Teen Pregnancy: State and Federal Efforts to Implement Prevention
Programs and Measure Their Effectiveness (Letter Report, 11/30/98,
GAO/HEHS-99-4).

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.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-4
     TITLE:  Teen Pregnancy: State and Federal Efforts to Implement
             Prevention Programs and Measure Their Effectiveness
      DATE:  11/30/98
   SUBJECT:  Pregnancy
             Program evaluation
             Teenagers
             Single parents
             Federal/state relations
             State-administered programs
             Public assistance programs
             Women
             State/local relations
IDENTIFIER:  California
             Georgia
             Illinois
             Louisiana
             Maine
             Maryland
             Oregon
             Vermont
             HHS Temporary Assistance for Needy Families Program
             Medicaid Program
             Maternal and Child Health Block Grant
             HHS Healthy People 2000 Program
             HHS Title X Family Planning Services Training Program
             HHS Adolescent Family Life Program
             HHS Community Coalition Partnership Program for the
             Prevention of Teen Pregnancy
             HHS Abstinence Education Program
             Social Services Block Grant
             Preventive Health and Health Services Block Grant

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Cover
================================================================ COVER

Report to the Chairman, Committee on Labor and Human Resources, U.S.
Senate

November 1998

TEEN PREGNANCY - STATE AND FEDERAL
EFFORTS TO IMPLEMENT PREVENTION
PROGRAMS AND MEASURE THEIR
EFFECTIVENESS

GAO/HEHS-99-4

Teen Pregnancy Prevention Efforts

(108324)

Abbreviations
=============================================================== ABBREV

  ACF - Administration for Children and Families
  AEP - Abstinence Education Program
  AFL - Adolescent Family Life
  CCPPPTP - Community Coalition Partnership Program for the
     Prevention of Teen Pregnancy
  CDC - Centers for Disease Control and Prevention
  HHS - Department of Health and Human Services
  HRSA - Health Resources and Services Administration
  ICTF - Indigent Care Trust Fund
  NIH - National Institutes of Health
  OPA - Office of Population Affairs
  SAMHSA - Substance Abuse and Mental Health Services Administration
  TANF - Temporary Assistance for Needy Families
  TPP - teen pregnancy prevention
  YRBS - Youth Risk Behavioral Survey

Letter
=============================================================== LETTER

B-277558

November 30, 1998

The Honorable James M.  Jeffords
Chairman, Committee on Labor
 and Human Resources
United States Senate

Dear Mr.  Chairman:

In 1996, about 1 million teenage girls in the United States became
pregnant and over half of them gave birth.  Among births to teens
aged 15 to 17, 84 percent occurred outside of marriage.  Although the
teen birth rate has been declining steadily in recent years, the
United States has the highest teen birth rate of all industrialized
nations--about 54 per 1,000 teens aged 15 to 19 as of 1996,\1 nearly
twice as high as the next nation, the United Kingdom.  Families
started by teenagers received an estimated $39 billion in federal
assistance in 1995 from programs such as Medicaid; Aid to Families
With Dependent Children\2 ; and the Special Supplemental Food Program
for Women, Infants, and Children.\3

Teenage pregnancy and parenthood have unfortunate consequences for
society, teenage mothers, and the children born to them.  Teen
mothers frequently do not complete high school, have poor earnings,
and have increased dependency on the welfare system.  A child born to
a teen mother is more likely to have a low birthweight and health
problems, suffer abuse, live in an inferior home environment, be
poor, and be less likely to succeed in school.  Moreover, a child
born to a teen is more likely to become a teenage parent.

In an effort to prevent teen pregnancy, the federal government and
states have taken a number of actions.  For example, the Congress
recently enacted welfare reform legislation that contains provisions
directed at reducing out-of-wedlock childbearing and welfare
dependency and promoting sexual abstinence education, especially to
teenagers.\4 The Department of Health and Human Services (HHS) is
developing a national strategy to prevent teen pregnancy, while
states and local governments and private entities are implementing
strategies for addressing the problem of teenage pregnancy and
childbearing.

Because of your interest in efforts to prevent teen pregnancy, you
asked us to provide 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.

