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Evaluation of Federal Abstinence-only Education Programs NOTE: This report represents information on this subject as of June 2000. Full Text At the American Medical Association (AMA) House of Delegates 1999 Interim Meeting, Council on Scientific Affairs (CSA) Report 7, "Sexuality Education, Abstinence, and Distribution of Condoms in Schools," was presented; the recommendations were adopted as amended in lieu of Resolution 416 (A-98) and the remainder of the report was filed. The report included five recommendations that addressed: family life education in the family and in schools; comprehensive, developmentally appropriate sexuality education programs; the importance of monitoring future research findings; consolidation of several AMA policies; and working with the United States Surgeon General to address the needs of specific communities. Although CSA Report 7 recommends tracking future research efforts relating to educational program outcomes, it is important to describe the federal process for evaluating state-administered, abstinence-only education programs due to its potential impact on our understanding of programs that may change the sexual risk-taking behavior of adolescents. Accordingly, this report is presented for the information of the House of Delegates. Methods The Combined Health Index Database and MEDLINE were searched to identify articles that described the evaluation process for federal abstinence-only education programs. Although limited sources were identified, two organizations are currently tracking the state funding process and its related activities. Consultations with the U.S. Department of Health and Human Services (DHHS) Assistant Secretary for Planning and Evaluation's Director for Human Services Policy who supervises this effort and the federal contractor's director provided additional information about their goals for and approach to the evaluation process. Section 510(b) Title V The Temporary Assistance to Needy Families Act (P.L.104-193), referred to as federal welfare reform, includes a provision that created an entitlement program in Section 510 Title V of the Social Security Act. The purpose of the new entitlement program, Section 510 (b), is to "enable the State to provide abstinence education, and at the option of the State, where appropriate, counseling, and adult supervision to promote abstinence from sexual activity, with a focus onthose groups which are most likely to bear children out-of-wedlock."1 This provision specifically defines abstinence education as a motivational or educational program that:(A) Has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; (B) Teaches abstinence from sexual activity outside marriage as the expected standard for all school children; (C) Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; (D) Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity; (E) Teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (F) Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child s parents, and society; (G) Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances; and (H) Teaches the importance of attaining self-sufficiency before engaging in sexual activity.2 The federal abstinence-only education program offers $50 million in annual federal funds for fiscal years 1998-2002 and requires a state match of $3 for each $4 that is provided. "Individual state funding is determined by a formula: the proportion of low-income children in the state as compared to the national statistic."3 The law also designates a $20 million "Bonus to Reward Decrease in Illegitimacy" to each of the top five states that demonstrates a net decrease in out-of-wedlock births. In June 1997, the federal Maternal and Child Health Bureau (MCHB), the agency charged with administering the program, released its federal Block Grant Application Guidance for abstinence-only education. By July 1997, all 50 states and the District of Columbia had applied for funding, with awards made in October 1997.1 At this time, survey reports confirm that most states use a combination of approaches to meet the federally required matching formulas.3 State abstinence-only programs that receive federal funding are required by the MCHB to use national performance measures to annually monitor their efforts. To comply with the performance measures, MCHB requires states to report information related to pregnancy rates for adolescents aged 15 to 17 years; percentage of adolescents 17 years and younger who have had sexual intercourse during the reporting period; the rate of bacterial sexually transmitted diseases among youth aged 15 to19 years; and the birth rate for teenagers aged 15 to 17 years at the time of delivery. Additional mandated measures require that states develop at least two of their own measures to track. A recent survey indicated that 36 states are placing equal emphasis on assessing behavioral modification aimed at delaying initiation of sexual activity, increases in knowledge about the benefits of abstinence, improvement in attitude about abstinence, and increases in refusal skills. Most states are tracking both process and outcome measures and report that they are using an average of 5% of their budgets for evaluation activities.3 Regardless of annual state rates for various measures, sustained behavior change is the critical measure of long-term assessment of overall program effectiveness. Responses to Section 510(b) Title V The federal abstinence-only education law has engendered mixed reactions from both its critics and supporters. Some concerns relate to the fact that the law was never debated by the public or Congress before it was enacted. Many states noted that they were "already conducting program activities, including abstinence education, to prevent teen pregnancies" 3 and that "good sexuality education always promotes abstinence& ."1 Other criticisms include a belief that program components B, D, and E are not based in fact; an abstinence-only-until-marriage philosophy excludes gays and lesbians; and the scientific literature does not support the effectiveness of these programs. Supporters of the law are concerned about control of the program at the state level, composition of advisory panels, key