Nationally, teen birth rates have declined steadily in the last several years. From 1991 to 1997, the number of teens having engaged in sexual activity has also decreased; for sexually active teens, the rate of condom use has increased. However, the teen birth rate in the United States is high at about 54 per 1,000 girls aged 15 to 19. Teen birth rates vary greatly by state, ranging in 1996 from 30 per 1,000 girls aged 15 to 19 in Vermont to 76 per 1,000 in Mississippi. Research shows that four risk factors consistently predict teen pregnancy: poverty, early school failure, early behavior problems, and family problems and dysfunction. Risk factors for teen pregnancy are common to other problem youth behavior, such as delinquency and substance abuse. Research has also identified several factors that can help protect against teen pregnancy, including positive relationships with parents and positive connections to a school community. Recent reviews of program evaluation results concluded that certain approaches are more promising than others, but too few programs have been rigorously evaluated to assess their effect on teen pregnancy. Numerous federal, state, and local agencies as well as private citizens and organizations have had a role in TPP activities. For decades, the federal government has supported efforts to prevent teen pregnancy. As part of HHS’ Healthy People 2000 initiative, each state sets goals to reduce teen pregnancy. To help meet these goals, the federal government provides funding to states and local communities for teen pregnancy prevention through a variety of grants and programs administered primarily by HHS. HHS also supports research and data collection and surveillance on the magnitude, trends, and causes of teen pregnancies and births. The 1996 welfare reform legislation also includes provisions aimed at reducing teen pregnancy. For example, the new law provides funding for abstinence-only education—sex education programs that emphasize abstinence from all sexual activity until marriage and exclude instruction on contraception—and allows states to use their TANF block grants for other TPP activities. In addition, the legislation requires states to set goals for decreasing out-of-wedlock births and will financially reward states with bonuses for the largest decreases in all out-of-wedlock births. The legislation also requires teen parents receiving assistance to stay in school and live at home or in another approved setting. States must also indicate how they intend to address the problem of statutory rape, and the government is required to study the link between teen pregnancy and statutory rape. Finally, the new law requires HHS to develop a national strategy to prevent out-of-wedlock teen pregnancy. States in our review have designed strategies for reducing teen pregnancy and have implemented and overseen programs that support their strategies. Generally, state health departments lead state TPP efforts. However, because of the crosscutting nature of teen pregnancy prevention, coordination is necessary with other state agencies whose programs and activities can affect efforts to prevent teen pregnancy, such as departments of social services, justice, and education. Governors’ offices, special commissions, and task forces can also play a central role in designing and implementing strategies and programs at the state level. States generally administer statewide programs, but most of the responsibility for implementing programs is delegated to local communities. States also encourage building coalitions among community groups and organizations involved in teen pregnancy prevention. State strategies must operate within the context of statutes, local policies, and other activities in the state. At the local level, public institutions, like schools and health departments as well as community-based and other organizations, often implement TPP programs or otherwise influence how TPP programs are implemented. Finally, some private organizations at the national, state, or local level may support public efforts or, in some cases, run independent initiatives. In their efforts to address the problem of teen pregnancy, the states that we visited developed prevention strategies with multiple components that included a variety of programs and services. But in all cases, a key objective of these states’ strategies was to target high-risk groups, such as teens living under impoverished conditions. Within the context of their broad strategies, states generally gave localities the flexibility to administer programs to meet local needs and preferences. States identified the federal government as a major contributor of funds that support their TPP strategies. Since the early 1980s, the TPP strategies in the eight states that we visited have evolved from focusing on services for teen parents to an array of programs with increased emphasis on prevention, while still providing programs and services for pregnant and parenting teens. The TPP strategies of all the states we visited contained six basic components: sex education, family planning services, teen subsequent pregnancy prevention programs, male involvement, comprehensive youth development, and public awareness. (See table 1.) Although each state generally had all of these components in their TPP strategies, the emphasis placed on the components and the types of services and programs included in their strategies varied. Two of these components—male involvement and youth development—are beginning to play prominent roles in states’ TPP strategies. Traditionally, pregnancy prevention efforts almost exclusively targeted young women. More recently, strategies have begun to focus on young men’s role in decisions to have sex and to use contraception. In 1995, 68 percent of males surveyed by the National Survey of Adolescent Males reported having had intercourse by age 18. The survey also observed that one of the biggest shifts in teen reproductive behavior is the improvement in teenage males’ use of contraception. These shifts suggest that male teens can be encouraged to delay sex or use contraception if they have begun having sex. All the states we visited included a male involvement component in their TPP strategies in an effort to change male behavior and produce more promising results. For example, California’s male involvement program—a 3-year, $8 million grant program established in 1995—funds 23 projects across the state to improve teen males’ motivation for being sexually responsible through peer education, mentoring, youth conferences, and other activities. California also supports prevention and parenting programs for incarcerated young men and has increased enforcement of statutory rape laws to increase the prosecution and conviction of adult men who have unlawful sex with minors. In addition, one of the state’s public awareness campaigns specifically