For this review, we focused on eight states that had longstanding
teen pregnancy prevention (TPP) strategies in place:  California,
Georgia, Illinois, Louisiana, Maine, Maryland, Oregon, and Vermont.
The teen birth rates in these states vary; some had experienced
recent declines, and some had more stable rates.  These states also
employed a variety of strategies to prevent teen pregnancy, but the
strategies are not necessarily representative of the nation.  During
our state visits, we interviewed officials from multiple state
agencies--health, social services, education, and justice--who were
responsible for implementing their states' TPP strategies.  We also
held discussions with local officials who were responsible for
implementing the state strategies and some of the teens involved in
the programs.  We obtained information on state TPP strategies and
programs, including state and federal financial assistance, and state
efforts to evaluate them.  Although we collected information on state
strategies and programs, we did not evaluate them.

To determine the federal role in preventing teen pregnancy, we met
with HHS officials who were knowledgeable about TPP activities.  We
also obtained written responses to questions on programs, funding,
surveillance, monitoring, and evaluation from HHS and other federal
agencies that HHS identified as having a role related to teen
pregnancy prevention.\5 To learn more about teen pregnancy
prevention, demographics, research, programs, and other issues, we
met with and obtained information from experts in academia and
relevant organizations.  (See app.  I for a detailed description of
our scope and methodology.) We conducted our work between April 1997
and November 1998 in accordance with generally accepted government
auditing standards.

--------------------
\1 National Center for Health Statistics, Monthly Vital Statistics
Report (Washington, D.C.:  Centers for Disease Control and
Prevention, June 30, 1998).

\2 Replaced in 1996 by the Temporary Assistance for Needy Families
(TANF) program.

\3 Advocates for Youth, Teen Pregnancy, the Case for Prevention:  An
Analysis of Recent Trends in Federal Expenditures Associated With
Teenage Pregnancy (Washington, D.C.:  Apr.  1998).

\4 The Personal Responsibility and Work Opportunity Reconciliation
Act of 1996 (P.L.  104-193, Aug.  22, 1996).

\5 The other federal agencies identified were the Departments of
Agriculture, Defense, Education, Housing and Urban Development,
Justice, and Labor; the Office of National Drug Control Policy; and
the Corporation for National Service.

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The eight states in our review have, over time, developed TPP
strategies involving numerous programs that fall into six areas:  sex
education, family planning services, teen subsequent pregnancy
prevention, male involvement, youth development, and public
awareness.  In general, these states targeted high-risk populations
and communities and tailored programs to three different groups of
teens--those not sexually active, those sexually active, and those
who are already parents.  While strategies were applicable statewide,
states typically relied on local communities to select and implement
specific programs from an array of alternatives.  States generally
gave localities the flexibility to choose the type and mix of
programs they wanted to put in place.  Some communities chose not to
implement programs that the state strategy encouraged.  For example,
even though some state strategies encouraged sex education in the
schools, some communities chose not to have sex education in
school-based settings.  As a result, programs implemented within and
across the states varied.  All of the states we visited relied on
federal funding to support their strategies, and in many of the
states, federal funding exceeded state funding for teen pregnancy
prevention.

The 1996 federal welfare reform legislation had a limited effect
overall on these states' TPP strategies, in part, because the states
in our 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.  Currently, only one of the
eight states plans to compete for the bonus provided by the law to
states that show the greatest success in reducing out-of-wedlock
births.  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.  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.

Although all eight states are tracking changes in teen births, few
are evaluating the effect of their TPP programs on teen pregnancy.
Only four states--California, Georgia, Illinois, and Maryland--are
attempting to link some of their TPP efforts to changes in teen
pregnancies, births, or other closely related outcomes, such as
sexual and contraceptive behavior.  Georgia and Maryland plan to
continue some evaluations for several years to gauge long-term
program effects.  In Louisiana, Maine, Oregon, and Vermont, most
program evaluations focus on outcomes, such as knowledge gains and
attitude changes, rather than behavior changes, even though research
studies have shown knowledge or attitude changes to be moderate or
weak predictors of teen pregnancy.  All states are evaluating program
processes to ensure that programs are operating as intended; however,
these provide little information on whether such programs really make
a difference.

