "very high motivation to avoid" pole, according to the observations of members of the Strategic Planning Work Group who deal every day with local youth. But some (how many? who?) would be in the middle of the scale, with weak or ambivalent motivation, somewhat indifferent to – or in denial of -- the risk of teen pregnancy or parenthood. Yet other adolescents (is this a small but growing number? a declining number?) would fall at the "very low motivation to avoid" end, representing their wish to become teen parents.

The conjectural distribution in Figure 4, by illustrating that teens’ motivation to avoid becoming a parent varies, suggests that prevention strategies must also vary.

For planning community efforts to prevent pregnancies and STDs, the strategic implications for youth who want to be a parent are obvious. In addition to whatever other more short-term interventions are proposed, in the parts of Charlottesville and Albemarle County where hope is elusive among teens, we should be working more intensively on systemic community changes through job training and decent-paying jobs, insuring safe and affordable housing, etc. Improving the socio-economic context in which teens make decisions about risk is difficult, expensive, and controversial. But without adjustments in the underlying situation, community teen pregnancy prevention programs – at least for less advantaged youth -- cannot be expected to have their optimal effect.

Simultaneously, many immediate things can be done to modify teens’ attitudes, beliefs, knowledge and behavior in ways shown to reduce teen pregnancy and STD rates.

In previous chapters we proposed more than fifty specific recommendations (see Chapter I.A. for the selection criteria). From among those proposals, nine priority recommendations have been selected on the basis of their cost-effectiveness. In addition, a new recommendation is offered after consideration of community consensus on the topic of teen pregnancy/STD prevention.

• Build on proven interventions: Ensure that the design of new teen pregnancy/STD prevention efforts, as well as the continuation or modification of existing efforts, takes advantage of the results of reliable evaluation research.

• Focus on each adolescent as a whole person: Recognize the value of broad-spectrum efforts, with interventions that involve parents and other family members, help with school work, provide sports, boost self-confidence, monitor physical health, offer after-school activities, and provide reproductive health information and services. In addition to reducing pregnancy and STD rates, such a well-rounded approach has other benefits for teens.

• Normalize and increase communication about sexuality and reproductive health, including teen pregnancy and STD prevention: Inspire adults in our community to develop greater knowledge, skills, and confidence for communicating constructively with teens and pre-teens – and each other – about reproductive health and sexuality. Encourage the media to provide consistent and long-term public education campaigns about teen pregnancy/STD prevention, and establish and maintain a bureau of speakers to talk knowledgeably with local groups about the topic.

• Spend more on teen pregnancy/STD prevention: To a greater degree, base the amount of public-sector money spent on teen pregnancy and STD prevention efforts on the public-sector costs of teen pregnancies and STDs. Our community should recognize the cost-effectiveness of good teen pregnancy-STD prevention programs, and expect the public sector, the private sector, and the not-for-profit sector to contribute more to the solution of this problem.

• Provide coordination for community teen pregnancy/STD prevention efforts: The community should recruit a professional to coordinate the various teen pregnancy/STD prevention efforts, to serve as a clearing house for information, to stimulate special efents, to help with program evaluation, and to assist in the drafting of grant applications. The position, filled at least half-time, should be initially funded for a minimum three year period.

• Strengthen parents' ability to communicate with their children of all ages about developmental issues, including responsible sexual behavior, and to articulate their own values. Although formal programs may assist in this process, the primary responsibility here lies with the parents.

• Expand existing highly effective programs that prevent teen pregnancy and STDs to provide a seamless "continuum of services": Charlottesville and Albemarle County have already begun to implement effective programs that reduce pregnancies and STDs, and should now establish a long-term goal of expanding these programs so that all eligible youth have access to them.

• Improve the implementation of Family Life Education in schools: Simply offering fact-based FLE, however controversial, is not enough to reduce pregnancy rates. But enhancing this education with skill-building activities (such as assertiveness and decision-making skills) in the context of providing basic factual and age-appropriate information has been shown to be effective in preventing pregnancies. This broadened approach, together with improved teacher training, should be the basis for FLE education in local schools.