targets males. Georgia’s male involvement effort aims to establish community-based programs that focus on male responsibility for pregnancy prevention, responsible fatherhood, and motivation for academic achievement and economic self-sufficiency. In 1996, Georgia used $265,500 from the Medicaid Indigent Care Trust Fund (ICTF) to sponsor 17 projects across the state. Grant recipients included health departments, community centers, and various chapters of Alpha Phi Alpha Fraternity, Inc. In 1997, Georgia used $200,000 from ICTF to award 23 grants that focused specifically on pregnancy prevention programs from a male perspective. All of the states we visited also included youth development—another nontraditional component—in their TPP strategies. Although many of these programs do not focus specifically on teen pregnancy prevention, states and some experts believe they can reduce teen pregnancy by improving teens’ belief in their future and improving their education and career opportunities. Youth development activities often include mentoring, after-school homework assistance and tutoring, peer leadership, self-esteem building, social and recreational activities, and sex education. For example, Illinois’ Teen REACH (Responsibility, Education, Achievement, Caring, and Hope)—an $8.4-million annual after-school program—aims to decrease teen pregnancies, arrests, alcohol and drug use and increase school attendance and completion and work or work-related activities. The program targets girls and boys aged 10 to 17 at 41 sites across the state and will link participants to other state and community-based programs and services. Table 2 summarizes the activities and services in the various components that the eight states used to implement their TPP strategies. A key objective of all the states’ strategies is to target their TPP efforts to groups or communities at higher risk of teen pregnancy. California, for example, targeted TPP efforts to communities and neighborhoods with high rates of teen births, high poverty and unemployment rates, and low education levels. The states’ strategies also focused on meeting the needs of three different groups of teens: those who were not yet sexually active, those who were sexually active, and those who were already pregnant or were parenting. Louisiana is targeting 12 zip codes in the New Orleans area with the highest teen birth rates in the city. Oregon offers special life-skills training for teens whose parents receive public assistance because they are at increased risk of becoming teen parents. California, Illinois, and Vermont developed programs aimed at youth in foster care or with foster parents because research has shown that these youth are at a greater risk for unsafe sexual behavior and teen pregnancy. Other state strategies target high-risk groups such as incarcerated males and siblings of teen mothers. The states we visited were using different types of data to target TPP efforts to high-risk communities and youth. For example, all of the states in our review use teen birth data, frequently broken down by zip code, to identify and target high-risk areas. Illinois uses data from a sexually transmitted disease reporting project sponsored by HHS’ Centers for Disease Control and Prevention (CDC) to help target TPP initiatives. In addition, the states that participated in the federal Youth Risk Behavioral Survey (YRBS) use this data in developing their strategies and programs. For example, to improve access to and use of contraception, Oregon uses YRBS data to target sexually active teens who report not using contraception. While TPP strategies were applicable statewide, the states we visited typically gave communities flexibility in selecting and implementing programs to meet local needs and preferences. States generally offered localities a choice among certain state-approved programs or programs that used promising approaches. Communities selected programs that they found most consistent with local policy and values. According to state officials, this resulted in a mix of programs, approaches, and services that varied among communities within a state. Some communities, for example, have chosen programs that encourage abstinence, while others chose a more comprehensive approach that includes abstinence-based sex education as well as access to family planning services, including contraceptive services. Still other communities emphasized youth development programs that focus not on teen pregnancy but on general skill building aimed at improving youth life options. In particular, family planning and sex education programs varied considerably among communities because of local preferences and policies, particularly in schools. Providing sex education and access to family planning services, particularly in school-based settings, varied considerably among communities because they adopted approaches consistent with their preferences and values. Even though each state we visited encouraged or mandated sex education in the schools, local policies dictated the content of such programs in school settings. In some cases, states offer these programs in settings other than schools; in others, state strategies tried to encourage a school-based approach. For example, Maine and Vermont provide funding for health educators who work with schools to provide technical assistance, develop curricula, and train teachers in sex education. But officials in these states said that not all schools offer sex education and in those that do, the curricula vary. Oregon’s strategy encourages the use of a specific abstinence education program for sixth- and seventh-graders and encourages comprehensive sex education in grades 5 through 12. Oregon officials report that 45 percent of the state’s sixth- and seventh-graders received the prescribed abstinence curricula but said that only a few schools are providing comprehensive sex education in the higher grades. Louisiana’s strategy encourages sex education in schools but only within a targeted area with high birth rates. Illinois’ strategy encourages sex education in community or home settings and funds community-based sex education programs. Maryland’s strategy includes a media campaign and outreach program that encourages parents to be the primary sex educators of their children as well as encouraging comprehensive health education in the schools. Two states, Oregon and Maine, are beginning to implement systems that are intended to encourage schools to teach sex education. Although not a part of the states’ strategies, all eight states received federal funding from CDC to support school HIV prevention education programs. The purposes of these programs are similar to those of some TPP programs—to increase the percentage of high school students who do not engage in intercourse and to increase the percentage of sexually active teens who correctly and consistently