For fiscal year 1997, HHS identified at least $164 million in funding
specifically for TPP programs or services--more than two-thirds of
which comes from Medicaid and title X (of the Public Health Service
Act) family planning programs.  In fiscal year 1998, the Congress
authorized an additional $50 million for abstinence education.  In
addition, block grants, such as Maternal and Child Health and TANF,
are used by states to fund teen pregnancy prevention; other HHS and
federal agency programs could be used to support activities related
to teen pregnancy--a total of 27 HHS programs and funding streams and
various programs within 8 other federal agencies.  However, funding
specifically for TPP activities through these streams could not be
isolated at the federal level, primarily because of the flexibility
on spending decisions given to states.  HHS also supports research
and surveillance that provide information on teen births and their
causes.  To date, HHS has undertaken very few evaluations to
determine whether and how these programs affect teen birth rates and
the behavioral outcomes related to teen pregnancy.  However, HHS has
recently begun program evaluations for two TPP programs that will
measure program effects on behavior outcomes closely related to teen
pregnancy.

   BACKGROUND
------------------------------------------------------------ Letter :2

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.\6 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.\7

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.\8 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.

--------------------
\6 K.  A.  Moore and others, Adolescent Sex, Contraception, and
Childbearing:  A Review of Recent Research (Washington, D.C.:  1995).

\7 Douglas Kirby, No Easy Answers:  Research Findings on Programs to
Reduce Teen Pregnancy (Washington, D.C.:  Mar.  1997), and K.  A.
Moore and others, Adolescent Pregnancy Prevention Programs:
Interventions and Evaluations (Washington, D.C.:  Child Trends,
1995).

\8 Healthy People 2000:  National Health Promotion and Disease
Prevention Objectives, released by HHS in 1990, sets national goals
on numerous health indicators, including reducing teen pregnancy.
Most states have emulated the national objectives but have tailored
them to their specific needs.  HHS tracks progress against objectives
and periodically reports progress.  HHS is in the process of
finalizing national health objectives for 2010.

   STATES' TEEN PREGNANCY
   PREVENTION STRATEGIES TARGET
   DIFFERENT GROUPS AND ARE
   IMPLEMENTED AT THE LOCAL LEVEL
------------------------------------------------------------ Letter :3

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.

      STATE STRATEGIES HAVE
      MULTIPLE COMPONENTS
---------------------------------------------------------- Letter :3.1

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,\9 the emphasis placed on the components and the types of
services and programs included in their strategies varied.

                                         Table 1

                         Six Components of the Eight States' TPP
                                        Strategies

Component                     Description
----------------------------  -----------------------------------------------------------
Sex education                 Includes several approaches: those that provide education
                              only about sexual abstinence (often called "abstinence-
                              only" programs), those that provide education about
                              abstinence and about contraceptive use for teens and
                              preteens who are or soon may become sexually active
                              (sometimes called "abstinence-based" programs), and those
                              that provide education about a broad range of topics on
                              human sexuality (sometimes called "sexuality education").
                              Sexuality education often addresses topics broader than
                              reproductive health and may address marriage and families,
                              dating, and gender psychology. Sex education may be
                              provided in the context of comprehensive health curricula
                              or family life education and may be provided in schools,
                              clinics, community settings, or at home.

Family planning services      Family planning services include counseling on abstinence,
                              contraception, sexually transmitted diseases, HIV, birth
                              options, and other sexual health issues. These services may
                              also include testing for pregnancy, sexually transmitted
                              diseases, and HIV as well as dispensing various forms of
                              contraception, such as condoms, birth control pills, and
                              implanted and injectable birth control. Family planning
                              services may be offered in the context of primary care or
                              targeted health care and may be provided by family planning
                              clinics, health clinics, school-based health centers, and
                              private physicians.

Teen subsequent pregnancy     This component aims to keep pregnant or parenting teens
prevention                    from becoming pregnant again. Services and programs in this
                              component help teens finish school; obtain job training,
                              parenting education, and day care; gain access to family
                              planning; and ensure consistent and effective methods and
                              use of contraception.

Male involvement              States have recently begun to adopt this strategy to
                              encourage young males to assume a stronger role in
                              preventing teen pregnancy. These programs teach young males
                              primary prevention skills and provide them motivation for
                              choosing to be sexually responsible through a variety of
                              settings and activities, such as mentoring, sex education
                              and contraception, counseling services, tutoring, and
                              sports activities.

Youth development             These programs--while not focusing specifically on teen
                              pregnancy prevention--often contain multiple components
                              aimed at reducing risky behaviors among teens, such as
                              sexual activity and drug and alcohol abuse. Youth
                              development activities include general skills building to
                              promote self-esteem, social skills, and negotiation
                              tactics; academic tutoring and vocational training; career
                              counseling; sex education, which may include an emphasis on
                              abstinence or delay of initiation of sexual activity or
                              sexuality and contraception education; youth and adult
                              mentoring; and recreational activities. These activities
                              are intended to motivate teenagers to continue in school
                              and become self-sufficient.