messages, and media campaigns. However, consensus was reached on the importance of including parents in programming and emphasizing their role in communicating with their children.1 The absence of required program evaluation in the welfare reform law has provoked debate. For example, few studies evaluate the effectiveness of abstinence education, even though Title V programs implemented under the Adolescent Family Life Act have included abstinence messages since the 1980s.3 Although some evaluated programs have shown a desirable effect on attitude, "no evaluated program with an exclusive abstinence message has been evaluated in such a way as to show a significantly positive impact on behavior."4 In spite of the critical necessity for evaluating the new state abstinence-only education programs, Congress passed the federal abstinence-only education law with no required provision for its evaluation within the funded states.2 At the urging of many concerned researchers, evaluation professionals, and health education advocates, the August 1997 Budget Reconciliation Bill stipulated that the U.S. Secretary of Health and Human Services could utilize up to $6 million of welfare-to-work evaluation funds to evaluate the Section 510(b) program.5 Subsequently, the U.S. Office of the Assistant Secretary for Planning and Evaluation (ASPE) requested comments on its evaluation plan with an application date of July 1, 1998. In August 1998, ASPE awarded the Section 510(b) evaluation contract to Mathematica Policy Research, Inc, with an evaluation subcontract to the University of Pennsylvania.1 Evaluation Process A synopsis of Mathematica s approach to the evaluation process features three major goals. The first is directed by a process that documents the nature and underlying theories of the abstinence-only education strategies that are being implemented. The second and third goals are designed to determine the extent to which, and in what ways, various abstinence-only education strategies affect youth behavior; examine the effects of community-wide abstinence-only education initiatives on the improvement of outcomes for youth; and study the role of the local environment in enhancing or impeding the ability of these initiatives to achieve their intended objectives. The national evaluation project is based on theoretical models of adolescent risk-taking behavior. It emphasizes the connections between youth backgrounds, abstinence-only interventions, and other intervening factors and how they influence key behaviors including teen pregnancies and births, out-of-wedlock sexual activity, and sexually transmitted diseases.6 The Mathematica evaluation has two major foci. Measuring the efficacy of curriculum-based abstinence-only education programs targeted at specific groups of youth is one focus.6 These programs will be evaluated through an experimental design that includes randomly selected control groups.7 Examining community-wide abstinence educational initiatives is the other major focus of the evaluation. Because the community programs are not curriculum-based, their evaluation will monitor systemic change, including shifts in values, culture, knowledge, attitudes, and behaviors of youth over time. Quantitative and qualitative data will be collected for evaluation of both the curricular and community programs.6 A special technical panel will address the issue of contamination (ie, prior exposure of study participants to abstinence-only messages) as a potentially confounding variable.7 A critical objective of the evaluation is to understand the nature of the interventions, including "how they induced behavior changes, the type of contextual influences that affected the local programs and their outcomes, and the conditions and strategies needed for replication of effective programs."6 At this time, six community sites and approximately seven school-based programs have been identified for inclusion. Most of the school programs are based in elementary schools and virtually all the community programs include a school component. Programs include youth who are enrolled in the study in Fall 1999 and in some cases continuing through Fall 2000. Interviews will take place at baseline, shortly after the intervention, and in Spring 2001.7 Key project staff members include professors at the University of Pennsylvania, University of North Carolina, and senior researchers at Mathematica. The project's Technical Work Group includes the director of the National Campaign to Prevent Teen Pregnancy, board president of the Medical Institute for Sexual Health, dean of the Harris School of Public Policy Studies at the University of Chicago, a representative from the Heritage Foundation, a representative from the Urban Institute, and the director of the University of Nebraska s Center on Children, Families, and the Law, along with psychiatry professionals and educational researchers.6 There is no question that abstinence from sexual activity is the most effective means for preventing sexually transmitted diseases, including human immunodeficiency virus, and unwanted pregnancies.3 In addition to abstinence-only messages that young people are receiving through the welfare reform initiatives, the federal government has further confirmed the important role of abstinence in Healthy People 2010. Responsible sexual behavior is one of the leading health indicators for Healthy People 2010 and is reinforced in Objective 25-11: Increase the proportion of adolescents who abstain from sexual intercourse or use condoms if currently sexually active.8 Mathematica's overall mission is to identify those programs that are helpful and why, in an effort to distribute this knowledge to everyone and ultimately do a better job for our young people. Although the evaluation is scheduled for completion in late 2001, Mathematica is arranging its evaluation process for the long-term to accommodate the possibility of continued funding availability.7 Its evaluation findings will be made available to the AMA s Board of Trustees and House of Delegates. RECOMMENDATIONS Because this is an informational report, it does not contain Recommendations. References
Also see the AMA's Adolescent health Web site |
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