use condoms. Officials in some of the states we visited cited HIV prevention education as one reason for the decline in teen pregnancy in their states. Illinois, Maine, and Oregon encouraged access to family planning in school-based health centers. However, local policies and statutes control the types of school-based family planning services—primarily contraceptives and information on abortion—that may be made available in these centers. Some communities permitted school health centers to dispense contraception—including condoms, birth control pills, and implantable and injectable birth control—while other communities only allowed school health centers to refer students to other facilities for these services. In some states, such as Georgia, laws restrict referrals and providing family planning information in schools. Louisiana state laws prohibit school-based health centers from providing any family planning services, but the law allows schools to refer students elsewhere for these services. Even though California and Maryland did not include school-based health centers in their strategies, these states had some school-based health centers that provided referrals and access to family planning where permitted by local communities. To improve teen access to family planning services, some states included in their strategies access to family planning in other settings. For example, California’s strategy includes over 2,200 state-funded community, hospital, university, and private practice providers that serve low-income males and females, with 56 of these clinics offering enhanced counseling for teens. Georgia provides similar services along with other youth services and activities in 27 community-based youth centers. Also, strategies in Georgia, Illinois, Maine, Maryland, Oregon, and Vermont included collaboration with the federal Title X Family Planning Program to overcome barriers to teen access by opening teen-only clinics, having clinics open at hours convenient for teens, and doing outreach to inform teens about available services. Although the Title X Family Planning Program serves teens in the remaining states, these states do not include title X programs in their TPP strategies. Some states also included Medicaid expansions to improve access to family planning. Other states’ Medicaid managed care programs also allow enrollees to obtain family planning services from other health care providers. Federal, state, and local governments and private entities fund state TPP activities. In the six states where data were available, the federal government provided a large share of the funds states use and distribute to local communities for teen pregnancy prevention. (See table 3.) In the six states that provided funding data, the federal share of total TPP funding ranged from 74 percent in Georgia to 12 percent in California. The primary mechanisms by which states receive federal funds for TPP efforts include block grants, entitlement programs, and categorical programs. Because federal funds provided through many of these programs are not designated specifically for teen pregnancy prevention, states have some flexibility in deciding what activities to support with federal funding and how much to devote to TPP efforts. The federal government also provides grants directly to local communities to fund TPP initiatives. Officials in the states we visited said that they do not keep track of funds communities receive directly from the federal and local governments or from private contributions. Federal welfare reform legislation contained several provisions related to teen pregnancy prevention, but the law did not require major changes to the TPP strategies of the states we reviewed. Before federal welfare reform, the eight states were already requiring teen mothers to live at home and stay in school in order to continue receiving welfare benefits—key welfare reform provisions. However, at the time of our review, state officials had mixed reactions to other welfare reform provisions intended to reduce teen pregnancy. Only one of the eight states currently plans to apply for an out-of-wedlock bonus, and all states were concerned about the prescriptive requirements surrounding federal grants for abstinence education, although each applied for and received funding. The eight states in our review had already begun requiring teen parents receiving welfare to live at home or in supervised living arrangements and stay in school or job training to receive assistance—requirements that were subsequently included in federal welfare reform. Officials in some states said they believe that these provisions may deter teens from having any more children until they finish school and become self-sufficient and discourage other teens from having their first child. In addition, all the states’ TPP strategies included a teen subsequent pregnancy prevention component that emphasized school completion and prevention of another pregnancy, and some states included activities to inform teens of the welfare requirements. For example, for more than 10 years, California’s Adolescent Family Life and Cal-Learn programs have encouraged pregnant and parenting teens to complete school as well as provided these teens case management and health and social services. Officials and teenagers in two of the states we visited said that they believe the states’ requirements related to school and living arrangements played a part in preventing some teens from getting pregnant. Federal welfare reform legislation provides a financial incentive for reducing the ratio of out-of-wedlock births to all births within the state. According to the proposed regulations for the “Bonus to Reward Decrease in Illegitimacy” provision, states can receive a total award of up to $100 million annually for 4 fiscal years starting in fiscal year 1999 for reducing the ratio of out-of-wedlock births without increasing the abortion rate. Each eligible state can receive up to $25 million a year. As proposed, the bonus would be based on a calculation of birth and abortion rates for a state’s population as a whole; bonuses would not be based on reductions for specific populations, such as teenagers. The five states that demonstrate the largest proportionate decrease in their out-of-wedlock birth ratios between the most recent 2 years and the prior 2-year period will be potentially eligible for a bonus award. Among the eight states we reviewed, state officials had mixed views about their chances to successfully compete for the bonus. Some say they will likely not be competitive for the bonus because they are focusing their prevention efforts on teens rather than adult women, who have most out-of-wedlock births; other states say they may not be eligible to compete because they do not have available the abortion data needed to compete. For example, California does not have an abortion reporting