Public awareness              Many states used television, radio, and print to
                              disseminate key messages. These and other public awareness
                              initiatives aim to increase knowledge and influence public
                              opinion or behavior related to teen pregnancy prevention.
                              They typically target teens, parents, adult males, or the
                              general public.
-----------------------------------------------------------------------------------------
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\10 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.\11 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.

                                                                                       Table 2

                                                                       TPP Programs and Services in Each of the
                                                                              Eight States, by Component

                                                                                           Teen subsequent
State goal and strategy        Sex education                 Family planning services      pregnancy prevention  Male responsibility    Youth development     Public awareness
-----------------------------  ----------------------------  ----------------------------  --------------------  ---------------------  --------------------  ----------------------
California
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
California's goal is to        --Teen information and        --State-funded family         --Adolescent and      --Male involvement     --Statewide           --Statewide media
reduce teen pregnancy for      education services are        planning program for low-     Family Life program,  program at 23          mentoring program     campaign aims to
ages 17 and under to no more   comprised of 31 youth         income men and women          a case management     grantees across the    aims to recruit       promote sexual
than 50 per 1,000. Its TPP     intervention projects         provides services through     program, aims to      state aims to promote  250,000 adult         abstinence; enhance
strategy uses numerous         targeting at-risk and foster  2,200 clinics, hospitals,     prevent second        the involvement of     mentors to be         male involvement in
prevention and intervention    care youth to enhance         universities, and private     pregnancy and         teen males to reduce   matched with 1        teen pregnancy
programs. Programs are based   knowledge, attitudes, and     practice providers.           prevent teen          teen pregnancy by      million at-risk       prevention and
on research indicating that    skills of boys and girls to   --Teen Smart clinics (56      pregnancy among       promoting primary      youth.                responsible
teen pregnancy and subsequent  make responsible decisions    state-funded and              siblings.             prevention skills and  --Community           fatherhood; heighten
births among teens are         about abstinence and sexual   administered) aim to reduce   --Cal-Learn and       motivation for         Challenge grants to   public awareness of
associated with many negative  behavior.                     teen pregnancy and sexually   Department of         choosing to be         112 grantees in       legal, social, health,
education, economic, health,   --Department of Education     transmitted diseases and      Education programs    sexually               high-risk areas       and economic
and social outcomes. The       grant programs, administered  provide enhanced counseling   aim to keep pregnant  responsible.           include abstinence    consequences of teen
programs provide education,    by 37 grantees, provide       for teens.                    and parenting teens   --Young Men as         education, life-      pregnancy; and
information, counseling,       abstinence-based education    --Federally funded title X    in school.            Fathers program        skills training,      heighten public
clinical services, and         in 450 elementary and         family planning clinics                             targets male teens in  decisionmaking        commitment.
community outreach to serve    secondary schools.            (over 230) administered by                          all state juvenile     skills, academic and
abstaining teens, sexually     --Most Community Challenge    the California Family Health                        detention facilities   employment skill
active teens, and teen         grants (112) offer family     Council, a nonprofit                                and emphasizes         development, sex and
parents. The programs are      life programs that include    corporation, serve about                            pregnancy prevention   contraception
administered both statewide    sex education and programs    150,000 teens annually.                             and fathering skills   education, and
and through local community    to help parents develop       Special teen services                               for teen fathers.      parent-child
grant programs.                effective communication       include a Teen Reproductive                         --Statutory Rape       communication.
                               skills when talking to        helpline and a Teen Family                          Vertical Prosecution
                               adolescents and children      Planning Retention program.                         program aims to
                               about sex and pregnancy                                                           increase prosecutions
                               prevention.                                                                       statewide.

