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Adolescent pregnancy-prevention program
J O U R N A L OF A D O L E S C E N T H E A L T H CARE 1986;7:77-87
Adolescent Pregnancy-Prevention Program A Model for Research and Evaluation LAURIE S. ZABIN~ P h . D . I M A R I L Y N B. H I R S C H r P h . D . r E D W A R D A. SMITH~ D R . P . H . / ROSALIE STREETTI M . S . r A N D J A N E T B. HARDY~ M . D . C . M .
Despite the increased :interest in the effects of adolescent pregnancy-prevention programs, most interventions lack the research design and data essential for evaluation. This article describes a model in which evaluative research was incorporated in program design. The derivation of the model, the selection of measurable parameters, characteristics of the population reflected in baseline and subsequent data, and problems in quantifying and interpreting appropriate variables are discussed. Clinic data and aggregate data from three self-administered surveys is used. The surveys were completed by students in the inner-city junior and senior high schools that cooperated in the education and clinical program. We demonstrate how these two types of data augment one another in assessing program effects. The study explores the evaluation and the timing of change in sexual knowledge, attitudes, and behavior (coital, contraceptive, and clinic) and thus may contribute to the design of measurable, replicable interventions.
number of creative and thoughtful programs have been designed to meet the education and clinical needs of the young, it has been difficult to demonstrate the specific effects of most service initiatives because evaluation has not been included in the initial design. This article describes a pregnancy-prevention program designed to permit rigorous evaluation (1). Our experience of a year and a half does not permit a complete evaluation of the project but does allow us to examine the ability of certain variables to measure change, to report changes in some of the attitudes, knowledge, and behavior assessed by the survey instrument, and to explore the timing of change in fertility measures that do not lend themselves to short-term evaluation. In the current climate, with increasing interest in the assessment of programs, such a focus on the designation of measurable objectives and on evaluative design may be of value.
KEY WORDS:
Pregnancy Contraceptive clinics Evaluation (program evaluation) School programs Pregnancy prevention Although adolescent contraception and pregnancy have received much research attention and a large
From The Johns Hopkins University Schoolof Medicine, Department of Gynecologyand Obstetrics (L. S.Z., M.B.H., E.A.S.) and Department of Pediatrics (R. S., J.B.H.), Baltimore, Maryland. Address reprint requests to: Laurie S. Zabin, Ph.D., The Johns Hopkins School of Medicine, Hygiene 4605, 615 North Wolfe Street, Baltimore, MD 21205. Manuscript acceptedAugust 15, 1985.
Methods The M o d e l The program was designed by a service and research staff whose prior work suggested its format. The education and medical personnel's experience suggested the following: 1) Education and counseling should be offered in the same facility and at the same time as medical services. Frequently young adolescents appear not to value the education component sufficiently to return for education once their immediate medical needs are met. 2) All services must be correlated but may require different personnel. Although some sympathetic medical professionals build up warm relationships with the
© Society for Adolescent Medicine, 1986 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017
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ZABINET AL.
young people they serve, time pressures, the high cost of medical personnel, and the teenager's perception of these authority figures may not permit the free and lengthy interchange that trained educators or social workers can offer. 3) Teenagers appear to need the support of the s a m e professional over time. The consistency of a relationship builds trust, thus allowing the adolescent to synthesize what he/she has learned and return to share private concerns. Specific findings from our prior work appeared to be relevant to program design. 1) Adolescents experience a disproportionately high risk of pregnancy in the first months of their sexual exposure (2). Consequently, an educational program might best be located in a setting involving young people on a continuing basis, not merely in clinics they must seek out after becoming sexually active. 2) The risk of pregnancy is proportionately higher w h e n coitus is initiated in early adolescence; therefore both males and females need to be reached before or immediately after puberty, underscoring the importance of the junior high school setting. Even earlier access may be desirable in some social milieus. 3) Young people tend to delay their first visit to professional contraceptive facilities for a mean of > 16 months after first intercourse. The median prior sexual exposure is almost a year, with close to 36% of first visits occurring only w h e n a pregnancy is suspected (3). 4)Young people need confidential treatment and facilities in Close proximity to their usual haunts if service soon after first sexual exposure is to be rendered (4). This finding suggests the advantage of services close to, if not in, the program schools, with personnel known and available to the students in both the education and health care settings. The model suggested by the above findings was a program in close cooperation with the Baltimore, MD school system, including a junior and a senior high school. An education and clinic facility was opened exclusively for students of the two schools; the clinic was adjacent to one school and a few blocks from the other. The program placed a social worker and nurse practitioner or nurse midwife in each school to assist in classroom presentations, to counsel small groups or individuals in a school health suite, and to make appointments for further education, consultation, and/or treatment at the clinic. Services were directed to male and female students alike. Our model differs from the St. Paul school program (5) in that 1) contraceptives could be supplied by the same staff at the same location as other clinical services because all clinical services
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
were located outside the school; 2) the clinic itself was open only after school hours; 3) it was not a comprehensive health service facility. Furthermore, the populations differ because the St. Paul project served only senior high; the Baltimore program reached a more uniformly low socioeconomic level (especially in the junior high) than the St. Paul staff reported was generally served in that program, and the proportion of students sexually active appeared to be much higher in the Baltimore than in the Minnesota school populations (6). The major difference, however, is the research component. Because one objective of our program was to develop and evaluate a replicable model, the experimental design included, as a condition of service, the administration of a detailed questionnaire to all students. The aggregate data collected before the program and at the end of each program year provided the baseline and subsequent measures against which components of the program could be evaluated. The data also provided insights that were valuable in the design and upgrading of the services offered. The preprogram survey had an unplanned effect on the program as well: it acquainted the students early, in one sitting, with the broad range of sexual areas the staff was willing to discuss. Although not quantifiable, one effect of the initial questionnaire may have been that it legitimized potential subjects for discussion that might otherwise have remained taboo for a longer time.
The Sample The schools in which the program operated were selected because they were nearest Johns Hopkins Hospital. The senior high, a magnet school with some highly motivated y o u n g people interested in health careers, also functions as a community school; the junior high draws exclusively from the local area, a section of the city characterized by a high percentage of public housing and public support, and high rates of unemployment, female-headed households, and adolescent conception and childbearing. Both populations were all black. Data were collected from a self-administered questionnaire following notification of the parent(s). Participation was voluntary, anonymous, and confidential. Questionnaires were administered in the first period, monitored by the homeroom teacher and program staff. For slow learners in the seventh grade, a member of the research team read the questionnaire separately to boys and girls, while each student, privately, filled out the form. Survey instruments for the seventh and eighth grades were abbreviated. A few pages of
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ADOLESCENTPREGNANCYPREVENTIONPROGRAM
split-sample questions for 9-12 grade students (in less sensitive areas where smaller numbers were acceptable) increased the breadth of the data. Baseline data (Round I) were collected before the program began. Approximately 90% of the students were present in the senior high and over 80% in the junior high; there were 1709 questionnaires from students generally 12-18 years old (there were a few 112 and 19-year-olds). Round II was completed by 1296 students representing 71.5% of registered students, and Round III provided 1251 replies from 73.3%. The smaller percentages in Rounds II and III were due solely to dramatically l o w e r springtime attendance because in each round refusals and unusable forms totalled Only about 2"3%. The timetable of research and service was as follows: September 1981-Round I administered, grades 8-12; November !981-Round I administered, grade 7; November 1981-school program initiated; January 1982-clinic program initiated; May 1982-Round II administered, all grades; and May 1983-Round III administered all grades. Sexual knowledge variables assessed included pregnancy risk and contraception; attitudes included beliefs about teen childbearing and contraception. Among behaviors assessed were sexual onset, contraception, clinic attendance, and pregnancy. The interpretation of these variables, the time required for them to measure change, and their potential usefulness in the final evaluation will be discussed against the background of the baseline data.