system for the data required under the proposed rules and, therefore, is unsure of its ability to compete. Illinois and Maryland had concerns about their abortion data being overstated because of current limitations in capturing information on marital status and residency. Oregon’s state law prohibits marriage under the age of 17 and, because the bonus encourages marriage, state officials do not believe the state will be competitive. Georgia, Maine, and Vermont will continue to focus their prevention efforts on teens, but since most out-of-wedlock births in these states occur among women 20 or older, these states believe they will not be competitive. Conversely, Louisiana—with its high teen birth rate—is very interested in getting any financial assistance available to support its TPP efforts and, thus, plans to compete for the bonus. Welfare reform also included a provision to enhance efforts to provide sexual abstinence education and authorized $50 million annually for 5 years in grants to states that choose to develop programs for this purpose. States must match 3 state dollars for every 4 federal dollars spent. States, local governments, and private sources often provide such funds in the form of cash or in-kind contributions, such as building space, equipment, or services. The funding can be used for abstinence-only education or mentoring, counseling, and adult supervision programs to promote abstinence until marriage and cannot be incorporated with programs that provide information on both abstinence and contraception. States had some concerns about the restrictive nature of the abstinence programs. One concern was that implementing education programs that stressed only abstinence would interfere with their efforts to develop and continue comprehensive programming. Maine, for example, encourages comprehensive sex education in the schools and felt that abstinence-only programs were not consistent with the state’s attempts to provide education that addresses both abstinence and contraception. Some states were also concerned that the research on abstinence-only education was limited. Moreover, they noted that the data that were available suggested that such programs have little or no effect on the initiation of sex, while research results on programs that provide information on both abstinence and contraception show that these types of programs do have some effect. Officials in seven of the eight states were also concerned about how to come up with the required matching funds without affecting the comprehensive programs they already had in place. Despite these concerns, all the states we visited applied for and received the federal funding to either initiate new programs or expand existing abstinence efforts. Fiscal year 1998 federal grants to the states for various abstinence-only initiatives ranged from $69,855 for Vermont to $5,764,199 for California. (See table 4.) As of June 1998, six of the eight states we visited had begun to implement their abstinence-only initiatives. In California, the state legislature did not approve the Governor’s proposal to implement the abstinence program, thereby preventing the use of federal funds. California has until September 1999 to approve a program and use the federal funds. Although Louisiana had received HHS approval on the basis of its initial application, the state withdrew the proposal in light of state pressure to implement a stronger abstinence program. HHS is currently reviewing the state’s revised plan. All of the states we visited had a variety of efforts under way to assess state TPP programs, including monitoring birth rates and conducting program evaluations. However, few of the evaluations measure program effect on the number of teens who become pregnant or on outcomes closely related to teen pregnancy, such as sexual and contraceptive behavior or high school achievement. Most of the state’s evaluations are measuring other outcomes, such as changes in knowledge, attitude, and behavioral intentions—outcomes that have been shown to be only moderate or weak predictors of teen pregnancy—or are monitoring program processes to determine whether certain aspects of programs were operating as intended, such as whether procedures and protocols were being followed. Some states are using performance measurement systems intended to assess their progress towards achieving TPP goals and improve accountability, but these alone will provide little information on program effectiveness. At the time of our review, all eight states were tracking the number of teen births and conducting evaluations of program operations, known as process evaluations. These data and evaluations enable states to know, for example, the number of program participants and whether or not programs were following procedures; however, they do not provide information on whether or not the program has had an effect on particular outcomes. While all states had begun evaluations that measure program effect on outcomes, most of the outcomes evaluated were of the type that research shows to be moderate or weak predictors of teen pregnancy.(See table 5.) Four states—California, Georgia, Illinois, and Maryland—had evaluations under way for some of their programs that would measure program effect on outcomes that research results have shown to be closely related to teen pregnancy, such as changes in sexual or contraceptive behavior or school achievement. However, most of the states’ outcome evaluations tended to measure program effects on knowledge, attitudes, and behavioral intention. Although evaluations of these indicators are useful, they do not necessarily show the long-term effects of the program or, more importantly, the effect the program has on teen pregnancy. The process evaluations being conducted in the eight states typically measured the number of clients served, types of services received, client responses to certain activities, and procedures and protocols followed. States use this information to monitor, evaluate, and modify program operations. In Maine and Vermont, for example, teens who used family planning clinics were surveyed to evaluate their satisfaction with the hours and locations of clinics, the types of services provided, and the overall appearance of the facility. The results were used to improve the delivery of teen-oriented services. States also used birth rates to track overall progress. Vermont officials told us that rather than conducting evaluations on each component in its strategy, the state’s oversight efforts focus on teen birth and pregnancy rates and responses to the state’s YRBS. These officials further believe that the availability of many TPP programs is responsible for the state’s low teen birth rate. Four states—California, Georgia, Illinois, and Maryland—are evaluating key programs in their TPP strategies that will likely give state officials some insight into the