Georgia
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Georgia's goal is to reduce    --Abstinence-based education  --Teen Plus centers in 27     --Resource mothers    --Grants for 23        --Micro Enterprise    --Statewide media
the pregnancy rate for girls   in schools supplements        sites provide multiple        work with pregnant    community-based        programs teach        campaign aims to
aged 15 to 19 by 15 percent    state-mandated kindergarten   services to promote health    and parenting teens   programs focus on      skills to prevent     increase awareness of
by 2002, reduce the rate of    through grade 12              and well-being, including     in 15 communities to  male responsibility    high-risk behavior,   consequences of teen
sexual activity among teens,   comprehensive sex education   abstinence education,         provide parenting     for pregnancy          including teen        pregnancies.
increase effective             and HIV prevention            counseling, health            education and         prevention,            pregnancy.
contraception use for          instruction.                  education, contraceptive      education to delay a  responsible            --Peer counseling
sexually active teens, and     --Grants provide training     services, as well as          subsequent            fatherhood, and        programs in 23
increase high school           for trainers in abstinence-   educational and recreational  pregnancy.            academic achievement   communities aim to
completion rates among teen    plus curricula in 10 health   programs designed to involve                        and economic self-     prevent pregnancy,
parents to reduce repeat       districts.                    teens in positive activities                        sufficiency.           sexually transmitted
pregnancies and increase                                     after school.                                                              diseases, and
employment opportunities. Its                                --Nontraditional family                                                    substance abuse.
strategy, Teen Plus, includes                                planning clinics aim to                                                    --Teen Plus
programs and clinical                                        improve access to                                                          community
services to improve health                                   contraceptive services for                                                 involvement grants
and social outcomes for                                      low-income women, including                                                to 17 communities
teens, systems to collect and                                teens, who are at high risk                                                support community-
disseminate data on teen                                     for unintended pregnancies.                                                based, nonclinical
well-being, measures to                                      --Community outreach by                                                    services.
strengthen state laws to                                     Medicaid staff encourages
protect and support teens,                                   at-risk teens and others to
and assisting families and                                   use family planning and
communities to ensure the                                    preventive services in the
well-being of teens and their                                Teen Plus centers and
families. Georgia's Family                                   nontraditional clinics.
Connection program encourages
community coalitions to
improve youth and family
outcomes, including reducing
teen pregnancy. Of the 76
Family Connection
communities, 60 have selected
teen pregnancy prevention as
a priority.

Illinois
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Illinois' goal is to reduce    --Many of the 42 adolescent   --Title X clinics (60 across  --Parents Too Soon    --Two family planning  --Adolescent health   --Help Me Grow
the birth rate among girls     health programs implemented   the state) develop teen       provides              clinics have male      programs in 42 of     helpline includes
aged 14 and younger to no      at the local level include    action plans for outreach,    intervention          responsibility         Illinois' 102         information on family
more than 2.5 per 1,000 and    sex education.                community education,          services for          projects.              counties include      planning, sexuality,
among girls aged 15 to 17 to                                 postponing sex, and access    pregnant and          --Ten of the 42        abstinence and        and sexually
no more than 28 per 1,000 by                                 to counseling and             parenting teens,      adolescent health      sexuality education;  transmitted diseases.
the year 2000. Its                                           contraception. Clinics are    including prevention  programs include male  self-esteem
multifaceted strategy                                        required to adjust hours to   of second pregnancy   responsibility         training; alcohol,
includes a variety of                                        accommodate teens.            at 25 sites across    components.            tobacco, drug, and
prevention programs and                                      --Twenty-two school-based     the state.                                   violence prevention;
services implemented at the                                  health centers throughout     --Projects at 10                             teen and parent
state and local level as well                                the state provide abstinence  sites across state                           communications; peer
as services for teen parents                                 education and family          use home visits and                          relationships; and
to encourage school                                          planning counseling.          peer support to help                         male responsibility
completion and delay of                                      Distribution of               teen mothers finish                          activities.
second pregnancy.                                            contraception is a local      school and                                   --Parents Too Soon
                                                             decision.                     effectively and                              (20 sites) for at-
                                                             --Medicaid expansion allows   consistently use                             risk and foster
                                                             for family planning coverage  birth control to                             teens focuses on
                                                             for postpartum women,         avoid another                                education
                                                             including teens.              pregnancy.                                   achievement and
                                                                                           --Teen Parent                                nonviolent and
                                                                                           Services--a TANF                             future-oriented
                                                                                           case management                              decisionmaking.
                                                                                           statewide program--                          --Teen REACH, an
                                                                                           helps teen parents                           after-school program
                                                                                           finish school and                            (41 locations),
                                                                                           obtain job training,                         includes a variety
                                                                                           parenting education,                         of services to
                                                                                           day care, and family                         prevent multiple
                                                                                           planning education.                          teen risks,
                                                                                                                                        including risk for
                                                                                                                                        teen pregnancy.