protection. Use at last intercourse, a measure estimating regularity of use, was less frequent. In other studies we have reported approximately a 20-point differential between these two measures (3). The differential here was generally within that estimate. Method distribution at last coitus showed considerable improvement with age, with oral contraceptive use approximately twice as likely among senior as junior high girls (36.2% versus 18.4%). Condom use was lower among older students, with a slight increase in reliance on r h y t h m and withdrawal. Pregnancy rates, despite higher than expected levels of contraceptive use, were also high; over 6.5% of junior high (11%, ninth grade) and over 15% of senior high girls reported having had a pregnancy, translating into rates of 13.3 and 22.1% among those who were sexually active. Outcomes were differently distributed between the two Schools, with abortion the choice for over half the ever-pregnant senior high girls and for just over one-third of the junior high ninth grade girls, generally a less upwardly bound, academically motivated population. In the baseline survey a relatively high percentage of boys and girls reported that their parents wished them to complete school and avoid pregnancy (or impregnating a partner) while still in school. Most students were aware of several contraceptive methods, but tended not to consider them reliable. Positive attitudes were expressed toward contraception, and students usually assigned responsibility for its use to both the male and female. Only a minority were seriously misinformed about the various methods. Teenage parenthood was not perceived as a sinecure; 61% of the young w o m e n in the senior and over 74% in the junior high reported that their mothers had their first children during adolescence. Almost 42% of the senior high w o m e n had never discussed contraception with their mothers, a figure that dropped only slightly (39%) among the sexually active. The 58% of the semor high w o m e n who had not used professional birth control services included over 44% of the sexually active. Because many of the y o u n g people in our sample began having sex at extremely early ages, junior high students' attitudes and knowledge were of considerable interest. Although the proportions who had discussed sex with parent(s) were not very different from the senior high students, knowledge levels appeared to be significantly lower. Knowledge of the existence of specific contraceptive methods and information about these methods was less, and the youngest students were much less likely to be aware that services were available without parental in-
Results B a s e l i n e Data
Findings from the Round I showed that 48.9% of the junior high girls and 84.0% Of the boys had had coitus compared to 72.3% of the girls and 91.0% o f the boys in senior high. The mean ages were: 14.! and 14.4 years, respectively, in the junior and 16.3 and 16.4 years, respectively, in the senior high schools. Although more boys were sexually active at each grade level, the gap closed with increasing age. In the seventh grade, for example, the differential was 77.1% (male) to 45.8% (female), but in the twelfth grade the percentages were 90.9% to 81.4%. With over three-quarters of the males sexually active by seventh grade, there was limited opportunity for the program to delay the mean age of first coitus. "Ever-use" of contraception was extremely high in Round I; approximately 90% of senior high sexually active males and females had used some form of
79
80
ZABINET AL.
volvement. These students were less likely to have been to a contraceptive clinic (82% had never attended, including 67% of the sexually active) and less likely ever to have u s e d any form of contraception. The early months of the program tended to confirm our baseline findings and prior experience and to suggest that younger students need considerable encouragement in addition t ° classroom education if they are to make individual contact with program staff in the school and the clinic. Small group sessions were used in both settings, for boys and girls alike. Initiatives directed at male students were focused on Seventh and eighth graders because coitus was already the norm .among the youngest boys. Both sexes appeared to be comfortable with a female counselor. At these young ages, their need for information, their anxiety about sexual development, and their confusion with partia ! and misinformation was freely acknowledged. The findings reported below suggest the degree to which these needs were met.
Clinic Use In the first five and a half months the clinic was open, 55 young w o m e n from the junior high and 139 from the senior high registered for service. Many more students came for education, films, discussions, and rap sesSions, but only the actual registrants are reported here. Fifty-one boys from the junior high registered, approximately equal to the number of girls, whereas only seven senior high males registered. During the second year, w h e n the clinic was open for the entire year rather than one term, 44 more junior and 187 senior high females registered, a n d 47 junior and 25 senior males registered. (The junior high school experienced a decline in enrollment in that year.) Data from Rounds II and III make it possible to estimate the percentage Of sexually active young women who were served in each period (Figure 1). It appears that approximately 23.1% of the sexually active junior high and 27.2% of the sexually active senior high girls were reached during the first five months, a rate that was generally maintained during the second year. By the end of the second year, 40.8% of sexually active junior high and 57.6% of sexually active senior high w o m e n had registered. It would be expected that a smaller percentage of the sexually active females in junior high would attend because at younger ages Smaller proportions of those who "ever" experienced coitus are likely to be sexually active at any given time. The sporadic nature of sexual exposure in early adolescence results in peri-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
ods of abstinence w h e n attendance at the clinic would be less likely.
Aggregate Data On Knowledge, Attitudes, and Behaviors Among all respondents, knowledge of contraception and pregnancy risk appears to have improved by 11.3 to 13.2% by Round II and little more, if at all, by Round III. The questions included in the knowledge scores were detailed questions about the use of various contraceptive methods and about the risk of pregnancy associated with a single exposure and with puberty. The increases in knowledge in important areas between Rounds I and II may only represent differences between the Fall and Spring because respondents might be expected to show some improvement in knowledge in seven months with or without a program. Because knowledge was higher than expected at the outset, the gains, though small, represent approximately 30% of the gap between Round I and a perfect score. Although the differences between those who attended lectures and those who did not were not large, there appears to have been a smaller increase in knowledge a m o n g the few not exposed to classroom discussions. Recognition of methods of contraception by name also increased, but once again, because recognition was high in the beginning there was little room for change. Knowledge Of the fertile time of the month is frequently used to determine students' levels of sexual knowledge; it is a Complex variable that Can easily be misinterpreted. Table 1 shows changes that suggest that young w o m e n will be less frequently "at risk" after exposure to the program than before; among junior high girls, 37.7% chose either midmonth or any time of the month (both of which tend to discourage inappropriate use of the r h y t h m method) compared to 21.5% chosing one or another of these responses in Round I. For all groups the differences between Rounds I and II were in the same direction, and for some groups the improvement continued in Round III. There was no consistent improvement in knowledge if responses were scored simply as correct (midmonth) or incorrect. However, we believe the first method of interpreting an adolescent's understanding of the time-of-the-month variable is more appropriate because the so-called correct response may be a poor measure of a program's ability to convey the message that best promotes responsible sexual behavior. Most programs discourage the rhythm method and emphasize the pregnancy risk
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ADOLESCENT PREGNANCY PREVENTION P R O G R A M
81
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Figure 1. CumuIative percent of sexually active students becoming regis-
trants at the program clinic, by school, sex, and month of program duration. Symbols: . . . . . . , male, senior high; , male, junior high; - - - --, female, senior high; . . . . . , female, junior h!gh. Note: The drop between months six and seven reflects loss of students graduating from the ninth or twelfth grades in June. (No twelfth grade males registered, So there was no drop in curve.) Numbers differ in Years 1 and 2 as follows:
inherent in all coital exposure; therefore, it is not surprising that m a n y studies have shown a poor response to this question. Teen parenthood, seen from the outset as a problem by a large majority of all groups, was seen as problematic by more young w o m e n at each survey, with particula r change noted among the junior high School ninth graders. This finding was not true for senior high boys, who were less likely to have had contact with the clinic and/or taken part in group discussions. More closely related to behavior were students' attitudes toward Contraception. Although few students thought responsibility for contraception belonged to neither the boy nor the girl, there
Senior
Year I Year II
(n) (n)
Junior
Males
Females
Males
Females
285 280
507 517
393 337
239 213
was some change in the allocation of responsibility for its use (Table 2). Between Rounds I and II all four groups showed increases in the percentage who believed both partners are responsible. The increases were largest for junior high school males and females. For all groups except the senior high boys, the proportion continued to rise in Round III. Although the percentage who believed responsibility belongs only to the boy is very different between subgroups, it decreased in all cases between subsequent rounds. Because sexual activity "ever," is a cumulative measure, it necessarily increased between Rounds I and II; a comparison of Rounds II and III is more appropriate because the young people at these sur-
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ZABIN ET AL.