impact these programs are having on outcome measures closely related to teen pregnancy. At least three of these evaluations will use more rigorous designs and include comparison groups and follow-up. Georgia has awarded a contract for a 4-year evaluation that will determine the effect of its key program—Teen Plus—on contraceptive use as well as on teen pregnancies and births. The results of this evaluation will give state policymakers insight into whether the presence of the clinical services offered at the centers improved teen-pregnancy-related outcomes. California’s Community Challenge Grant Program is evaluating program effect on delay of sexual activity, contraceptive use, and school and job achievement and comparing results of its program participants with a group of nonprogram participants after 1 year. Illinois plans to evaluate the effect of its after-school program by assessing high school drop-out rates, graduation rates, and births to teens under age 18 and comparing these results with those for similar communities that did not participate in the program. Maryland plans to track over 5 years participants in its after-school programs to assess program effect on teen pregnancy. Two states we visited have used the results of previous outcome evaluations to modify their strategies. For example, when evaluation results of Illinois’ teen subsequent pregnancy prevention program showed an increased rate of school completion and a lower rate of subsequent pregnancy among participants, the state expanded the program to other communities. When an outcome evaluation of a California education program that focused on postponing sexual activity of 12- to 14-year-olds showed some improvement in knowledge gain but no delay of sexual intercourse, improved use of birth control, or reduced teen pregnancy, the state discontinued the program and implemented a more comprehensive TPP program. Officials in most states we visited expressed interest in knowing the effect of their programs on teen pregnancy. However, state officials said that available funding and resources limited their ability to conduct rigorous and long-term outcome evaluations, which research indicates may be necessary to evaluate and measure program effectiveness. Also, some program staff are reluctant to spend program dollars on evaluations. Four states we visited—Illinois, Maine, Maryland, and Oregon—were implementing performance measurement systems. Performance measurement—the ongoing monitoring and reporting of program accomplishments, particularly toward preestablished goals—is intended to improve program accountability and performance by requiring programs to establish and meet agreed-upon performance goals. In assessing their progress, states can use process, output, outcome measures, or some combination of these. To measure progress toward its goal of reducing teen pregnancy, Oregon plans to compare program performance measures—including the number of students remaining abstinent, the percent of sexually active teens using contraception, and the percent of teen mothers with no subsequent births—with established goals. Oregon has adopted an official statewide benchmark for the pregnancy rate among girls aged 10 through 17: The state has set a goal of reducing this rate to 15 by the year 2000 and to 10 by the year 2010. Maine requires all state health service contracts to be performance based and has established specific goals and objectives against which teen pregnancy programs are to be measured. The state plans to use assessment results in budgeting decisions. Maryland’s Partnership for Children and Families performance management system will measure teen birth rates, among other indicators. Illinois, which is in the early stages of developing its program performance measurement system, plans to use performance measurement in all program and service contracts, including teen pregnancy prevention. The federal government funds numerous TPP programs and supports research and data collection and surveillance on indicators related to teen pregnancy. Although a number of federal agencies provide funding, HHS has the primary federal role in supporting programs to reduce teen pregnancy. Together, 27 different HHS programs are available to states and local communities to support teen pregnancy prevention. Some of the funds are solely for teen pregnancy prevention; but others, such as the Maternal and Child Health Block Grant, allow states to fund various activities that improve the health of women, infants, and children. Although HHS could not isolate all of the funding specifically for TPP efforts, it was able to identify at least $164 million in fiscal year 1997. HHS also supports research, data collection, and surveillance related to teen pregnancy prevention and, in some cases, evaluates programs and demonstration projects related to teen pregnancy prevention at the state and local levels. HHS has evaluated very few of its programs to determine whether and how these programs affect teen pregnancies, births, or closely related behavioral outcomes. HHS recently began program evaluation efforts for two of its TPP programs—the multisite Community Coalition Partnership Program and the new Abstinence Education Program—that will measure the programs’ effects on behavior outcomes closely related to teen pregnancy. Also, in its strategic plan required by the Government Performance and Results Act of 1993, HHS established performance measures against which the performance of HHS-funded activities will be assessed. Nine federal agencies support programs that could be used to support TPP efforts: HHS; the Departments of Agriculture, Defense, Education, Housing and Urban Development, Justice, and Labor; the Corporation for National Service; and the Office of National Drug Control Policy. (See app. II for a list of these agencies’ programs related to teen pregnancy prevention.) HHS has the primary federal leadership role in teen pregnancy prevention. In fiscal year 1997, the agency provided at least $164 million in federal support to reduce teen pregnancy. About $126 million of this total was from Medicaid and the Title X Family Planning Program. Another $28 million was for two of the three federal programs whose primary goal is teen pregnancy prevention—the Adolescent Family Life (AFL) Program and the Community Coalition Partnership Program for the Prevention of Teen Pregnancy (CCPPPTP). The remaining $10 million is from the Preventive Health and Health Services Block Grant and several broad youth programs that were able to isolate specific funds for teen pregnancy prevention. Beginning fiscal year 1998, HHS provided states with $50 million in funding for the new Abstinence Education Program (AEP). AFL and CCPPPTP are funded directly to local communities and may not be included in a state’s strategy, whereas funding for AEP goes directly to states. Many other TPP