Population Health: The Big Picture
Interview: Sarah S. Brown
Sarah S. Brown is director of the National Campaign to Prevent Teen Pregnancy, a nonprofit, nonpartisan initiative she helped created in 1996 to improve the wellbeing of children, youth, and families by reducing teen pregnancy. As she explains in the following interview, the campaign played a critical role in a remarkably successful effort that reduced by one-third the number of pregnancies and births among teenage girls. This experience can serve as a model and an inspiration for other public health programs.
A specialist in women’s and adolescent health, Brown has worked in the public health sector for more than 30 years. Before cofounding the campaign, she served as senior study director at the Institute of Medicine, where she directed a range of maternal and child health projects, including The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, a widely cited study of the probable causes, effects, and possible remedies of unintended pregnancy. Brown has served on the boards of the Alan Guttmacher Institute and the District of Columbia’s Mayor’s Advisory Board on Teenage Pregnancies and Out-of-Wedlock Births. She is the recipient of numerous awards, including the Irvin M. Cushner Lectureship Award from the Association of Reproductive Health Professionals, the Institute of Medicine’s Cecil Award for Excellence in Research, and the Martha May Elliot Award of the American Public Health Association.
Why was the National Campaign to Prevent Teen Pregnancy organized, and what made you think this progress was possible?
The National Campaign to Prevent Teen Pregnancy was organized in 1996 by a diverse group of individuals who had concluded that the problem of teen pregnancy was not receiving the intense national focus that it deserved; that too few Americans understood the central role that teen pregnancy plays in child poverty, out-of-wedlock childbearing, and welfare dependence; and that there was merit in raising the profile of this problem and in pushing hard for solutions. At its first meeting, the National Campaign’s board defined the organization’s mission: to improve the well-being of children, youth, and families by reducing teen pregnancy. The board also set a numerical goal for the nation and the National Campaign: to reduce the rate of teen pregnancy by onethird between 1996 and 2005.
Most observers considered this goal—to put it charitably—overly ambitious. Because rates of teen pregnancy spiked upward during the mid- and late1980s, there were many who felt that this nation’s high rates of teen pregnancy were inevitable and intractable. Our reading was a bit different. Taking a longer view, we saw that rates of teen pregnancy and birth had been declining slowly but steadily (more or less) for over two decades, with the exception of this late-1980s blip. Consequently, we believed that teen pregnancy rates could again start heading in the right direction, provided that the issue received the national attention it deserved.
What strategy has the National Campaign used?
The National Campaign’s strategy is based on a straightforward concept: Reducing teen pregnancy can be accomplished only by fewer teens being sexually active and/or by better use of effective contraception among those who are. Both behaviors contributed to earlier declines in teen pregnancy, and more of both are needed in going forward to sustain the decline. All of the National Campaign’s efforts center on affecting these two behaviors by communicating directly with teens themselves or by influencing intermediaries that research has shown influence the sexual behavior of teens.
The organization’s strategy works on two main fronts: building a more coordinated and effective grassroots movement in states and communities and influencing social norms and popular culture. In all of our work, we engage a range of sectors—teens, parents, state and community leaders, entertainment media executives, educators, faith leaders, policy-makers, the press, other national nonprofit groups, and more. In addition, we approach teen pregnancy in a nonideological big-tent way and work hard to reduce the conflicts that often impede action on this tough problem. All activities are based on high-quality research, an emphasis on using partnerships as a way to increase the reach and power of our efforts, and a commitment to evaluating our work. And, as a small group trying to influence a vast country, we rely heavily on technology—the Internet, in particular—to reach millions of teens and their parents.
What does this mean in practice?
The first strategy—building a grassroots movement— involves working with people in states and communities. The National Campaign provides research and data that they can use in their programs or coalitions, and we also offer direct technical assistance through site visits, regional conferences, and access to our Resource Bureau, which includes contacts and experts in all 50 states. Our Web site (www.teen pregnacy.org), which currently averages more than a million visitors each year, is another source of extensive information and support to practitioners in states and communities. For example, data on teen pregnancies and births are provided on the Web site for every county in the United States; many of our manuals about what to do at the local level to reduce teen pregnancy can be downloaded free of charge; and extensive bibliographical material is also posted.