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2
T a b l e 1. Distribution of S t u d e n t ' s R e s p o n s e s to Q u e s t i o n I d e n t i f y i n g Fertile Time of the M o n t h b y Sex a n d School: R o u n d I Versus R o u n d s II a n d III Senior high school ROUND I (n = 252) FEMALES Right before, during, or right after period About two weeks after period begins
Anytime Don't know
37.6
R O U N DIII (n = 221)
49.3
3 2 " 1 { 11"121.038'6{ 2153 3.341"1{ 30.2 ROUND I (n = 119)
MALES Right before, during, or right after period About two weeks after period begins Anytime Don't know
ROUND II (n = 215)
Junior high school ROUND II (n = 236)
R O U N DIII (n = 212)
46.6
40.6
38.9
38.1
217"6 3.521"5{
17.2 4.337'7{
212'3 5.437"3{
23.1 14'2
12.1 ROUND II (n = 89)
12.2 R O U N DIII (n = 84)
37.9 R O U N DI (n = 286)
23.3 ROUND II (n = 221)
24.5 R O U N DIll (n = 194)
58.4
60.8
36.0
35.8
35.6
51.3 { 20.1
R O U N DI (n = 293)
{ 6.7 13.4 28.6
24.7
13.5 11.2
2 0 . 2 [ 11.98"3 19.0
16.9
veys were similar in age (Table 3). Differences in Spring of the first and second years are very small, with sexual activity insignificantly down among senior high males and females and insignificantly up among junior high students. The program did not appear significantly to affect the initiation of coitus in its first year and a half of operation, which is not surPrising in view of the high rates of early sexual activity reported in the baseline data. Contraceptive use showed gains (Table 4), with the most dramatic increases coming between
29.0{11.517.5 35.0
30.3{ 21.78"6 33.9
34.1{11.922.2 30.4
Rounds I and II. Use at last intercourse was apparently up 7.7% and 18.3% for young w o m e n and 13.5% and 15.3% for young men in the senior and junior high schools, respectively, between the first two rounds. These figures suggest that there was some change in the early months of the program and that the importance of our contraceptive intervention may have been greater in the junior high than in the senior high. Why a similar level of improvement could not be repeated in the second year is not yet clear. The same pattern is shown in Table
T a b l e 2. A t t i t u d e s of S t u d e n t s T o w a r d C o n t r a c e p t i v e Responsibility b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III Percent who believe it is the responsibility of
FEMALES Girl Boy Both Neither Total MALES Girl Boy Both Neither Total
Senior high school
Junior high school
ROUND I (n = 654) 10.1 0.9 88.8 0.2 100.0
R O U N DII (n = 493) 5.5 0.6 93.5 0.4 100.0
R O U N DIII (n = 517) 4.4 0.2 95.4 0.0 100.0
ROUNDI (n = 361) 21.3 7.8 67.6 3.3 100.0
R O U N DII (n = 301) 11.3 3.7 84.1 1.0 100.1
R O U N DIII (n = 256) 9.8 2.7 85.5 2.0 100.0
ROUND I (n = 290) 10.3 5.2 84.5
R O U N DII (n = 213) 5.2 1.9 92.5 0.5 100.1
R O U N DIII (n = 217) 9.7 1.8 87.6 0.9 100.0
ROUNDI (n = 338) 13.0 26.6 58.0 2.4 100.0
R O U N DII (n = 271) 7.0 14.0 78.2 0.7 99.9
R O U N DIII (n = 237) 8.4 9.7 78.9 3.0 100.0
-
-
100.0
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ADOLESCENT PREGNANCY PREVENTION PROGRAM
Table ~. gtudents Who Have Ever Had Intercourse, by School: Round I versus Rounds II and IIIa Junior high school
Senior high school
Females Percent n Males Percent n
Round I
Round II
Round III
Round I
Round II
Round III
72.3 643
78.2 486
76.7 507
48.9 360
56.7 298
60.1 248
91.0 289 -
95.3 211
92.3 209
84.0 344
88.6 272
89.7 233
aFor this and other cumulative measures, Rounds II and III are expected to be higher than Round I because students were approximately eight m o n t h s older at the time of the Spring survey.
5, which summarizes a few important categories of use. The decline in no protection at last intercourse and the sharp increase in the use of medical methods is again marked between Rounds I and II. Although the level of improvement is not continued between Rounds II and III, and is in fact reversed in some cases, the overall differences between the baseline data and the end of the second year are significant. There was an increase of almost 61% in the use of medical methods among junior high girls and an increase of over 34% in the use of medical methods by more than half of our sexually active young w o m e n in the senior high. The aggregate data will permit future exploration of a "substitution" effect: Did the respondents substitute the program clinic for other services? To what extent were these services used where other services might not have been? There was considerable oral
contraceptive use among those w h o did not use this service, suggesting use of other facilities, but the differences between attenders of the program clinic and nonattenders were in the expected direction in all groups: more attenders used the pill at last intercourse than nonattenders. Thus, the program clinic appears to account for much of the difference in use between Round I and subsequent rounds (Table 5). The interval between first intercourse and first clinic visit is of paramount importance in reducing pregnancy and may provide evidence of change long before the pregnancy rate would reflect a program effect. The mean and median intervals (lines a and c, Table 6) generally decreased between Rounds I and II for senior high girls (11.6% and 9.6%, respectively). For junior high girls the numbers were more dramatic (67.7% and 77.5%, respectively). The junior high numbers are small because only ninth graders were
Table 4. S e x u a l l y A c t i v e S t u d e n t s U s i n g C o n t r a c e p t i o n E v e r a n d A t L a s t C o i t u s , b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III Senior high school
Females Ever used contraception Percent n Used contraception at last intercourse Percent n Males Ever used contraception Percent n Used contraception at last intercourse Percent n
Junior high school
Round I
Round II
Round III
Round I
Round II
Round III
89.6 461
94.1 374
94.8 389
72.7 172
69.4 160
75.9 141
73.4 458
79.1 369
81.9 381
60.7 163
71.8 149
66.4 137
89.2 259
89.2 194
92.4 184
71.3 268
73.9 222
78.1 192
62.9 256
71.4 189
67.8 180
56.1 244
64.7 215
62.4 186
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T a b l e 5. C h a n g e s in M e t h o d of C o n t r a c e p t i o n U s e d at L a s t I n t e r c o u r s e , b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III~ Method used at last intercourse
FEMALES Using nothing (%) Using medical (diaphragm, pill, IUD alone or combination with anything) (%) Using condom alone or in combination (%)
MALES Using nothing (%) Using medical (%) Using condom (%)
Senior high school
Junior high school
ROUND I (n = 458) 26.6
ROUNDII (n = 369) 20.9
ROUND III (n = 381) 18.1
PERCENT C H A N G E ROUNDI I-III (n = 163) -32.0 39.3
39.5
42.8
53.0
+34.2
23.1
30.9
28.6
+23.8
ROUND I (n = 256) 37.1 23.4 33.2
ROUNDII (n = 189) 28.6 37.0 36.5
ROUND III (n = 180) 32.2 32.8 35.0
ROUND II (n = 149) 28.2
ROUND III (n = 137) 33.6
PERCENT CHANGE I-III --14.5
22.7
35.6
36.5
+60.8
28.2
33.6
28.5
+1.1
ROUND II (n = 215) 35.3 26.5 42.3
ROUND III (n = 186) 37.6 25.3 34.4
PERCENT CHANGE I-III -14.4 +16.6 +4.0
PERCENT C H A N G E ROUNDI I-III (n = 243) -13.2 43.9 +40.2 21.7 +5.4 32.8
aAlone or in combination; respondent may appear in two categories if both methods were used at last intercourse (combinations of methods including pill or condom were used by approximately 8% of respondents).
T a b l e 6. M e a n a n d M e d i a n N u m b e r of M o n t h s A m o n g F e m a l e s f r o m First I n t e r c o u r s e to First C o n t r a c e p t i v e Clinic Visit a n d P e r c e n t W h o E v e r M a d e a Clinic Visit, b y School: R o u n d I v e r s u s R o u n d s II a n d III Senior high school
a. Mean interval Months n b. Mean interval ind. precoital = 0 b Months n c. Median interval Months n d. Median interval, incl. precoital = 0 b Months n e. All ever to clinic or doctor Percent n f. Sexually active ever to clinic or doctor Percent n g. To clinic precoitus Percent n
Junior high school
Round I
Round II
Round III
Round I
Round II
15.5 174
13.7 153
13.7 179
26.0 9
8.4 10
13.4 a 15
11.9 226
11.2 188
10.6 232
18.0 13
7.0 12
9.1 a 22
12.5 174
11.3 153
10.8 179
20.0 9
4.5 10
8.0 a 15
5.8 226
8.5 188
7.5 232
17.0 13
3.2 12
4.8 a 22
41.5 650
54.0 487
54.7 514
18.0 472
31.7 385
55.6 464 27.8 241
66.2 376 24.3 202
69.4 386 26.0 242
32.9 225 40.0 15
48.8 213 28.6 14
Round III
34.2 330 51.0 198 40.0a 25
aBased on ninth grade only; seventh and eighth grades not asked date of clinic visit. bAll respondents with precoital first clinic/doctor visits are included in estimate if they received a contraceptive at that visit; to calculate mean, interval is made equal to zero.
