Promoting Science-based Approaches to Prevent Teen Pregnancy, HIV and STDs: Creativity, Capacity, and Partnerships American Public Health Association Annual Meeting & Exposition Washington, D.C. November 3-7, 2007 Carla P. White Myriam Hernandez-Jennings Brigid Riley

Objectives Understand CDC’s definition of science-based approaches to teen pregnancy, STD and HIV prevention. Articulate the need to build capacity for science-based approaches promoting adolescent sexual and reproductive health. Identify opportunities to build partnerships and policy support at the state and community level to promote science-based approaches to preventing teen pregnancy, STDs, and HIV.

Teen birth rates, U.S., 1990-2004 As is well known, the U.S. has seen a substantial decline in teen birth rates over the past 15 years. In 2004, the overall teen birth rate was 41.1 live births per 1,000 women 15-19 years. Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2004. National vital statistics reports; vol 55 no 1. Hyattsville, MD: National Center for Health Statistics. 2006. http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_01.pdf

Birth Rates Among Females Aged 15--19 Years, by State — U.S., 2004 Of course vast disparities exist. By state and territory, Washington, DC had the highest rate at 66.7 in 2004 (Texas and Guam in second place each with a 62.6 teen birth rate), New Hampshire the lowest at 18.2. Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a6.htm

Birth Rates per 1,000 females age 15 – 19 years by Race and Hispanic Ethnicity, and males by race: U.S., 2004 Martin et al, 2006.

STDs among teens The chlamydia case rate per 100,000 population for females in 2005 was more than three times higher than for males (496.5 vs. 161.1). However, much of this difference reflects the fact that women are far more likely to be screened than men. Females aged 15 to 19 had the highest chlamydia rate (2,796.6), followed by females aged 20 to 24 (2,691.1). African-American women are also disproportionately affected by chlamydia. In 2005, the rate of reported chlamydia cases per 100,000 black females (1,729.0) was more than seven times that of white females (237.2) and more than twice that of Hispanic females (733.2). The rate among American Indian/Alaska Native women was the second highest, at 1,177.7 per 100,000 population, and the rate among Asian/Pacific Islander women was the lowest, at 222.3. CDC. Trends in Reportable Sexually Transmitted Diseases in the United States, 2005. http://www.cdc.gov/nchstp/dstd/Stats_Trends/Stats_and_Trends.htm

HIV/AIDS among teens Under 13 168 Age 13-14 43 Age 15-19 1,213 Estimated number of HIV/AIDS cases in the 33 states with confidential name-based HIV infection reporting, person’s age at time of diagnosis (2005): Under 13 168 Age 13-14 43 Age 15-19 1,213 Age 20-24 3,876 Age 25-29 4,581 CDC HIV/AIDS Statistics and Surveillance http://www.cdc.gov/hiv/topics/surveillance/basic.htm

What’s behind the downward trend? Santelli et al, 2007: 1995 and 2002 NSFG data on 15-19 year old women Overall: 14% of decline due to decrease in percentage of sexually active women age 15-19 years 86% due to increased contraceptive use 15-17 year olds: 23% of decline due to decline in percentage of sexually active young women 77% due to increased contraceptive use 18-19 year olds: All change due to increased contraceptive use Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. American Journal of Public Health 2007; 97(1):150-156.

CDC’s Promoting Science-based Approaches to Prevent Teen Pregnancy, STDs and HIV (PSBA) Using demographic, epidemiological and social science research to identify populations at risk of early pregnancy and/or sexually transmitted infections, and to identify the risk and protective factors for those populations. Using health behavior or health education theory for selecting risk and protective factors that will be addressed by the program, and guide the selection of intervention activities. Using a logic model to link risk and protective factors with program strategies and outcomes. Selecting, adapting if necessary, and implementing science-based programs. Conducting process and outcome evaluation of the implemented program, and modifying approach based on results.

Science-Based Program (SBP) Research has shown program to be effective in: Delaying sexual initiation Reducing the frequency of sexual intercourse Reducing the number of sexual partners Increasing the use of condoms and other contraceptives DRH does not directly identify effective interventions, nor recommend/promote particular programs. Instead, we have established criteria to determine the rigor of study design used to evaluate programs. Our national grantees have established lists of science-based programs and we steer project partners to these lists.

SBP: Evaluated using Rigorous Research Design Experimental/quasi-experimental evaluation design Knowledge, attitude, and behavior Adequate sample size Follow-up data Results published

How are programs identified in PSBA? National Campaign to Prevent Teen Pregnancy: What Works: Curriculum-Based Programs that Prevent Teen Pregnancy* Definition and programs from Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, D. Kirby 2001** 2007 update funded through PSBA The National Campaign uses Kirby’s definition of programs that work as it appears in Emerging Answers. Criteria are that research was done in the U.S. or Canada in 1980 or later; target populations were 12-18 year olds; there are follow up data; an impact on behavior was shown; at least 100 people in treatment and control groups; two or more evaluations completed; desired program outcomes reduced primary pregnancy, HIV or STD rates in teens. The Campaign relies on the authors, and do not do any of their own reviews in house. Kirby’s 2007 update of Emerging Answers will be out soon and is funded through PSBA. *http://www.teenpregnancy.org/works/default.asp **http://www.teenpregnancy.org/resources/data/report_summaries/emerging_answers/