• Expect health care providers to play a more active role in educating youth – and their parents – about reproductive health and pregnancy/STD prevention: Health care professionals should promote positive messages about sexual development throughout the lifespan of their patients. Age-appropriate sexual information should be part of normal anticipatory guidance in health care visits from birth through adolescence.

This strategic plan begins by observing that teen pregnancies, particularly those that result in teen parenthood, extract a high price – to the adolescents themselves, their babies, and society. So, too, do sexually transmitted diseases among adolescents have high costs. The document goes on to review strategies that have been demonstrated, through objective evaluations in other communities, to reduce the rates of teen pregnancies and STDs.

Further, this plan argues that we in Charlottesville and Albemarle County can – should -- strengthen efforts to deal with teen pregnancy and STDs, and that investing in these tested prevention programs can be cost effective.

But agreeing on a common vision – on this (or any) strategic plan – is not an easy first step. A review of the lessons learned from recent program evaluations around the country (Philliber and Namerow 1995, p. 3) points out that

Conversely, programs of demonstrated effectiveness have been rejected because small groups have opposed them on moral or religious grounds.

For any community to effect change, some degree of consensus is required about both the problems and their solutions (Kotloff et al., 1995, p. 6). We can probably reach consensus that adolescence is a time for education and growing up, not for pregnancy and childbearing (National Campaign to Prevent Teen Pregnancy, 1997a).

But it may be more difficult to find agreement in our community for this document’s definition of the problems and, even more formidable, to reach consensus in favor of the solutions proposed in this strategic plan. In the past few years this inability to find unanimity has derailed proposals for teen pregnancy programs here as elsewhere, a problem well summarized in the title of a thoughtful publication by the National Campaign to Prevent Teen Pregnancy (1998): "While the adults are arguing, the teens are getting pregnant."

One way through these differences is for all sides to embrace a new ethic of "unity of purpose, diversity of means" (National Campaign to Prevent Teen Pregnancy, 1997b, p. 14):

We will never reach 100% agreement on what to do about teen pregnancies and STDs, and we should not expect to. There will always be people who insist that community leaders are moving too fast or too slow, or that the proposed actions are counterproductive or even immoral.

But the lack of total concurrence must not be allowed to paralyze the community’s ability to take meaningful steps. In this regard Tillamook County, Oregon, provides an instructive model. The essence of their approach was to take action in an atmosphere of tolerance, with all sides "agreeing to disagree" ( National Campaign to Prevent Teen Pregnancy, 1997a, p. 2):

Those of us in Charlottesville and Albemarle County who are concerned about our teen pregnancy and STD rates may not aspire to a 70 % reduction in four years. But we can, working with planners and program developers, seek to avoid simplistic solutions, to implement programs with the greatest evidence for success, and give attention to the broad array of risk factors that reduce motivation to avoid pregnancy (e.g., poverty, lack of opportunity)(Kirby 1997). Even more important, we can agree not to fight each other’s efforts. In the public sector particularly, we can agree to include "opt out" mechanisms that allow teens (and their parents) to not be subjected to any programs they find objectionable on the basis of religion or conscience.

So, for a final recommendation:

This strategic plan represents a modest, mainstream approach to teen pregnancy and STD prevention. Surely a community with the wealth of resources that Charlottesville and Albemarle County enjoys can find the will to implement it.

Allen, J. P., J. Philliber, S. Herrling, and G. P. Kuperminc (1997). "Preventing

Aretakis, Dyan (1999). Director of the University of Virginia Teen Health Center,

Bachrach

Berne, Linda and B. Huberman (1999). European Approaches to Adolescent

Brick, Peggy (1999) "How does Europe do it?." In Family Life Matters (Rutgers

Burstein, Gale R. et al. (1998) "Testing for Chlamydia among adolescent girls."