initiatives are funded through block grants, but HHS could not isolate the amount of additional funding. Because of the nature of block grant programs, funds are not specifically allocated to teen pregnancy at the federal level and states have some flexibility in deciding how to use them. The states we visited said they relied on programs such as the Maternal and Child Health Block Grant, the Social Services Block Grant, and TANF to support their TPP strategies. Other funding streams that support programs addressing other issues may include teen pregnancy prevention as one of the objectives. For example, the Community Services Block Grant funds programs that address poverty in communities, but the programs can include teen-pregnancy-related initiatives, such as family planning, substance abuse prevention, and job counseling. Table 6 shows fiscal year 1997 funding available through HHS that could be used to support teen pregnancy prevention. To complement the activities summarized in table 6, HHS is developing a TPP strategy at the federal level. In 1997, HHS released the National Strategy to Prevent Teen Pregnancy, a departmentwide effort to prevent out-of-wedlock teen pregnancy and support and encourage teens to remain abstinent. As part of the strategy, HHS has reported that it is strengthening its efforts to improve data collection, research and evaluation, and the dissemination of information. In addition, HHS said it will strengthen its support for promising research-based approaches that are tailored to the unique needs of individual communities. In addition to its funding for programs, HHS supports data collection, surveillance, and research related to teen pregnancy prevention through broader public health activities and research on issues such as adolescent health. Within HHS, CDC has the primary role of monitoring teen pregnancy and births by collecting data on pregnancies, live births, fertility, contraception, and teen sexual behavior and collaborating with state vital statistics offices to develop data on the incidence and trends of teen pregnancies and births. CDC also monitors sexual risk behaviors among high school students at national and state levels and monitors TPP policies and programs implemented by the nation’s state education agencies, school districts, and schools. The National Institutes of Health (NIH) supports research on the causes of and risks associated with teen pregnancy. (See table 7.) HHS has conducted very few evaluations to determine whether and how programs that it supports actually affect teen pregnancies, births, or the behavioral outcomes closely related to teen pregnancy. Because block grants—a source of funding used by the eight states to support their TPP strategies—give states flexibility in using funds, specific program evaluations are not typically required. Other programs that can support TPP activities do not evaluate their effect on teen pregnancy because teen pregnancy prevention is not their primary goal. HHS does require evaluations of three HHS programs whose primary goal is teen pregnancy prevention. Two of these program evaluations will measure program effects on teen sexual behavior, use of contraceptives, and teen births. AFL, one of three TPP programs, provides local and state grantees with funding for abstinence programs. The enabling legislation requires annual evaluations and are supposed to be funded by not less than 1 percent and not more than 5 percent of program funds. According to HHS officials, evaluations of AFL programs have shown positive short-term results in increased knowledge and changed attitudes but have not examined program effects on teen pregnancy. CDC’s Community Partnership Program requires all grantees to evaluate program processes and allocates about 20 percent of program funds to evaluations. All 13 of these communities will collect similar data, including behavioral data that are closely related to teen pregnancy, so that comparisons across sites can be made. Six of the 13 communities are participating in enhanced evaluations that will include a special focus on certain program components. CDC is providing supplementary funding and technical assistance to the communities participating in the enhanced evaluation. Although there is no evaluation requirement for states participating in AEP to evaluate their abstinence-only programs, the Balanced Budget Act of 1997 authorized HHS to use up to $6 million in fiscal years 1998 and 1999 to evaluate AEP. In May 1998, HHS issued a request for proposals to evaluate the effectiveness of selected AEP programs. The evaluation’s goal is to determine the effects of the abstinence education programs in achieving key outcomes, including reduced rates of sexual activity, teen pregnancies and births, and sexually transmitted diseases. In August 1998, HHS awarded the contract to Mathematica Policy Research, Inc. In addition to these evaluations, HHS is currently evaluating or has recently completed evaluating two multisite teen parent programs that measure TPP outcomes, including teen subsequent pregnancies and births, sexual activity, contraceptive practices, as well as other measures related to education attainment, employment, welfare dependency, and child well-being. According to HHS officials, HHS plans to direct additional funds toward evaluation of the specific TPP programs the agency funds. As part of a national strategy, HHS announced in May 1998 the availability of $300,000 to enhance ongoing state, local, or private evaluations. HHS officials said they recognize that even more program evaluations need to be done. According to some experts, higher quality evaluation is also needed. These evaluations should measure program effects on the behavioral goals of the program and risk factors associated with teen pregnancy; they should also follow program participants to learn about long-term effects. HHS officials also suggested that evaluation dollars be used selectively on promising programs and not be spread too thinly. As required under the Results Act, HHS recently began implementing performance goals and measures for all of its programs, including those intended to prevent teen pregnancy. In 1997, the Maternal and Child Health Bureau worked with states and other stakeholders to pilot test the new Results Act requirements on the Maternal and Child Health Services Block Grant Program. For this program, state grantees must set numeric goals for each performance measure and are required to report progress in achieving these goals. The Bureau and its eight pilot states—including Maine, a state in our review—collaborated to pretest the new reporting requirements, such as those related to reducing the birth rate among teens aged 15 to 17—one of the 18 national core performance measures.According to an HHS official, the pilot resulted in the automated reporting of more uniform data and a much more