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asked for the dates; therefore, it is only the size of the differences and their consistency that tend to lend them credibility. Second-year decreases among the older girls were small. Among the younger girls, although a large share of the reduction was maintained, there were small increases. The percentages of all (line e) and of sexually active (line f) ever having attended a contraceptive clinic went up in each interval, with overall increases of 90% and 55% for the two parameters, respectively, among junior high girls (including seventh and eighth graders). Increases among older girls were larger in Year I than Year 2 and were not as large as among the younger students. It appears from line g that the program was not able to affect the proportion w h o attended the program precoitus; perhaps w h e n so large a proportion of the population is already sexually active it is not possible to affect this behavior. Lines b and d show the effect of including the young w o m e n w h o had attended precoitus in an estimate of the interval to clinic attendance (',making the interval equal 0 for those w h o attended and received a birth control method before initiating intercourse); this reduces the interval but does not significantly change the relationships. Unfortunately, the most important variables in the evaluation of a pregnancy-prevention program are the most difficult to assess and compare as well as taking the longest to affect, i.e., pregnancy rates, fertility, and/or abortion. These parameters are problematic for many reasons: 1)The appropriate comparisons involve rates based on 12-month estimates, which may be difficult to establish. 2) "Ever pregnant" proportions are cumulative, i.e., the Spring survey of the first program year should report higher proportions than the Fall baseline data
because it is eight months later. Even the 12-month rates for this parameter should be high because the girls are a little older. 3) Miscarriages may not be identified by young adolescents, or may be more readily identified w h e n their awareness of pregnancy risks is heightened. In the present data, large increases in this outcome between rounds represent variations that are not credible if interpreted in any other way. 4) The statement that one is "pregnant now" may be a guess. For example, in other data we found that fewer than 15% of female students w h o had "thought they were pregnant" in the past year actually were (not published). Because we have no way of knowing w h o had actually established a current pregnancy, estimates of "pregnant n o w " may be inflated. 5) Pregnancy, especially childbirth, affects school attendance; therefore, we must be cautious in claiming to capture a true pregnancy rate even when large proportions of the students respond to the appropriate questions. A disproportionate number of recently pregnant girls may be absent. 6) It takes time to affect a rate. If the two 12month periods reflected in a rate are not to overlap, it would take approximately 15 months to affect an abortion or miscarriage rate and 21 months to change a birth rate. Table 7 reports changes in the two outcomes for which greatest accuracy can be expected, baby and abortion, for the 12 months prior to each round. Changes between Rounds II and III are the only changes that could be attributable to the program. Even in Round IIIa large percentage of last-12-month births were conceived before the clinic opened, not only because over one-third of the applicable period of conception predated the January 1982 clinic opening, but also because those with outcomes late in the
85
Table 7. Sexually Active Females Reporting Pregnancies in Last 12 Months by Outcome, School, and Percent Change: Rounds II and III Senior high school
Baby or abortion Percent n Baby Percent n Abortion Percent n aNinth grade only.
Junior high school
Round II
Round III
Change
Round II
Round III
Change
8.7 368
7.0 369
-19.5
6.5 46
6.5 45
0.0
2.9 373
3.2 375
+10.3
4.3 47
4.3 46
0.0
5.7 369
3.8 372
-33.3
2.2 46
2.1 47
-4.5
86
ZABINET AL.
period were less likely to be back in school at the time of the survey. Thus, these numbers are not evaluative; rather they are included to suggest h o w long it takes to carry out a true evaluation of program effects on pregnancy, even when use of contraception improves. Although only preliminary, our results suggest that whereas births may require 21 months to reflect real change, abortions may begin to drop earlier. This fact underlines the long time lags and breadth of information that are necessary before contraceptive effects can be identified and a reported fertility outcome can accurately be attributed to a specific pregnancy-prevention program.
Discussion The findings reported here do not constitute an "evaluation;" they may, however, give some insight into the ability of selected variables to detect change. Some changes, especially in the softer variables, may be fortuitous because two points in time after the program's onset do not establish a trend. Problems encountered in evaluating school-based programs are clear: different attendance in Fall and Spring compromises random selection, and different ages in Fall and Spring underscore the need for control populations or baseline data collected at the same time of year as follow-up. On some critical variables, considerable time is needed to assess substantive change. It appears however that there is a suggestion of change and that many parameters designated at the outset as quantifiable and measureable will ultimately serve as useful evaluative tools. For example, the interval between first coitus and clinic attendance is amenable to rapid change even if pregnancy as a program effect cannot be assessed for several years. Aggregate school data appears to be useful in the evaluation process. Preliminary results seem to confirm those studies showing that education programs are related to changes in knowledge, whereas clinic programs are necessary to change practice (7). Although there are some differences in contraceptive use overall, the greatest drops in nonuse appear to be related to whether or not the student attended the clinic; a longer period and more detailed analysis will be necessary to detect contraceptive effects of the education component per se. Changes in individual variables may help in the interpretation of the variables themselves. One example is the change in knowledge of the fertile period. Whereas accurate designation of midmonth risk did not improve, there appeared to be a change to-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
ward better understanding of the risk of intercourse overall. This may be a better educational objective. An emphasis on midmonth safety may promote the misapprehension that there is a consistently safe period for every young woman, a particularly dangerous concept among postpubertal young w o m e n whose cycles are often irregular. Future analysis will use detailed data--staff logs, sexual histories, cohort comparisons with nonprogram schools--for a more rigorous evaluation and an assessment of cost-effectiveness. Even data from other parts of the school community are relevant. For example, there is evidence of a drop in transfers from the junior high to a school maintained for pregnant adolescents between Rounds II and III; this could suggest a real decline in pregnancy if the drop-out rate due to pregnancy did not increase. An in-school study alone cannot collect this information; some outside data is required. One might ask: Is it necessary, then, to await a formal, scientific evaluation, with control populations, before a model such as this can offer positive information to the field? Our data suggest that when there is room for substantive change the early findings may be of value. For example, our data suggest that the effects of the program are more dramatic among junior than senior high students. Not only were the males much more involved in the program, but the behavior of males and females alike, their attitudes toward contraceptive responsibility, and in some cases their knowledge, appeared to show greater change. Shorter intervals to clinic attendance and increased percentages attending clinics were more marked among the younger students. Clearly, the potential for change is greatest w h e n sexual exposure is relatively brief and/or clinic attendance and contraceptive use is low prior to program intervention. In such cases, early findings may assist in program design. Thus, the extremely early sexual involvement reported by y o u n g boys, their extraordinary interest in the program, and the changes it appeared to bring about among them suggest that programs are needed to reach this age level. Future projects must find out h o w much earlier y o u n g people might profitably be reached with similar education initiatives because our baseline data suggest that junior high may be too late to affect sexual onset for about half of these boys and girls, or, indeed, to reach the sexually active among them in their highrisk early period of exposure. This research was supported primarily by grants from the Ford, W. T. Grant, and Hewlett Foundations.
MARCH 1986
References 1. Zabin LS, Hardy JB, Streett R, et al. A school, hospital and University-based adolescent pregnancy prevention program. J Reprod Med 1984;29:421-6. 2. Zabin LS, Kantner JF, Zelnik M. The risk of adolescent pregnancy in the first months of intercourse. Faro Plann Perspect 1981;11:215-22. 3. Zabin LS, Clark SD. Why they wait: A study of teenage family planning clinic patients. Fam Plann Perspect 1981;13:205-21. 4. Zabin LS, Clark SD. Institutional factors affecting adolescents'
ADOLESCENT PREGNANCY PREVENTION PROGRAM
87
choice of contraceptive clinics. Fam Plann Perspect 1983; 15:2529. 5. Edwards LE, Steinman ME, Arnold KA et al. Adolescent pregnancy prevention services in high school clinics. Fam Plann Perspect 1980;12:6-14. 6. Edwards LS, and other clinic staff. St. Paul project: Personal communication, 1984. 7. Kirby D, Alter J, Scales P. Analysis of U.S. sex education programs and evaluation methods. Report No CDC-2021-79-DKFR, U.S. Department of Health, Education and Welfare, June 1979.
Adolescent Pregnancy-Prevention Program A Model for Research and Evaluation LAURIE S. ZABIN~ P h . D . I M A R I L Y N B. H I R S C H r P h . D . r E D W A R D A. SMITH~ D R . P . H . / ROSALIE STREETTI M . S . r A N D J A N E T B. HARDY~ M . D . C . M .