Center for Health Statistics (1998). Virginia Health Statistics: Teenage

Centers for Disease Control and Prevention (1998). Youth Risk Behavior

Department of Education (1992). "The 1992 Virginia Youth Risk Survey,"

Donovan, J.E. and R. Jessor (1985). "Structure of problem behavior in

Frost, J. J and J. D. Forest (1995). "Understanding the impact of effective

Hayes, Cheryl D. , Ed. (1987) Risking the Future: Adolescent Sexuality,

Hoffman, Saul D. (1998). "Teenage childbearing is not so bad after all… Or is

Huberman, Barbara (1999) "Lessons Learned," Family Life Matters (Rutgers

University), No. 36 (Winter 1999)

Institute of Medicine (1995) The Best Intentions: Unintended Pregnancy and the

Jessor, R. and S. L. Jessor (1977). Problem Behavior and Psychosocial

Kars-Marshall, Cri and Jack Marshall (1992). Preliminary Figures on Teenage

Keyser, Sue (1998). "Teaching values in the public schools." In Piedmont

Kirby, Doug (1997). No Easy Answers: Research Findings on Programs to

Koo, H. P., G. H. Dunteman, C. George, Y. Green, and M. Vincent (1994).

Kotloff, L. J., P.A. Roaf, and M.A. Gambone (1995). The Plain Talk Planning

Maynard, R. A. (1996). "The costs of adolescent childbearing," In R. A. Maynard

McLeod, Susan (1998). Director of the Thomas Jefferson Health Department,

Miller, Brent C. (April 1998). "Family Matter: A Research Synthesis of Family

Moore, K. A., A. K. Driscoll and L. D. Lindberg (1998). A Statistical Portrait of

National Campaign to Prevent Teen Pregnancy (1997a). Snapshots from the Front

National Campaign to Prevent Teen Pregnancy (1997b). Whatever Happened to

National Campaign to Prevent Teen Pregnancy (1998). While the Adults are

Nonte, D. M. (1999) "Henley putting character on the curriculum". Daily

Progress, March 10, 1999, p. B1.

Oregon Action Agenda: Teen Pregnancy Prevention (1997). Department of

Human Resources and Oregon Health Division, Salem.

Philliber, Susan and Pearila Namerow (1995) "Trying to maximize the odds:

Rhode, D. L. (1993-94) "Adolescent pregnancy and public policy". Political

Roanoke [strategic plan]

Stepp, Laura Sessions (1999) "Beyond AIDS: Teenagers and STDs." The

Vincent, M., A. Clearie and M. Schluchter (1987). "Reducing adolescent

Virginia Department of Health (1998) Virginia Health Statistics: Teenage

Virginia Center for Health Statistics (1998). "1997 Preliminary Data Release,

Vobeja, Barbara (1998) "Sex among teens falls sharply." Washington Post News

Service, September 18, 1998.

Warren, C. W., J. S. Santelli, L. Kann, J. L. Collins, L. Morris and L. J. Kolbe

(Institutional affiliations are shown only to identify the individual members of the Strategic Planning Work Group; it is not meant to imply institutional endorsement of this document.) THIS LIST IS NOT READY FOR DISTRIBUTION

John F. (Jack) Marshall, Ph.D. (Chair) – Council on Adolescent Pregnancy

Prevention (CAPP)

Joseph Allen, Ph.D. – Department of Psychology, University of Virginia

Dyan Aretakis, FNP/MSN – Teen Health Center, University of Virginia

Cri Kars-Marshall, Ph.D. – Council on Adolescent Pregnancy (CAPP)