The second strategy focuses on influencing cultural values and messages. Simply put, it’s fine to work with states and communities to make their efforts more research-based, tolerant of differing views, and tailored to local realities. But doing so is a futile exercise if the entire culture, especially popular teen culture, is sending the message that getting pregnant at a young age is no big deal, that having sex “early and often” with multiple partners is just fine, that contraception is not all that important, that sex has little meaning and few consequences, that postponing sex is a hollow idea, and that parents can’t do anything about their children’s sexual attitudes and behavior. The fact is that we have to work at both levels —state/local as well as popular culture—and the National Campaign is a pioneer in doing so.
Where have you encountered resistance?
Because teen pregnancy is closely connected to aspects of our lives that we hold most dear—our understanding of family and children; the meaning of love, marriage, and commitment; the role of self-expression and self-fulfillment; and, for many people, their religious beliefs—we fully expected that there would be disagreements over how best to reduce teen pregnancy. However, I think we have been surprised at the depth of disagreements and how these disagreements can often stymie action.
It seems to us that one of the most strident arguments at present—fighting over which strategy is better, sexual abstinence or contraceptive use—is a recipe for stalemate. This ideological struggle is obscuring an important cause of teen pregnancy: namely, that many teens are insufficiently motivated to adopt either approach. Note that in current American life and culture, both sexual abstinence and careful use of contraception require a lot of self-discipline, determination, and sometimes even money (in the case of the better methods of contraception). And while the adults argue over which means of pregnancy prevention is better, too many teens are becoming pregnant because they neither abstain nor use contraception. Research shows that both strategies, perhaps in equal portions, have driven the teen pregnancy rates down in recent years. There is no need to choose between the two.
Having said that, it is also important to note that Americans prefer by large margins that teens choose abstinence over sex with contraception. That is, they prefer that teens wait until they are adults to become sexually active and, in particular, to start families. But that does not mean that they think teens should be denied information about sex, love, and reproduction or the health care needed to avoid pregnancy and sexually transmitted diseases (STDs), including HIV/AIDS.
We have also learned that in a diverse country, it is essential to have many helpful approaches to preventing teen pregnancy. It is unrealistic to think that individuals or groups will always be able to put aside their deeply held beliefs on this issue and agree on one single way to reduce teen pregnancy. Often the best strategy is unity of goal but tolerance for a diversity of means.
What role has research played in your work?
The Campaign’s work is supported and shaped by a deep respect for data and research. Our feeling has always been that in a field so often buffeted by ideological skirmishing, having a sound grounding in science would help to stabilize the organization and make it more effective. Since the National Campaign to Prevent Teen Pregnancy was established in 1995, we have tried hard to build a solid reputation for conducting careful analyses and preparing top-notch research products that are widely used and relied on by the research community, professionals in teen pregnancy prevention and related fields, parents, government officials and policymakers, and the press. Our research activities are overseen by a top-notch scientific advisory group chaired by Brent Miller, the vice president for research at Utah State University.
We are constantly asking what implications new research and information have for our own work and for efforts nationwide to reduce teen pregnancy. As such, the Campaign can be seen in part as an intense effort to move relevant research into practice and to disseminate high-quality information to individuals working on this issue. For example, since the Campaign was established in 1996, we have commissioned over 20 research reports on topics such as evaluating abstinence programs, the role of men and boys in pregnancy prevention, programs that may help teen mothers avoid additional births while still in adolescence, and parental influence.
In addition, we emphasize how high-quality evaluation can improve the design and impact of prevention programs. The flagship and perhaps most widely requested product of the National Campaign is a review we commissioned of all the peer-reviewed published literature on the effectiveness of various community-based programs to reduce teen pregnancy. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, written by Douglas Kirby, senior research scientist at ETR Associates, has been widely disseminated—about 200,000 copies have been distributed or downloaded—to program leaders, foundation and government officials, and others who want to know what works. The enormous demand for the document signals to us that there was a need not only for more research-based information in this field, but also for information presented in simple and straightforward language.
Is the National Campaign’s strategy still evolving?