Despite the increased :interest in the effects of adolescent pregnancy-prevention programs, most interventions lack the research design and data essential for evaluation. This article describes a model in which evaluative research was incorporated in program design. The derivation of the model, the selection of measurable parameters, characteristics of the population reflected in baseline and subsequent data, and problems in quantifying and interpreting appropriate variables are discussed. Clinic data and aggregate data from three self-administered surveys is used. The surveys were completed by students in the inner-city junior and senior high schools that cooperated in the education and clinical program. We demonstrate how these two types of data augment one another in assessing program effects. The study explores the evaluation and the timing of change in sexual knowledge, attitudes, and behavior (coital, contraceptive, and clinic) and thus may contribute to the design of measurable, replicable interventions.
number of creative and thoughtful programs have been designed to meet the education and clinical needs of the young, it has been difficult to demonstrate the specific effects of most service initiatives because evaluation has not been included in the initial design. This article describes a pregnancy-prevention program designed to permit rigorous evaluation (1). Our experience of a year and a half does not permit a complete evaluation of the project but does allow us to examine the ability of certain variables to measure change, to report changes in some of the attitudes, knowledge, and behavior assessed by the survey instrument, and to explore the timing of change in fertility measures that do not lend themselves to short-term evaluation. In the current climate, with increasing interest in the assessment of programs, such a focus on the designation of measurable objectives and on evaluative design may be of value.
KEY WORDS:
Pregnancy Contraceptive clinics Evaluation (program evaluation) School programs Pregnancy prevention Although adolescent contraception and pregnancy have received much research attention and a large
From The Johns Hopkins University Schoolof Medicine, Department of Gynecologyand Obstetrics (L. S.Z., M.B.H., E.A.S.) and Department of Pediatrics (R. S., J.B.H.), Baltimore, Maryland. Address reprint requests to: Laurie S. Zabin, Ph.D., The Johns Hopkins School of Medicine, Hygiene 4605, 615 North Wolfe Street, Baltimore, MD 21205. Manuscript acceptedAugust 15, 1985.
Methods The M o d e l The program was designed by a service and research staff whose prior work suggested its format. The education and medical personnel's experience suggested the following: 1) Education and counseling should be offered in the same facility and at the same time as medical services. Frequently young adolescents appear not to value the education component sufficiently to return for education once their immediate medical needs are met. 2) All services must be correlated but may require different personnel. Although some sympathetic medical professionals build up warm relationships with the
© Society for Adolescent Medicine, 1986 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017
77 0197-0070/86/$3.50
78
ZABINET AL.
young people they serve, time pressures, the high cost of medical personnel, and the teenager's perception of these authority figures may not permit the free and lengthy interchange that trained educators or social workers can offer. 3) Teenagers appear to need the support of the s a m e professional over time. The consistency of a relationship builds trust, thus allowing the adolescent to synthesize what he/she has learned and return to share private concerns. Specific findings from our prior work appeared to be relevant to program design. 1) Adolescents experience a disproportionately high risk of pregnancy in the first months of their sexual exposure (2). Consequently, an educational program might best be located in a setting involving young people on a continuing basis, not merely in clinics they must seek out after becoming sexually active. 2) The risk of pregnancy is proportionately higher w h e n coitus is initiated in early adolescence; therefore both males and females need to be reached before or immediately after puberty, underscoring the importance of the junior high school setting. Even earlier access may be desirable in some social milieus. 3) Young people tend to delay their first visit to professional contraceptive facilities for a mean of > 16 months after first intercourse. The median prior sexual exposure is almost a year, with close to 36% of first visits occurring only w h e n a pregnancy is suspected (3). 4)Young people need confidential treatment and facilities in Close proximity to their usual haunts if service soon after first sexual exposure is to be rendered (4). This finding suggests the advantage of services close to, if not in, the program schools, with personnel known and available to the students in both the education and health care settings. The model suggested by the above findings was a program in close cooperation with the Baltimore, MD school system, including a junior and a senior high school. An education and clinic facility was opened exclusively for students of the two schools; the clinic was adjacent to one school and a few blocks from the other. The program placed a social worker and nurse practitioner or nurse midwife in each school to assist in classroom presentations, to counsel small groups or individuals in a school health suite, and to make appointments for further education, consultation, and/or treatment at the clinic. Services were directed to male and female students alike. Our model differs from the St. Paul school program (5) in that 1) contraceptives could be supplied by the same staff at the same location as other clinical services because all clinical services
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
were located outside the school; 2) the clinic itself was open only after school hours; 3) it was not a comprehensive health service facility. Furthermore, the populations differ because the St. Paul project served only senior high; the Baltimore program reached a more uniformly low socioeconomic level (especially in the junior high) than the St. Paul staff reported was generally served in that program, and the proportion of students sexually active appeared to be much higher in the Baltimore than in the Minnesota school populations (6). The major difference, however, is the research component. Because one objective of our program was to develop and evaluate a replicable model, the experimental design included, as a condition of service, the administration of a detailed questionnaire to all students. The aggregate data collected before the program and at the end of each program year provided the baseline and subsequent measures against which components of the program could be evaluated. The data also provided insights that were valuable in the design and upgrading of the services offered. The preprogram survey had an unplanned effect on the program as well: it acquainted the students early, in one sitting, with the broad range of sexual areas the staff was willing to discuss. Although not quantifiable, one effect of the initial questionnaire may have been that it legitimized potential subjects for discussion that might otherwise have remained taboo for a longer time.
The Sample The schools in which the program operated were selected because they were nearest Johns Hopkins Hospital. The senior high, a magnet school with some highly motivated y o u n g people interested in health careers, also functions as a community school; the junior high draws exclusively from the local area, a section of the city characterized by a high percentage of public housing and public support, and high rates of unemployment, female-headed households, and adolescent conception and childbearing. Both populations were all black. Data were collected from a self-administered questionnaire following notification of the parent(s). Participation was voluntary, anonymous, and confidential. Questionnaires were administered in the first period, monitored by the homeroom teacher and program staff. For slow learners in the seventh grade, a member of the research team read the questionnaire separately to boys and girls, while each student, privately, filled out the form. Survey instruments for the seventh and eighth grades were abbreviated. A few pages of
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ADOLESCENTPREGNANCYPREVENTIONPROGRAM
split-sample questions for 9-12 grade students (in less sensitive areas where smaller numbers were acceptable) increased the breadth of the data. Baseline data (Round I) were collected before the program began. Approximately 90% of the students were present in the senior high and over 80% in the junior high; there were 1709 questionnaires from students generally 12-18 years old (there were a few 112 and 19-year-olds). Round II was completed by 1296 students representing 71.5% of registered students, and Round III provided 1251 replies from 73.3%. The smaller percentages in Rounds II and III were due solely to dramatically l o w e r springtime attendance because in each round refusals and unusable forms totalled Only about 2"3%. The timetable of research and service was as follows: September 1981-Round I administered, grades 8-12; November !981-Round I administered, grade 7; November 1981-school program initiated; January 1982-clinic program initiated; May 1982-Round II administered, all grades; and May 1983-Round III administered all grades. Sexual knowledge variables assessed included pregnancy risk and contraception; attitudes included beliefs about teen childbearing and contraception. Among behaviors assessed were sexual onset, contraception, clinic attendance, and pregnancy. The interpretation of these variables, the time required for them to measure change, and their potential usefulness in the final evaluation will be discussed against the background of the baseline data.