Steven Stern, Ph.D. – Department of Economics, University of Virginia

Mary Sullivan –

LARGE WORK GROUP

Debra Abbott – Educational Programs Director, MACAA; Director, Beating the

Saphira Baker – Executive Director, Commission on Children and the Family

Maureen Burkhill – Teensight at FOCUS

Betsy Collins – Martha Jefferson Hospital; Chair of CAPP

Bonnie Drumm

Kate Gaston

Tonya Grinde –

Allen Hughes – Comdial; United Way

Carol Grace Hurst – CYFS Runaway Program

Alicia Lugo – Teensight at FOCUS

Helen Marek – Albemarle County Dept. of Social Services

Diantha McKeel

Rhonda Miles

Ray Mishler – Martha Jefferson Hospital Melody

Jane Moore – United Way

Warrick Palmer – Coordinator, Young Guys of Distinction at MACAA

Kathy Parker

Sally Thomas – Albemarle County Board of Supervisors

Joanne Ring – Teen Health Center, University of Virginia

Cathy Train – United Way

Mick Watson

Roxanne White – Albemarle County Executive’s Office

Elizabeth K. Williams, M.D. – Pediatric Associates

Susan McLeod, M.D. – Thomas Jefferson Health Department

The strategic plan in this document has been produced in direct response to a consensus recommendation made at a May 30, 1997, town meeting on "Partners in Teen Pregnancy and STD Prevention." The public meeting, sponsored by a consortium of organizations, was convened to review the community's present approach to teen pregnancy prevention and to suggest the next steps for concerted effort. Participants urged that four topics be addressed immediately: parents' communication with their children about sexuality and other subjects (repeating the theme from the 1995 Roundtable Discussion); after-school activities for teens; expansion into more public schools of existing teen pregnancy prevention projects; and strategic planning. A working group was established to deal with each issue.

The Strategic Planning Work Group began meeting in the summer of 1997, and adopted a two-tier approach, a result of the difficulty finding more than a few volunteers who could spend much time on the plan. The initial research, the preliminary preparation of documents, and the rewriting of drafts was undertaken by the "small group". This group consisted of six community members who were in some way professionally involved with teen pregnancy/STD prevention and who were willing to devote considerable time to the exercise. The small group averaged about two meetings per month over the year, in addition to research and writing by individual members. The drafts were critically reviewed by the "big group", which represented a broader spectrum of the community including knowledgeable citizens who had less time to spend on the effort; this group met about seven times. The members of both groups are listed in Appendix A.

A Mission Statement was adopted by the Work Group early in the process to direct the community focus of the Strategic Plan:

To avoid reinventing the wheel, the small group initially sought to identify and build on ideas from other communities' strategic plans. Despite networking through national teen pregnancy organizations and working through the internet, few appropriate community-level strategic plans for teen pregnancy/STD prevention could be found. An early meeting of the Big Group, however, was devoted to discussion with the Teen Pregnancy Prevention Coordinator in Roanoke, who was instrumental in the development of her city's strategic plan. The group devoted a great deal of attention to reviewing the literature assessing the impact of programs tried elsewhere (see section I.C.).

In Charlottesville and Albemarle County surprising variation exists in the number of teens at each age. This occurs because 18 and 19 year olds move into the area to attend UVA and PVCC, swelling the census figures. Because many of the older teens are college students living away from home, and because many of the younger teens are physiologically and behaviorally distinct from older teens, it is often useful to examine teen pregnancy data in three are groups: 10-14, 15-17, and 18-19.

In Charlottesville and Albemarle County notable variation exists among the numbers of teens at 10-17 years of age and those at 18 and at 19 years. This occurs because 18- and 19–year-olds move into the area to attend the University of Virginia and Piedmont Virginia Community College, swelling the census figures. Because many of the older teens are college students living away from home, and because many of the younger teens are physiologically and behaviorally distinct from older teens, for many purposes it is useful to examine teen pregnancy data in three age groups: 10-14, 15-17, and 18-19.

For many purposes, even more important than the number of teen pregnancies is the rate of teen pregnancies. A pregnancy rate takes into account the size of a specific population which is "at risk" of pregnancy (e.g. all teen females from 10-19, or all Charlottesville teen females aged 15-19), and indicates how many pregnancies occur per thousand females. This allows direct comparisons among groups of females (e.g. American teens and French teens), or among the same group at different times (e.g. Charlottesville teens in 1990 and in 1997).

Number of pregnancies to teen females in a population teen

Number of teen females in the same population rate

For example, in 1990 for the entire state of Virginia, the pregnancy rate for teens aged 15-19 was 90.4.

No. of pregnancies to Va females aged 15-19 = 19,236

Number of Virginia females aged 15-19 = 212,892

Appendix E. Calculating teen pregnancy rates

This appendix lists alphabetically and briefly describes the local organizations and agencies involved in preventing teen pregnancy and/or treating sexually transmitted disease. Because programming changes over time to meet the perceived needs of the target populations, and because the number of teens seeking or willing to participate in services varies, the descriptions below are necessarily more general than specific at points.