streamlined process, making it easier for Bureau officials to assess program performance against goals. The official stated that the piloted process has the potential to improve state accountability for progress toward state goals. Officials in Maine said that the experience they gained from participating in the pilot prompted them to reexamine priorities and focus on current needs of its Maternal and Child Health Services Block Grant population. In developing its 1998 plan, Maine added a state-initiated performance measure of lowering the number of unintended births among women under age 24. Maine officials also reported that the new application and reporting process helped them make resource decisions that were more consistent with agreed-upon state and federal priorities. The federal government provides millions of dollars to support TPP efforts. Although the states in our review relied on research findings in developing certain aspects of their strategies, too few programs are systematically evaluated to guide TPP program efforts. Some programs within the state strategies are being evaluated, but most do not measure the known risks or outcomes that are linked to teen pregnancy, such as school achievement, delay of sexual initiation, and contraceptive and sexual behavior. Furthermore, most do not allow for sufficient follow-up to determine long-term program effects. Evaluation efforts at the federal level have also been limited. However, HHS is beginning two major evaluations of TPP programs that will look at their long-term impact on outcomes known to be related to teen pregnancy prevention. The results of evaluations that focus on outcomes related to teen pregnancy should help states, the federal government, and others in choosing the programs or approaches most likely to be effective in preventing teen pregnancy. Four of the states we visited and the federal government are establishing performance measures systems to allow for assessments of program performance toward achieving established TPP goals and to help improve accountability. Although performance measurement alone will not provide the information necessary to understand the link between the programs and their effects on reducing teen pregnancy, the Results Act encourages a complementary role for performance measurement results and program evaluation findings. Performance measurement combined with program evaluations of outcome measures that are predictors of teen pregnancy is more likely to yield results that can be used to improve the overall effectiveness of states’ TPP efforts. We obtained comments on a draft of this report from HHS; the eight states we visited; the Director of the Center for Reproductive Health Policy Research, University of California; and the Director of the National Campaign to Prevent Teen Pregnancy. The reviewers generally agreed with the findings and conclusions in the report. HHS felt that the Department’s commitment to evaluating TPP programs described in the report could be expanded to include other efforts that evaluate how teen parent programs affect teen births and behavioral outcomes related to teen pregnancy. We added the information HHS provided. Each reviewer provided additional information and clarification and suggested technical changes, which we incorporated where appropriate. We plan no further distribution of this report until 30 days from the date of this letter. At that time, we will send copies to the Secretary of HHS, officials of the states included in our review, appropriate congressional committees, and other interested parties. We will also make copies available to others upon request. Please contact me on (202) 512-7119 if you or your staff have any questions about this report. Other major contributors to this report were James O. McClyde, Assistant Director; Martha Elbaum; and Karyn Papineau. In response to congressional concern about teen pregnancy, we were asked to identify the strategies states have been implementing to prevent teen pregnancy and how states fund these strategies, determine if federal welfare reform had an effect on these strategies, identify these states’ efforts to evaluate their pregnancy prevention efforts, and describe the federal government role in supporting state efforts to prevent teen pregnancy. To accomplish these objectives, we first contacted HHS and experts from the National Campaign to Prevent Teen Pregnancy, the Urban Institute, the National Governor’s Association, the Annie E. Casey Foundation, and the Henry J. Kaiser Family Foundation to learn about states that had strategies or were embarking on interesting approaches. Complementing this information, we used HHS’ teen birth rate data by state from 1991 to 1994, the most current data available at the time, to determine which states had high, low, and moderate birth rates. Subsequent to our review of state-level data in April 1997, the National Center for Health Statistics published state-level teen birth rates for 1995 and 1996. The variations among states in 1995 and 1996 were not markedly different from those reported for 1994. Using this information and the 1994 data, we selected eight states for review: California, Georgia, Illinois, Louisiana, Maine, Maryland, Oregon, and Vermont. All had their TPP strategies in place or had initiatives or reorganization under way. The teen birth rates in these states were high, low, or stable. (See table I.1.) These states provided a cross section of approaches to teen pregnancy prevention, but the results of our work cannot be generalized nationally—particularly since we chose states that had strategies under way. Table I.1: Changes in Birth Rates Per 1,000 Teens Aged 15 to 19 in the Eight Selected States, 1991, 1994, and 1996 Ga. Ill. La. Md. Oreg. Vt. To learn about each state’s TPP strategy, we interviewed state officials within the lead agencies responsible for TPP efforts, along with officials from other state agencies that had a supporting role in the strategy, as shown in table I.2. To describe state strategies and programs and the effect welfare reform may have had on these efforts, we obtained and analyzed program documents and data in each of the case study states and obtained descriptions of applicable laws. We also interviewed local program officials from county governments, local health departments, and community organizations responsible for implementing TPP programs. In the states where Title X Family Planning Program funding does not go directly to the state, we interviewed officials in the nonprofit corporations who administer the program. In the states where major private TPP programs were operating independent of the state strategy, we interviewed relevant officials to determine their involvement with the states. To determine how states evaluate their strategies and programs, we reviewed and analyzed completed evaluations and discussed with officials