protection. Use at last intercourse, a measure estimating regularity of use, was less frequent. In other studies we have reported approximately a 20-point differential between these two measures (3). The differential here was generally within that estimate. Method distribution at last coitus showed considerable improvement with age, with oral contraceptive use approximately twice as likely among senior as junior high girls (36.2% versus 18.4%). Condom use was lower among older students, with a slight increase in reliance on r h y t h m and withdrawal. Pregnancy rates, despite higher than expected levels of contraceptive use, were also high; over 6.5% of junior high (11%, ninth grade) and over 15% of senior high girls reported having had a pregnancy, translating into rates of 13.3 and 22.1% among those who were sexually active. Outcomes were differently distributed between the two Schools, with abortion the choice for over half the ever-pregnant senior high girls and for just over one-third of the junior high ninth grade girls, generally a less upwardly bound, academically motivated population. In the baseline survey a relatively high percentage of boys and girls reported that their parents wished them to complete school and avoid pregnancy (or impregnating a partner) while still in school. Most students were aware of several contraceptive methods, but tended not to consider them reliable. Positive attitudes were expressed toward contraception, and students usually assigned responsibility for its use to both the male and female. Only a minority were seriously misinformed about the various methods. Teenage parenthood was not perceived as a sinecure; 61% of the young w o m e n in the senior and over 74% in the junior high reported that their mothers had their first children during adolescence. Almost 42% of the senior high w o m e n had never discussed contraception with their mothers, a figure that dropped only slightly (39%) among the sexually active. The 58% of the semor high w o m e n who had not used professional birth control services included over 44% of the sexually active. Because many of the y o u n g people in our sample began having sex at extremely early ages, junior high students' attitudes and knowledge were of considerable interest. Although the proportions who had discussed sex with parent(s) were not very different from the senior high students, knowledge levels appeared to be significantly lower. Knowledge of the existence of specific contraceptive methods and information about these methods was less, and the youngest students were much less likely to be aware that services were available without parental in-
Results B a s e l i n e Data
Findings from the Round I showed that 48.9% of the junior high girls and 84.0% Of the boys had had coitus compared to 72.3% of the girls and 91.0% o f the boys in senior high. The mean ages were: 14.! and 14.4 years, respectively, in the junior and 16.3 and 16.4 years, respectively, in the senior high schools. Although more boys were sexually active at each grade level, the gap closed with increasing age. In the seventh grade, for example, the differential was 77.1% (male) to 45.8% (female), but in the twelfth grade the percentages were 90.9% to 81.4%. With over three-quarters of the males sexually active by seventh grade, there was limited opportunity for the program to delay the mean age of first coitus. "Ever-use" of contraception was extremely high in Round I; approximately 90% of senior high sexually active males and females had used some form of
79
80
ZABINET AL.
volvement. These students were less likely to have been to a contraceptive clinic (82% had never attended, including 67% of the sexually active) and less likely ever to have u s e d any form of contraception. The early months of the program tended to confirm our baseline findings and prior experience and to suggest that younger students need considerable encouragement in addition t ° classroom education if they are to make individual contact with program staff in the school and the clinic. Small group sessions were used in both settings, for boys and girls alike. Initiatives directed at male students were focused on Seventh and eighth graders because coitus was already the norm .among the youngest boys. Both sexes appeared to be comfortable with a female counselor. At these young ages, their need for information, their anxiety about sexual development, and their confusion with partia ! and misinformation was freely acknowledged. The findings reported below suggest the degree to which these needs were met.
Clinic Use In the first five and a half months the clinic was open, 55 young w o m e n from the junior high and 139 from the senior high registered for service. Many more students came for education, films, discussions, and rap sesSions, but only the actual registrants are reported here. Fifty-one boys from the junior high registered, approximately equal to the number of girls, whereas only seven senior high males registered. During the second year, w h e n the clinic was open for the entire year rather than one term, 44 more junior and 187 senior high females registered, a n d 47 junior and 25 senior males registered. (The junior high school experienced a decline in enrollment in that year.) Data from Rounds II and III make it possible to estimate the percentage Of sexually active young women who were served in each period (Figure 1). It appears that approximately 23.1% of the sexually active junior high and 27.2% of the sexually active senior high girls were reached during the first five months, a rate that was generally maintained during the second year. By the end of the second year, 40.8% of sexually active junior high and 57.6% of sexually active senior high w o m e n had registered. It would be expected that a smaller percentage of the sexually active females in junior high would attend because at younger ages Smaller proportions of those who "ever" experienced coitus are likely to be sexually active at any given time. The sporadic nature of sexual exposure in early adolescence results in peri-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
ods of abstinence w h e n attendance at the clinic would be less likely.
Aggregate Data On Knowledge, Attitudes, and Behaviors Among all respondents, knowledge of contraception and pregnancy risk appears to have improved by 11.3 to 13.2% by Round II and little more, if at all, by Round III. The questions included in the knowledge scores were detailed questions about the use of various contraceptive methods and about the risk of pregnancy associated with a single exposure and with puberty. The increases in knowledge in important areas between Rounds I and II may only represent differences between the Fall and Spring because respondents might be expected to show some improvement in knowledge in seven months with or without a program. Because knowledge was higher than expected at the outset, the gains, though small, represent approximately 30% of the gap between Round I and a perfect score. Although the differences between those who attended lectures and those who did not were not large, there appears to have been a smaller increase in knowledge a m o n g the few not exposed to classroom discussions. Recognition of methods of contraception by name also increased, but once again, because recognition was high in the beginning there was little room for change. Knowledge Of the fertile time of the month is frequently used to determine students' levels of sexual knowledge; it is a Complex variable that Can easily be misinterpreted. Table 1 shows changes that suggest that young w o m e n will be less frequently "at risk" after exposure to the program than before; among junior high girls, 37.7% chose either midmonth or any time of the month (both of which tend to discourage inappropriate use of the r h y t h m method) compared to 21.5% chosing one or another of these responses in Round I. For all groups the differences between Rounds I and II were in the same direction, and for some groups the improvement continued in Round III. There was no consistent improvement in knowledge if responses were scored simply as correct (midmonth) or incorrect. However, we believe the first method of interpreting an adolescent's understanding of the time-of-the-month variable is more appropriate because the so-called correct response may be a poor measure of a program's ability to convey the message that best promotes responsible sexual behavior. Most programs discourage the rhythm method and emphasize the pregnancy risk
MARCH 1986
ADOLESCENT PREGNANCY PREVENTION P R O G R A M
81
EC-
C 55u m • 50" P o 45. r c a 40" n t 35.
./ /-
S t u 30.
s/~
,J•
d a n 25.
,J"
/~..._ - /
t s
//
.
•s
20. g a g t5.
f
J I
t 8
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t iO. a
/ I
•s. ##*"
r e d
5-
O.
I
I
I
2
4
6
"
Program
I
O Duration
I
I
I
I
I
lO
t2
t4
iS
ie
(Hontha]
Figure 1. CumuIative percent of sexually active students becoming regis-
trants at the program clinic, by school, sex, and month of program duration. Symbols: . . . . . . , male, senior high; , male, junior high; - - - --, female, senior high; . . . . . , female, junior h!gh. Note: The drop between months six and seven reflects loss of students graduating from the ninth or twelfth grades in June. (No twelfth grade males registered, So there was no drop in curve.) Numbers differ in Years 1 and 2 as follows:
inherent in all coital exposure; therefore, it is not surprising that m a n y studies have shown a poor response to this question. Teen parenthood, seen from the outset as a problem by a large majority of all groups, was seen as problematic by more young w o m e n at each survey, with particula r change noted among the junior high School ninth graders. This finding was not true for senior high boys, who were less likely to have had contact with the clinic and/or taken part in group discussions. More closely related to behavior were students' attitudes toward Contraception. Although few students thought responsibility for contraception belonged to neither the boy nor the girl, there
Senior
Year I Year II
(n) (n)
Junior
Males
Females
Males
Females
285 280
507 517
393 337
239 213
was some change in the allocation of responsibility for its use (Table 2). Between Rounds I and II all four groups showed increases in the percentage who believed both partners are responsible. The increases were largest for junior high school males and females. For all groups except the senior high boys, the proportion continued to rise in Round III. Although the percentage who believed responsibility belongs only to the boy is very different between subgroups, it decreased in all cases between subsequent rounds. Because sexual activity "ever," is a cumulative measure, it necessarily increased between Rounds I and II; a comparison of Rounds II and III is more appropriate because the young people at these sur-
82
ZABIN ET AL.