How are programs identified in PSBA? Advocates for Youth: Science & Success Uses CDC definition of SBP, but specify change in > 2 behaviors 2003 = 16 sex ed and 3 youth development 2006 Supplement added 5 more programs, including 4 clinic-based Review of research done by Advocates staff Not funded through PSBA Advocates for Youth uses our definition, except they specify that a program must be shown to result in at least two sexual health-related behaviors. They first issues a list of programs that work in 2003 that identified 16 curriculum based and 3 youth development programs; their 2006 added 5 new programs, 4 of which are clinical. If they hear of a positive outcome of a particular program or if a program appears, e.g., on the Campaign’s list, they dig up the research and run it through Advocates’ review process. Staff with strong program and research backgrounds thoroughly review the research, assess whether the evaluations were done well, and hold the results up to the definition of a SBP. If they are unsure of anything, e.g., the quality of the evaluation, they farm further review out to other researchers. Science and Success is not funded through PSBA, but is critical to the project, as is the Campaign’s and other lists of effective programs.

1. Teenstar (school-based curriculum) 2006 added 1. Teenstar (school-based curriculum) 2. SiHLE 3. Tailoring Family Planning Services to the Special Needs of Adolescents 4. HIV Risk Reduction for African American and Latina Adolescent Women 5. Project SAFE—Sexual Awareness for Everyone SiHLE: STI & HIV Prevention for African American Teenage Women Advocates for Youth, 2003 http://www.advocatesforyouth.org/publications/ScienceSuccess.pdf

Promising Program Has not been formally evaluated Has most of the 17 Characteristics of Effective Sex and STD/HIV Education Programs (Kirby et al, 2006) http://www.etr.org/recapp/programs/SexHIVedProgs.pdf This list of characteristics was developed by conducting a systematic review of 83 domestic and international sexuality education and HIV prevention program evaluations. In their review, Kirby et.al., found that the majority of the effective programs incorporated most of the 17 common characteristics of successful curriculum-based programs identified in the analysis. The characteristics are divided into three categories: program development, program design/content and program implementation. This list of characteristics applies only to curriculum-based sexuality/HIV education programs. To date there is not a comparable list of characteristics for other types of programs, such as clinic-based, youth development, or parent education programs.

Many programs, many lists… Advocates for Youth Science & Success http://www.etr.org/recapp/programs/SexHIVedProgs.pdf National Campaign to Prevent Teen Pregnancy What Works http://www.teenpregnancy.org/works/default.asp and Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy http://www.teenpregnancy.org/resources/data/report_summaries/emerging_answers/ Program Archive on Sexuality, Health & Adolescence (PASHA) http://www.socio.com/pasha.htm DHAP/CDC’s Compendium of HIV Prevention Interventions with Evidence of Effectiveness http://www.cdc.gov/hiv/pubs/HIVcompendium/HIVcompendium.htm (Mention issue of different criteria  different lists of effective programs)

Gaps in Programs Identified Promising programs (Wise Guys, Plain Talk – publication in peer reviewed journal can be difficult) Youth development Clinical Secondary teen pregnancy prevention Replication in diverse populations/communities Race, ethnicity Rural vs. urban LGBTQ youth Youth in foster care

Dissemination: PSBA Cooperative Agreement Purpose Increase the capacity of state and local organizations to promote and use science-based approaches (SBA), including to select, implement and evaluate science-based programs (SBP)

PSBA Cooperative Agreement Three National Organizations: (National Campaign to Prevent TP, Advocates for Youth, Healthy Teen Network) Identify & promote use of SBA Develop capacity-bldg materials Training, tech assistance to state and local organizations Nine State Teen Pregnancy Coalitions (CO, HI, MA, MN, NC, OK, PA, SC, WA) Four Title X Regional Training Centers (MA-Reg. 1, PA-Reg. 3, IN-Reg. 5, WA-Reg. 10) Work with local (and state) organizations to: Increase awareness of SBA Build capacity to use SBA Plan, implement and evaluate science-based adolescent reproductive health programs, or adapt a promising program Youth-serving Local Organizations

Dissemination & Implementation Create more supportive environment for SBA Policy-makers, program decision makers, funders Increase capacity at Local Level to implement and sustain SBP Knowledge of SBA and SBP Behavioral and health education theory Risk and protective factor data Logic models Community fit Characteristics of effective programs Program evaluation Belief that SBA is important Confidence to use SBA Board / leadership support Financial resources We support two types of dissemination/implementation efforts: the first targets decision-makers, funders, etc. to increase their awareness of and create a more supportive environment for SBP. Activities include our national organizations issuing publications on prevalence and costs of teen pregnancy, offering less-intensive trainings on SBA, presenting at conferences to increase awareness/motivation, mailings, list serve, etc. There has been quite a bit of collaboration among our grantees as well as with external partners; increased awareness at these higher levels has in several cases resulted in change at the local level (such as the work you will be hearing about from Myriam and Brigid).

Dissemination & Implementation: Getting to Outcomes (PSBA-GTO) #1 Needs/ Resources #2 Goals #3 Best Practices #4 Fit #5 Capacities #6 Plan #7 Implementation Process Evaluation #8 Outcome #9 Improve / CQI #10 Sustain

Evaluation Desired outcomes Increased # of local orgs have implemented and can sustain science-based program Increased # of youth served by SBP, positive changes in sexual and reproductive health behaviors Model for lower cost capacity-building, dissemination, and implementation Initially no implementation funds provided for local organizations Year 3 some funds added for state coalitions, RTCs to provide incentives to locals to participate

Contact Carla White CarlaWhite@cdc.gov