Yes. Although we are delighted that the country has made such stunning progress in reducing high rates of teen pregnancy (the rate has declined by about 30 percent over the past decade and more), the United States still has the highest rates of teen pregnancy, birth, and abortion in the fully industrialized world. Moreover, it may be that the “easy gets” have already been won and that sustaining the momentum going forward will be particularly difficult. Consequently, we are trying to focus particular attention in areas where rates of teen pregnancy remain stubbornly high. For example, although pregnancy and birth rates among Hispanic teen girls have declined in the past decade and more, it is still the case that 51 percent of Latina girls get pregnant at least once before age 20, as compared to the national average of 35 percent. The Hispanic community is currently the largest minority population in the United States, now making up 13 percent of the overall population and 16 percent of the teen population. But their representation is even larger in the issues central to our work: 23 percent of overall teen pregnancies and 30 percent of teen births are now Hispanic. Over the next 20 years, the Latino teen population will increase by 60 percent, whereas the overall teen population will grow by only 8 percent. By the year 2020, one in five teens will be Latino. All of these data suggest that Hispanic communities merit more intense support and attention in the national effort to reduce teen pregnancy. As a nation, we have not done a particularly good job of crafting messages and interventions specifically for the Hispanic community. As is true with any community, careful attention to cultural and religious differences is critical.
What seems to be working?
The teen pregnancy and birth rate in the United States has declined by about one-third since the early 1990s. Most investigators credit a decrease in sexual activity in addition to an increase in contraceptive use among teens as the reasons why these rates have improved. We usually offer several reasons why teens may be changing their behavior: concern about STDs in general and AIDS in particular; evidence that teens are taking a slightly more cautious approach to casual sex; the availability of long-lasting hormonal contraception such as Depo-Provera; possible effects from welfare reform; and increased attention to the sexual behavior of young people generally (in families, in the media, and elsewhere) may all help explain what has motivated teens to reduce their risk of pregnancy. But we are the first to say that there is often a lot of uncertainly about what precisely accounts for changes in fertility rates and trends, of which changes in teen pregnancy rates are only one recent example.
If the question is what seems to be working programmatically, we certainly know much more now than we did even five or six years ago. Thanks to some important investments in program evaluation, we now know more about the relative effectiveness of certain classes of teen pregnancy prevention programs. Interestingly, it appears that several approaches can help, all the way from classroom-based sex and HIV education programs, to intense youth development interventions, to programs that involve young people in community service. Many of these can be effective in helping teens delay first intercourse, increase the use of contraception, and—our goal—decrease teen pregnancy. Having an array of effective approaches is a heartening development, given that until quite recently, little was known about what programs might be most useful in preventing teen pregnancy. This growing pool of effective programs is particularly good news for communities searching for programmatic answers to still-high rates of teen pregnancy.
Of course, there are limits to programmatic solutions to a problem as complex as teen pregnancy. Most programs have not been well evaluated. Consequently, we know less than we would like to about their efficacy. It may very well be that there are any number of creative programs that are effective in helping adolescents avoid risky sexual behavior that simply have not been evaluated at all. Of those programs that have been carefully examined, many have not shown positive results. Put another way, since teen pregnancy is rooted partly in popular culture and social values, it is unreasonable to expect that programs alone can change forces of this size and power. Making true and lasting progress in preventing teen pregnancy will likely require a combination of community programs and broader efforts to influence values and popular culture.
What about abstinence-only approaches?
The jury is still out on abstinence-only programs. Because very little rigorous evaluation of this approach has been completed—and because those few studies that have been completed do not reflect the great diversity of abstinence-only programs currently offered—no definitive conclusion can be drawn. That might change in the future, because a rigorous federally funded study of some of these programs is under way.
Because, as noted earlier, there is a strong preference in America that school-age teens not be sexually active, programs that strongly support a delay in sexual activity are likely to remain popular in many communities. Still, it is also important to recognize the value of convincing sexually active teens to use contraception consistently and carefully. After all, the only teens who are getting pregnant or contracting an STD are those who are having sex but not using contraception consistently and carefully. For example, what is gained if we succeed in encouraging teens to delay first sex only to find that, once sexual intercourse begins (as it usually does in later adolescence), rates of unintended pregnancy and STDs are high because young people do not know enough about contraception and protection.
Did you evaluate the importance of supervised activities such as after-school and community center programs?