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2
T a b l e 1. Distribution of S t u d e n t ' s R e s p o n s e s to Q u e s t i o n I d e n t i f y i n g Fertile Time of the M o n t h b y Sex a n d School: R o u n d I Versus R o u n d s II a n d III Senior high school ROUND I (n = 252) FEMALES Right before, during, or right after period About two weeks after period begins
Anytime Don't know
37.6
R O U N DIII (n = 221)
49.3
3 2 " 1 { 11"121.038'6{ 2153 3.341"1{ 30.2 ROUND I (n = 119)
MALES Right before, during, or right after period About two weeks after period begins Anytime Don't know
ROUND II (n = 215)
Junior high school ROUND II (n = 236)
R O U N DIII (n = 212)
46.6
40.6
38.9
38.1
217"6 3.521"5{
17.2 4.337'7{
212'3 5.437"3{
23.1 14'2
12.1 ROUND II (n = 89)
12.2 R O U N DIII (n = 84)
37.9 R O U N DI (n = 286)
23.3 ROUND II (n = 221)
24.5 R O U N DIll (n = 194)
58.4
60.8
36.0
35.8
35.6
51.3 { 20.1
R O U N DI (n = 293)
{ 6.7 13.4 28.6
24.7
13.5 11.2
2 0 . 2 [ 11.98"3 19.0
16.9
veys were similar in age (Table 3). Differences in Spring of the first and second years are very small, with sexual activity insignificantly down among senior high males and females and insignificantly up among junior high students. The program did not appear significantly to affect the initiation of coitus in its first year and a half of operation, which is not surPrising in view of the high rates of early sexual activity reported in the baseline data. Contraceptive use showed gains (Table 4), with the most dramatic increases coming between
29.0{11.517.5 35.0
30.3{ 21.78"6 33.9
34.1{11.922.2 30.4
Rounds I and II. Use at last intercourse was apparently up 7.7% and 18.3% for young w o m e n and 13.5% and 15.3% for young men in the senior and junior high schools, respectively, between the first two rounds. These figures suggest that there was some change in the early months of the program and that the importance of our contraceptive intervention may have been greater in the junior high than in the senior high. Why a similar level of improvement could not be repeated in the second year is not yet clear. The same pattern is shown in Table
T a b l e 2. A t t i t u d e s of S t u d e n t s T o w a r d C o n t r a c e p t i v e Responsibility b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III Percent who believe it is the responsibility of
FEMALES Girl Boy Both Neither Total MALES Girl Boy Both Neither Total
Senior high school
Junior high school
ROUND I (n = 654) 10.1 0.9 88.8 0.2 100.0
R O U N DII (n = 493) 5.5 0.6 93.5 0.4 100.0
R O U N DIII (n = 517) 4.4 0.2 95.4 0.0 100.0
ROUNDI (n = 361) 21.3 7.8 67.6 3.3 100.0
R O U N DII (n = 301) 11.3 3.7 84.1 1.0 100.1
R O U N DIII (n = 256) 9.8 2.7 85.5 2.0 100.0
ROUND I (n = 290) 10.3 5.2 84.5
R O U N DII (n = 213) 5.2 1.9 92.5 0.5 100.1
R O U N DIII (n = 217) 9.7 1.8 87.6 0.9 100.0
ROUNDI (n = 338) 13.0 26.6 58.0 2.4 100.0
R O U N DII (n = 271) 7.0 14.0 78.2 0.7 99.9
R O U N DIII (n = 237) 8.4 9.7 78.9 3.0 100.0
-
-
100.0
MARCH 1986
83
ADOLESCENT PREGNANCY PREVENTION PROGRAM
Table ~. gtudents Who Have Ever Had Intercourse, by School: Round I versus Rounds II and IIIa Junior high school
Senior high school
Females Percent n Males Percent n
Round I
Round II
Round III
Round I
Round II
Round III
72.3 643
78.2 486
76.7 507
48.9 360
56.7 298
60.1 248
91.0 289 -
95.3 211
92.3 209
84.0 344
88.6 272
89.7 233
aFor this and other cumulative measures, Rounds II and III are expected to be higher than Round I because students were approximately eight m o n t h s older at the time of the Spring survey.
5, which summarizes a few important categories of use. The decline in no protection at last intercourse and the sharp increase in the use of medical methods is again marked between Rounds I and II. Although the level of improvement is not continued between Rounds II and III, and is in fact reversed in some cases, the overall differences between the baseline data and the end of the second year are significant. There was an increase of almost 61% in the use of medical methods among junior high girls and an increase of over 34% in the use of medical methods by more than half of our sexually active young w o m e n in the senior high. The aggregate data will permit future exploration of a "substitution" effect: Did the respondents substitute the program clinic for other services? To what extent were these services used where other services might not have been? There was considerable oral
contraceptive use among those w h o did not use this service, suggesting use of other facilities, but the differences between attenders of the program clinic and nonattenders were in the expected direction in all groups: more attenders used the pill at last intercourse than nonattenders. Thus, the program clinic appears to account for much of the difference in use between Round I and subsequent rounds (Table 5). The interval between first intercourse and first clinic visit is of paramount importance in reducing pregnancy and may provide evidence of change long before the pregnancy rate would reflect a program effect. The mean and median intervals (lines a and c, Table 6) generally decreased between Rounds I and II for senior high girls (11.6% and 9.6%, respectively). For junior high girls the numbers were more dramatic (67.7% and 77.5%, respectively). The junior high numbers are small because only ninth graders were
Table 4. S e x u a l l y A c t i v e S t u d e n t s U s i n g C o n t r a c e p t i o n E v e r a n d A t L a s t C o i t u s , b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III Senior high school
Females Ever used contraception Percent n Used contraception at last intercourse Percent n Males Ever used contraception Percent n Used contraception at last intercourse Percent n
Junior high school
Round I
Round II
Round III
Round I
Round II
Round III
89.6 461
94.1 374
94.8 389
72.7 172
69.4 160
75.9 141
73.4 458
79.1 369
81.9 381
60.7 163
71.8 149
66.4 137
89.2 259
89.2 194
92.4 184
71.3 268
73.9 222
78.1 192
62.9 256
71.4 189
67.8 180
56.1 244
64.7 215
62.4 186
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JOURNAL OF ADOLESCFNT HEALTH CARE Vol. 7, No. 2
T a b l e 5. C h a n g e s in M e t h o d of C o n t r a c e p t i o n U s e d at L a s t I n t e r c o u r s e , b y Sex a n d School: R o u n d I v e r s u s R o u n d s II a n d III~ Method used at last intercourse
FEMALES Using nothing (%) Using medical (diaphragm, pill, IUD alone or combination with anything) (%) Using condom alone or in combination (%)
MALES Using nothing (%) Using medical (%) Using condom (%)
Senior high school
Junior high school
ROUND I (n = 458) 26.6
ROUNDII (n = 369) 20.9
ROUND III (n = 381) 18.1
PERCENT C H A N G E ROUNDI I-III (n = 163) -32.0 39.3
39.5
42.8
53.0
+34.2
23.1
30.9
28.6
+23.8
ROUND I (n = 256) 37.1 23.4 33.2
ROUNDII (n = 189) 28.6 37.0 36.5
ROUND III (n = 180) 32.2 32.8 35.0
ROUND II (n = 149) 28.2
ROUND III (n = 137) 33.6
PERCENT CHANGE I-III --14.5
22.7
35.6
36.5
+60.8
28.2
33.6
28.5
+1.1
ROUND II (n = 215) 35.3 26.5 42.3
ROUND III (n = 186) 37.6 25.3 34.4
PERCENT CHANGE I-III -14.4 +16.6 +4.0
PERCENT C H A N G E ROUNDI I-III (n = 243) -13.2 43.9 +40.2 21.7 +5.4 32.8
aAlone or in combination; respondent may appear in two categories if both methods were used at last intercourse (combinations of methods including pill or condom were used by approximately 8% of respondents).
T a b l e 6. M e a n a n d M e d i a n N u m b e r of M o n t h s A m o n g F e m a l e s f r o m First I n t e r c o u r s e to First C o n t r a c e p t i v e Clinic Visit a n d P e r c e n t W h o E v e r M a d e a Clinic Visit, b y School: R o u n d I v e r s u s R o u n d s II a n d III Senior high school
a. Mean interval Months n b. Mean interval ind. precoital = 0 b Months n c. Median interval Months n d. Median interval, incl. precoital = 0 b Months n e. All ever to clinic or doctor Percent n f. Sexually active ever to clinic or doctor Percent n g. To clinic precoitus Percent n
Junior high school
Round I
Round II
Round III
Round I
Round II
15.5 174
13.7 153
13.7 179
26.0 9
8.4 10
13.4 a 15
11.9 226
11.2 188
10.6 232
18.0 13
7.0 12
9.1 a 22
12.5 174
11.3 153
10.8 179
20.0 9
4.5 10
8.0 a 15
5.8 226
8.5 188
7.5 232
17.0 13
3.2 12
4.8 a 22
41.5 650
54.0 487
54.7 514
18.0 472
31.7 385
55.6 464 27.8 241
66.2 376 24.3 202
69.4 386 26.0 242
32.9 225 40.0 15
48.8 213 28.6 14
Round III
34.2 330 51.0 198 40.0a 25
aBased on ninth grade only; seventh and eighth grades not asked date of clinic visit. bAll respondents with precoital first clinic/doctor visits are included in estimate if they received a contraceptive at that visit; to calculate mean, interval is made equal to zero.