700 Harris Street, Charlottesville, VA 22903

804-979-7714

The ASG provides condoms, dental dams, and lubricants as part of the safe sex kits distributed through their outreach programs. The ASG Education Department offers a peer education program called HIT SQUAD (HIV Intervention for Teens) that trains high school students to teach the facts about HIV/AIDS in any classroom, such as History or English. The ASG outreach workers are trained to work with all at-risk populations and use various educational models to encourage behavioral change, such as (1) multiple sessions that encompass information about STDs and sexual negotiation and communication skills; (2) one-on-one prevention case management in a series of meetings that focus on the individual’s behaviors and potential risk-reduction. Annually, ASG serves approximately 90 case clients and reaches approximately 12,000 people through education and outreach programs. These programs are funded by the Virginia Department of Health and fundraising efforts. Evaluation tools are designed by ASG staff with the support of the Virginia Commonwealth University Survey and Research Lab and the University of Virginia Evaluation Department.

509 Park Street, Charlottesville, VA 22902

804-977-4002

The Infant Development Project (part of the Growing Healthy Families Collaborative) provides home visits to infants (birth through three years) who are at risk of developmental disabilities. AS part of this services, ARC works with mothers to help create a stimulating environment for their children. The Project also counsels mothers of infants at risk of disabilities to postpone subsequent pregnancies. ARC does not keep statistics on teen mothers served. Serves the City of Charlottesville, as well as the counties of Albemarle, Green, Fluvanna, Louisa, and Nelson.

Smith Recreation Center, Cherry Avenue, Charlottesville VA 22902

804-977-2001 (Harold Young and Dave Hilyard)

The Boys and Girls Clubs offer recreational, instructional, and social activities for boys and girls aged 6-18. A series of programs begun in November of 1998 specifically address the risks of drug and alcohol abuse as well as teen pregnancy. Groups form 3-4 times per year with 12-15 participants each. Smart Moves, for 13-15 year olds, and Smart Start, for 10-12 year olds, run 1-2 hour weekly sessions for 13 weeks; Smart Kids, for 6-9 year olds, runs for 6 weeks; Smart Parents helps parents of 13-15 year olds recognize indicators of risky behavior. The programs are too new to have completed evaluation.

2101 Arlington Blvd., Charlottesville, VA 22903

804-977-1120

800-552-2208

Provides short- and long-term residential care for teens with psychiatric or substance abuse issues. Only local hospital that provides separate adolescent programming, specifically designed for 11-18 year olds. Number of teens served varies.

1138 Rose Hill Drive, Charlottesville, VA 22903

804-296-5525

Volunteer health professionals provide free primary, acute mental health and follow-up services to people without health insurance who do not qualify for free care at other sites.*

___ West Main Street, Charlottesville, VA 22903

804-979-8888

Counseling programs are available to provide women with information about pregnancy and pregnancy alternatives. Abortion is discouraged. The Center serves approximately 100 clients per month, seeing each client an average of three visits. Evaluation is informal. Funding is provided through local churches, small grants, and private donations. The Center’s educational component uses a program that combines methods and ideas from a number of national, abstinence-only education programs. It has been used only a few times in the local high schools and churches without evaluation.

116 West Jefferson Street, Charlottesville, VA 22902

804-296-4118

Promotes the healthy growth of children and the positive development of family relationships by providing a continuum of services from prevention to mediation. Services include individual and family counseling, parent education, respite care, and the Runaway Emergency Shelter program for all income levels in the locality.*

907 East Jefferson Street, Charlottesville, VA 22902

804-970-3577

All Community Attention programs counsel and/or educate teens on pregnancy issues in either individual or group formats. Community Attention works with other local agencies--such as the Teen Health Center, Teen Pregnancy Prevention, PAT, SARA, TEENSIGHT--to educate and advise clients on such issues. Provides a teen volunteer service program, Teens GIVE, that serves up 40 youths per day in spring, summer, and fall sessions. Similar programs have been shown effective in reducing teen pregnancy. Community Attention programs served approximately 420 teens in FY 1998.