Because the reasons behind teen pregnancy vary, so do the types of programs designed to combat the problem. Although the most important antecedents of teen pregnancy and childbearing relate directly to sexual attitudes, beliefs, and skills, many factors closely associated with teen pregnancy actually have little to do directly with sex (such as growing up in a poor community, having little attachment to one’s parents, or failing at school). In fact, as noted earlier, certain community service programs, which might not focus on sexual issues at all, have very strong evidence that they reduce actual teen pregnancy rates while the youth are participating in the programs.
Here is what research tells us: Large amounts of unsupervised time are associated with risky sexual behavior among teens. Adult supervision, which many of these programs provide, is strongly linked to reduced sexual risk-taking. After-school programs may reduce risky sexual behavior by simply involving teens in activities that provide alternatives to sex. Such programs may also put young people in close touch with caring adults who are able to provide much-needed guidance and support. Finally, teens who believe that they have future opportunities have incentives to postpone sexual involvement, use contraception more consistently, and avoid unwanted pregnancies or births.
How do you assess your organization’s results?
The most important result is that teen pregnancy rates are now coming down. Between 1990 and 2000, the teen pregnancy rate declined 28 percent; the teen birth rates declined by a third between 1991 and 2003; and declines occurred in all 50 states and in all of the major racial and ethnic groups. This, in turn, has contributed to a leveling off of the proportion of all children being born outside marriage. And both have contributed importantly to the decline in the child poverty rate—and especially in the black child poverty rate—since 1993. These trends suggest that progress is possible and that the National Campaign’s efforts and those of others are paying off. Of course, the precise contribution of the National Campaign’s effort is unknowable, but we do take some credit! Why not?
What changes do you see in national attitudes toward teen pregnancy?
A strong national consensus has developed among adults and teens alike that middle-and high-school kids, in particular, should be given a clear message that abstinence from sexual intercourse is the right thing to do because of the numerous important consequences of sexual activity, and because sexual intercourse should be associated with meaning and serious commitment. The view is not that abstinence should be presented to young people as one of several equally attractive options but as the strongly preferred one. As one father said, “Abstinence is options one through five.” Fully 9 in 10 adults and teens surveyed agreed that “it is important for teens to be given a strong message from society that they should abstain from sex until they are at least out of high school.” Some go on to urge abstinence until marriage specifically.
But it is also true that even when given strong advice to remain abstinent, some young people will not do so. After all, about 6 in 10 high-school kids report that they have had sex at least once by the time they graduate from high school. Some of these young people can perhaps be encouraged to stop having sex, but experience suggests that many will continue to be sexually active. For these young people—and, after all, only those kids who are sexually active are at risk of pregnancy and STDs—the clear national consensus is that young people should be provided with information about contraception and have access to appropriate medical care.
Are there other public health problems where your approach might be successful?
On reflection, several organizational aspects of the National Campaign have seemed especially important to our success and progress, and we commend them to others working on complex problems, particularly at the national level:
- Set a clear goal or two that can be measured in order to assess progress. It has been a wonderful discipline to have an actual target and to follow progress.
- Develop a board that is well connected, diverse in background and sector, and willing from day one to raise money. The first attribute has been especially important to us; there is nothing like having powerful people on your team. It can make all the difference. Corollary for those who are focused on legislative action: Line up bipartisan champions in the House and Senate.
- About 6 in 10 high-school kids report they have had sex at least once by the time they graduate from high school.
- Start with the science. The world is littered with advocacy groups who are seen as just that: advocacy groups. We have found it more effective to be seen as a research-based group tackling a tough social problem in a sensible, research-based, and bipartisan manner. Without such grounding, one gets caught up in the hurly burly of it all.
- We chose not to develop state affiliates but rather to work with a variety of state-level groups. That has saved us endless amounts of time and aggravation. We suspect that the outcomes would have been the same.
What’s next for the National Campaign?
As the National Campaign celebrates its 10th anniversary in 2005, and building on the great progress the country has made over the past decade plus, our new challenge to the nation for the next decade will be to reduce teen pregnancy by another one-third. We will keep pushing hard, because even with recent declines, 35 percent of girls become pregnant at least once before turning 20, and U.S. taxpayers shoulder at least $7 billion each year in direct costs and lost tax revenues associated with teen pregnancy and childbearing. Should our new goals be reached, the United States would probably then sink from having the highest rate of teen pregnancy among industrialized nations to number two or three. Wouldn’t it be great to not be number one for a change?