MARCH1986
ADOLESCENTPREGNANCYPREVENTIONPROGRAM
asked for the dates; therefore, it is only the size of the differences and their consistency that tend to lend them credibility. Second-year decreases among the older girls were small. Among the younger girls, although a large share of the reduction was maintained, there were small increases. The percentages of all (line e) and of sexually active (line f) ever having attended a contraceptive clinic went up in each interval, with overall increases of 90% and 55% for the two parameters, respectively, among junior high girls (including seventh and eighth graders). Increases among older girls were larger in Year I than Year 2 and were not as large as among the younger students. It appears from line g that the program was not able to affect the proportion w h o attended the program precoitus; perhaps w h e n so large a proportion of the population is already sexually active it is not possible to affect this behavior. Lines b and d show the effect of including the young w o m e n w h o had attended precoitus in an estimate of the interval to clinic attendance (',making the interval equal 0 for those w h o attended and received a birth control method before initiating intercourse); this reduces the interval but does not significantly change the relationships. Unfortunately, the most important variables in the evaluation of a pregnancy-prevention program are the most difficult to assess and compare as well as taking the longest to affect, i.e., pregnancy rates, fertility, and/or abortion. These parameters are problematic for many reasons: 1)The appropriate comparisons involve rates based on 12-month estimates, which may be difficult to establish. 2) "Ever pregnant" proportions are cumulative, i.e., the Spring survey of the first program year should report higher proportions than the Fall baseline data
because it is eight months later. Even the 12-month rates for this parameter should be high because the girls are a little older. 3) Miscarriages may not be identified by young adolescents, or may be more readily identified w h e n their awareness of pregnancy risks is heightened. In the present data, large increases in this outcome between rounds represent variations that are not credible if interpreted in any other way. 4) The statement that one is "pregnant now" may be a guess. For example, in other data we found that fewer than 15% of female students w h o had "thought they were pregnant" in the past year actually were (not published). Because we have no way of knowing w h o had actually established a current pregnancy, estimates of "pregnant n o w " may be inflated. 5) Pregnancy, especially childbirth, affects school attendance; therefore, we must be cautious in claiming to capture a true pregnancy rate even when large proportions of the students respond to the appropriate questions. A disproportionate number of recently pregnant girls may be absent. 6) It takes time to affect a rate. If the two 12month periods reflected in a rate are not to overlap, it would take approximately 15 months to affect an abortion or miscarriage rate and 21 months to change a birth rate. Table 7 reports changes in the two outcomes for which greatest accuracy can be expected, baby and abortion, for the 12 months prior to each round. Changes between Rounds II and III are the only changes that could be attributable to the program. Even in Round IIIa large percentage of last-12-month births were conceived before the clinic opened, not only because over one-third of the applicable period of conception predated the January 1982 clinic opening, but also because those with outcomes late in the
85
Table 7. Sexually Active Females Reporting Pregnancies in Last 12 Months by Outcome, School, and Percent Change: Rounds II and III Senior high school
Baby or abortion Percent n Baby Percent n Abortion Percent n aNinth grade only.
Junior high school
Round II
Round III
Change
Round II
Round III
Change
8.7 368
7.0 369
-19.5
6.5 46
6.5 45
0.0
2.9 373
3.2 375
+10.3
4.3 47
4.3 46
0.0
5.7 369
3.8 372
-33.3
2.2 46
2.1 47
-4.5
86
ZABINET AL.
period were less likely to be back in school at the time of the survey. Thus, these numbers are not evaluative; rather they are included to suggest h o w long it takes to carry out a true evaluation of program effects on pregnancy, even when use of contraception improves. Although only preliminary, our results suggest that whereas births may require 21 months to reflect real change, abortions may begin to drop earlier. This fact underlines the long time lags and breadth of information that are necessary before contraceptive effects can be identified and a reported fertility outcome can accurately be attributed to a specific pregnancy-prevention program.
Discussion The findings reported here do not constitute an "evaluation;" they may, however, give some insight into the ability of selected variables to detect change. Some changes, especially in the softer variables, may be fortuitous because two points in time after the program's onset do not establish a trend. Problems encountered in evaluating school-based programs are clear: different attendance in Fall and Spring compromises random selection, and different ages in Fall and Spring underscore the need for control populations or baseline data collected at the same time of year as follow-up. On some critical variables, considerable time is needed to assess substantive change. It appears however that there is a suggestion of change and that many parameters designated at the outset as quantifiable and measureable will ultimately serve as useful evaluative tools. For example, the interval between first coitus and clinic attendance is amenable to rapid change even if pregnancy as a program effect cannot be assessed for several years. Aggregate school data appears to be useful in the evaluation process. Preliminary results seem to confirm those studies showing that education programs are related to changes in knowledge, whereas clinic programs are necessary to change practice (7). Although there are some differences in contraceptive use overall, the greatest drops in nonuse appear to be related to whether or not the student attended the clinic; a longer period and more detailed analysis will be necessary to detect contraceptive effects of the education component per se. Changes in individual variables may help in the interpretation of the variables themselves. One example is the change in knowledge of the fertile period. Whereas accurate designation of midmonth risk did not improve, there appeared to be a change to-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
ward better understanding of the risk of intercourse overall. This may be a better educational objective. An emphasis on midmonth safety may promote the misapprehension that there is a consistently safe period for every young woman, a particularly dangerous concept among postpubertal young w o m e n whose cycles are often irregular. Future analysis will use detailed data--staff logs, sexual histories, cohort comparisons with nonprogram schools--for a more rigorous evaluation and an assessment of cost-effectiveness. Even data from other parts of the school community are relevant. For example, there is evidence of a drop in transfers from the junior high to a school maintained for pregnant adolescents between Rounds II and III; this could suggest a real decline in pregnancy if the drop-out rate due to pregnancy did not increase. An in-school study alone cannot collect this information; some outside data is required. One might ask: Is it necessary, then, to await a formal, scientific evaluation, with control populations, before a model such as this can offer positive information to the field? Our data suggest that when there is room for substantive change the early findings may be of value. For example, our data suggest that the effects of the program are more dramatic among junior than senior high students. Not only were the males much more involved in the program, but the behavior of males and females alike, their attitudes toward contraceptive responsibility, and in some cases their knowledge, appeared to show greater change. Shorter intervals to clinic attendance and increased percentages attending clinics were more marked among the younger students. Clearly, the potential for change is greatest w h e n sexual exposure is relatively brief and/or clinic attendance and contraceptive use is low prior to program intervention. In such cases, early findings may assist in program design. Thus, the extremely early sexual involvement reported by y o u n g boys, their extraordinary interest in the program, and the changes it appeared to bring about among them suggest that programs are needed to reach this age level. Future projects must find out h o w much earlier y o u n g people might profitably be reached with similar education initiatives because our baseline data suggest that junior high may be too late to affect sexual onset for about half of these boys and girls, or, indeed, to reach the sexually active among them in their highrisk early period of exposure. This research was supported primarily by grants from the Ford, W. T. Grant, and Hewlett Foundations.
MARCH 1986
References 1. Zabin LS, Hardy JB, Streett R, et al. A school, hospital and University-based adolescent pregnancy prevention program. J Reprod Med 1984;29:421-6. 2. Zabin LS, Kantner JF, Zelnik M. The risk of adolescent pregnancy in the first months of intercourse. Faro Plann Perspect 1981;11:215-22. 3. Zabin LS, Clark SD. Why they wait: A study of teenage family planning clinic patients. Fam Plann Perspect 1981;13:205-21. 4. Zabin LS, Clark SD. Institutional factors affecting adolescents'
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choice of contraceptive clinics. Fam Plann Perspect 1983; 15:2529. 5. Edwards LE, Steinman ME, Arnold KA et al. Adolescent pregnancy prevention services in high school clinics. Fam Plann Perspect 1980;12:6-14. 6. Edwards LS, and other clinic staff. St. Paul project: Personal communication, 1984. 7. Kirby D, Alter J, Scales P. Analysis of U.S. sex education programs and evaluation methods. Report No CDC-2021-79-DKFR, U.S. Department of Health, Education and Welfare, June 1979.