Contact: Leslie Harris

804-980-3164

Biblically based project pairs young pregnant women (Marys) with supportive Christian women (Elizabeths) for 12-week sessions discussing prenatal, childbirth, and child-rearing issues. The Project is a pregnancy intervention program that seeks to enable adolescents to give birth to healthy babies through education and encouragement. The goal is to help each Mary realize her influences on her baby’s development, to help her gain confidence to make healthy decisions and choices. The Project seeks to collaborate with the adolescent community services and health care providers. Evaluation is informal. Serves approximately 8-24 young women each year, depending on enrollment. Sponsored and administered through the Virginia Council of Churches.

1508 Grady Avenue, Charlottesville, VA 22903

804-295-8336

Funding for the following three programs administered through FOCUS derives from a combination of local funds and outside grants.

1 Garnett Center Drive, Charlottesville, VA 22901

804-977-3425

Psychiatric day treatment center for youth offering counseling on an individual basis, in a group setting, and to families; also offering supplemental educational and emergency services.*

1025 Park Street, Charlottesville, VA 22902

804-295-3171

Funding for the following three programs administered through MACAA derives from a combination of local funds and outside grants.

1160 Pepsi Place, Suite 114-A, Charlottesville, VA 22901

804-973-3463

Non-profit charitable organization providing services, education, and research related to [preventing] birth defects.*

1928 Arlington Blvd., Suite 100, Charlottesville, VA 22903

804-296-2330

PPBR, a non-profit agency, offers confidential, respectful, and affordable reproductive health care on a sliding scale. Services include routine gynecological care; family planning and contraceptives; pregnancy testing and counseling; referrals for prenatal care, adoption and abortion services; STD/HIV testing and treatment; patient counseling and education to reduce risk behaviors. The Education Department provides professional training for family life education teachers, counselors, health care, and other professionals. Workshops on sexuality issues are also offered to teens, school or church groups, and parents. The Resource Center offers videos, books, and research packets on sexuality issues. PPBR also provides advocacy for reproductive rights. The PPBR clinic served approximately 33 teens under the age of 18 and 147 young women aged 18-19 in 1998. The PPBR education department served approximately 1,980 clients in 1998. Funding is secured through patient services, fundraising, private donations, and education fees.

300 West Main Street, 2^nd Floor, Charlottesville, VA 22902

804-972-1760

Project LINK serves women and children affected by chemical dependency. Through home visits, resource counselors provide information, referrals, transportation, and emotional support. Programs are tailored to meet each client’s needs. When enough teens are clients, support and educational groups are formed. Serves approximately 10-15 pregnant and parenting teens per year.

800 Preston Ave., Charlottesville, VA 22903

804-972-1800

Agency responsible for the provision of mental health, mental retardation, and substance abuse services in the community.*

804-977-4260

Provides shelter and informal educational material (video tapes, pamphlets, etc.) for teens in need. Number of teens served per year was not available.

P. O. Box 6705, Charlottesville, VA 22906

804-295-7273

SARA supports survivors of sexual assault and seeks to prevent harassment, assault, and incest. Services include individual counseling, sexual assault prevention programs for elementary schools through college, self-defense classes, outreach, legal advocacy, and a volunteer-staffed hotline. In addition, SARA has collaborated with the Shelter for Help in Emergency (SHE) to create a peer education group called Voices for Interpersonal Violence (VIVA). VIVA provides a teen-driven forum for awareness, discussion and education regarding sexual violence and harassment, and for encouraging healthy relationships. SARA served approximately 11,025 people through educational programming in fiscal year 1997-98. SARA served 357 primary victims, of which 41were under the age of 18, in fiscal year 1997-98.

1400 West Main Street, Charlottesville, VA 22903

804-982-0090

The Teen Health Center offers routine adolescent health care for teens aged 12-20, seeing approximately 300 patients per month. Services include routine checkups, acute medical problem care, routine gynecological care, immunizations, pregnancy testing and counseling, prenatal and postpartum care, family planning and contraceptives, STD/HIV testing and treatment, patient counseling and education to reduce risk behaviors. Community outreach offers group education for health care professionals, teens, school or church groups, and parents. The Center will begin training ten teens as peer health and wellness educators, including sexuality issues and pregnancy prevention.