plans to conduct additional evaluations. We also reviewed the literature on the current status of evaluating TPP programs and conducted interviews with program evaluators. To determine how much states spend on teen pregnancy prevention, we asked each state to provide financial information for their fiscal year 1997 programs. We asked the states to provide us the dollar amount and sources of federal and state funding for programs to prevent teen pregnancy. Some states were able to identify the amount of money from various federal sources, but some states were unable to break out TPP spending from the various block grants used to fund the effort. Federal requirements do not mandate that funding for TPP efforts be separated from more broad categories, such as the Maternal and Child Health Block Grant, and block grants offer states discretion in the use of funds. We did not verify the funding information the states provided. To obtain information on the federal role in supporting state efforts to reduce teen pregnancy, we met with HHS officials, who identified all agencies within HHS that administer TPP programs along with other federal agencies that fund TPP efforts. Through HHS, we asked each HHS agency and the other federal agencies to provide us information on the programs they administer that can impact teen pregnancy. We also asked them to provide information on the programs’ total funding and the amount of the funding directly for teen pregnancy. Many of the programs could not isolate funding for teen pregnancy prevention because it was not an explicit focus of their programs. We did not verify the funding data provided. We performed our work between April 1997 and November 1998 in accordance with generally accepted government auditing standards. The Cooperative State Research, Education, and Extension Service links education resources and Department of Agriculture programs and works with land grant universities and other educational institutions. A systemwide initiative on children, youth, and families at risk has highlighted programs and research related to teen pregnancy prevention. In addition, the service reaches 5.6 million youth through 4-H programs managed by state land grant partners. Programs vary from state to state; state land grant institutions typically do not have a budget line item for teen pregnancy prevention. Supports youth programs that offer no specific efforts to prevent teen pregnancy. Most Department of Defense youth program staff can refer youth to appropriate education or health programs, and many youth programs provide curricula geared to informing teens about pregnancy prevention services offered by military medical treatment facilities. Some educational activities at U.S. installations have prevention education for teens and preteens. Programs are not authorized to allocate money for TPP activities, but some of the money distributed to states in the form of grants may be used for that purpose. No specific programs for teen pregnancy prevention; however, the Department does have some grant programs that local grantees may use for broad purposes, such as youth development programs with more specific teen pregnancy prevention goals. Administers programs focused on at-risk youth and designed to reduce juvenile delinquency, which may have a tangential impact on teen pregnancy. Youth programs that target poor areas and at-risk youth and seek to ameliorate youth problems by providing services and education, training, and work opportunities. Programs may include education, counseling, and services related to teen pregnancy prevention. Volunteers through the Corporation’s volunteer program work with communities on various activities, some of which may be TPP activities or youth development programs. Does not provide direct programming on teen pregnancy prevention. The Office coordinates substance abuse prevention focus of other federal agencies, with a focus on youth. 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Summary: Pursuant to a congressional request, GAO provided information on: (1) state strategies to reduce teen pregnancy and how states fund these efforts; (2) how welfare reform affected states' strategies; (3) the extent to which programs that are part of states' prevention strategies are evaluated; and (4) what teen pregnancy prevention activities the federal government supports. GAO noted that: (1) the eight states in GAO's review have, over time, developed teenage pregnancy prevention (TPP) strategies involving numerous programs that fall into six areas; (2) in general, these states targeted high-risk populations and communities and tailored programs to three different groups of teens; (3) while strategies were applicable statewide, states typically relied on local communities to select and implement specific programs from an array of alternatives; (4) states generally gave localities the flexibility to choose the type and mix of programs they wanted to put in place; (5) some communities chose not to implement programs that the state strategy encouraged; (6) all of the states GAO visited relied on federal funding to support their strategies and in many of the states, federal funding exceeded state funding for TPP; (7) the 1996 federal welfare reform legislation had a limited effect overall on these states' TPP strategies, in part, because the states in GAO's review already required that teen parents live at home and stay in school to receive assistance--two key provisions now mandatory under federal welfare reform; (8) only two of the eight states plan to compete for the bonus provided by the law to states that show the greatest success in reducing out-of-wedlock births; (9) the other states are unlikely to compete because they lack the data needed to show reductions or because their prevention efforts focus on teens who account for a relatively small proportion of out-of-wedlock births; (10) although the eight states initially had concerns about the prescriptive nature and administrative requirements of the new law's grant program for sexual abstinence education, the eight states applied for the grants, received funding, and plan to either initiate new abstinence education programs or expand programs that they had already included as part of their strategies to prevent teen pregnancy; (11) although all eight states are tracking changes in teen births, few are evaluating the effect of their TPP programs on teen pregnancy; (12) only four states are attempting to link some of their TPP efforts to changes in teen pregnancies, births, or other closely related outcomes; (13) for fiscal year 1997, the Department of Health and Human Services identified at least $164 million for TPP programs or services; and (14) however, funding specifically for TPP activities could not be isolated at the federal level, primarily because of the flexibility on spending decisions given to states.