1138 Rose Hill Drive, Charlottesville, VA 22093

804-9972-6237

The Health District offers basic health care services to the community. For adolescents, the Health District’s services include routine checkups, acute medical problem care, routine gynecological care, immunizations, pregnancy testing and counseling, prenatal and postpartum care, family planning and contraceptives, STD/HIV testing and treatment, patient counseling and education to reduce risk behaviors. Community outreach is also available. [No response to calls for further details].

Chapter V.B. describes our methods for calculating the economic benefits of the births averted by Camp Horizon. The method of calculating the benefits of the other community teen pregnancy prevention programs follows the approach used for Camp Horizon, though the assumptions about the number of births averted, and other components of the calculation, must be adjusted. In this appendix we describe those adjustments.

For Beating the Odds, we assume its effect will be the same as Camp Horizon. Beating the Odds is too new to evaluate in the same way as Camp Horizon, but the two programs are similar in both structure and management. The three necessary adjustments occur because the average Beating the Odds participant is 10 years old, and participants can participate for 3 years. Thus there are two more years to give birth (at very low rates) and cost savings must be discounted two extra years. After making the necessary adjustments, the conservative estimate of benefits is $85.9 thousand, and the more realistic estimate is $180.0 thousand. We assume that the proposed expansion of Beating the Odds will result in benefits proportional to its size. This leads to added estimated conservative benefits of $109.2 thousand and more realistic benefits of $240.6 thousand.

For Teensight, the calculations change because the birth rate for participants changes to 1.0% and the average age of participants is 16 with two years of participation. After making the necessary adjustments, the conservative estimate of benefits is $114.2 thousand, and the more realistic estimate is $220.8 thousand. We assume that the proposed expansion of Teensight will result in benefits proportional to its size. This leads to added estimated conservative benefits of $114.2 thousand and more realistic benefits of $220.8 thousand.

The Reach program is hard to evaluate; we assume it is an average of a Teensight program and a Teens Give program (described below). Presently, this program is too new to evaluate in the same way as Camp Horizon. So our assumption is really just a guess. However, because it has a significant volunteer component (like Teens Give) and also has features similar to Teensight and the same management as Teensight, our assumption seems reasonable. The average age of participants is 14 years with three years of participation. This implies a teen conservative birth rate of participants of (0.01 +.5 x 0.167)/2 = 0.0468 and a more realistic rate of (0.01+.5 x .335)/2 = 0.089. After making the necessary adjustments, the conservative estimate of benefits is $46.8 thousand, and the more realistic estimate is $95.8 thousand. We assume that the proposed expansion of Reach will result in benefits proportional to its size. This leads to added estimated conservative benefits of $33.4 thousand and more realistic benefits of $68.4 thousand.

The Young Guys of Distinction program is modeled like Reach, so we make similar assumptions. After making the necessary adjustments, the conservative estimate of benefits is $46.8 thousand, and the more realistic estimate is $95.8 thousand. We assume that the proposed expansion of The Young Guys of Distinction program will result in benefits proportional to its size. This leads to added estimated conservative benefits of $93.6 thousand and more realistic benefits of $191.6 thousand.

Teens Give is very much like the programs described in [the earlier section]. Though there have been no formal studies of its effect on teen pregnancy, in other ways (e.g., school performance, criminal recidivism) it has performed very well. We can therefore assume it is like one of the national volunteer-oriented programs and reduces teen pregnancy by 50%. The average age of participants is 15. This implies, conservatively, a teen birth rate for participants of 59.3 (per thousand) and a more realistic rate of 117.0 (per thousand). After making the necessary adjustments, the conservative estimate of benefits is $341.0 thousand, and the more realistic estimate is $648.4 thousand. We assume that the proposed expansion of Teens Give will result in benefits proportional to its size. This leads to added estimated conservative benefits of $115.6 thousand and more realistic benefits of $219.8 thousand.