Louisiana
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Louisiana's goal is to reduce  --Abstinence-based            --Family planning services    --Clinics for         --Community-based      --Community-based     --No media campaign is
the rate of unwed teen         curriculum is provided to     for teens are not             pregnant and          programs are offered   youth development     currently in place,
pregnancy by at least 1        public and private schools    specifically included in the  parenting teens and   in the pilot area (4   programs in pilot     but statewide media
percent statewide and by 2     in pilot area.                strategy but counseling, sex  their babies provide  sites).                area include teen     campaigns are being
percent in 1998 in the pilot   --Abstinence program aims to  education, and contraceptive  primary and           --Adolescent male      pregnancy             planned: one as part
area. Its strategy is to       simulate the demands of       services are available to     preventive care,      project trains two     prevention,           of the new abstinence
implement community-and        parenting in pilot area (3    teens through the state       with a goal of        students as peer       tutoring, mentoring,  education plan, and
school-based programs whose    middle schools).              health department family      preventing            counselors in          and other after-      one as part of the
goals are to delay the start   --Sex education is            planning program, funded in   subsequent            reproductive health,   school activities (3  state's overall TPP
of sexual activity; reduce     encouraged in middle and      part with title X funding.    pregnancies.          sexually transmitted   sites).               strategy.
the incidence of teen          high schools in pilot area.   --School-based health                               disease prevention,                          --Cable TV talk show
pregnancy, repeat teen         (In the rest of the state,    centers have a strong                               and drug prevention                          in pilot area
pregnancies, and all out-of-   sex education is prohibited   abstinence focus and are                            (1 site).                                    discusses teen issues,
wedlock births; and increase   before and under local        prohibited from providing                                                                        including teen
the number of parenting teens  control after grade 7.)       family planning counseling                                                                       sexuality.
who complete high school,                                    and services but can refer
improving the employability                                  for these services (31
of parenting teens and other                                 sites).
at-risk youth.

Maine
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Maine's goals are to           --Strategy advocates          --Title X and state-funded    --Pregnant and        --Child support        --Peer Leader         --TV campaign provides
eliminate pregnancy among 10-  comprehensive health          family planning clinics (34   parenting program in  enforcement education  program is offered    information on parent-
to 14-year-olds, reduce the    education in the schools and  statewide) conduct outreach   each of Maine's 16    directed at young      at 130 sites.         child communication on
rate among 15-to 17-year-      funds health educators to     and education programs for    counties provides     males aims to help     --Local prevention    sexuality issues, life
olds to 20 per 1,000 and       assist schools in curricula   teens and provide family      social, education,    them understand the    programs in two       aspirations, and
among 18-to 19-year-olds to    development and               planning counseling and       medical, and support  economic impacts of    communities for       refusal skills.
80 per 1,000, and reduce the   instruction.                  contraceptive services for    services, including   teen pregnancy.        teens at high risk
rate of repeat teen pregnancy  --Family life educators are   teens.                        prevention of                                for early pregnancy
and sexually transmitted       available to schools to       --Eleven school-based health  subsequent                                   include self-esteem
diseases in teens. Its         develop comprehensive health  centers provide family        pregnancies among                            building and support
strategy encourages and        and sexuality education       planning counseling; three    teens.                                       groups for middle
supports community             curricula, train teachers,    distribute contraception.                                                  school boys and
coalitions--through the        and do classroom              --Teen Access to                                                           girls.
Governor's Children's Cabinet  instruction.                  Contraception toll-free
and Communities for Children                                 hotline provides
program--to assess risks,                                    contraception and counseling
develop action plans to                                      services.
address teen pregnancy, and
develop partnerships with the
state. It also advocates
comprehensive health
education in the schools,
makes family planning
accessible, supports broad
prevention efforts, and
provides services to teen
mothers.

Maryland
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Maryland's goal is to reduce   --Statewide media campaign    --Three Teen Outreach         --Five community      --Two community        --Several of the 15   --Statewide media
teen births to no more than    promotes abstinence and       clinics are in areas with     incentive grantees    incentive grants fund  community incentive   campaign established
30 per 1,000 for teens aged    encourages parents to be      high rates of teen birth and  focus on parenting    male responsibility    grants fund           in 1987 promotes
15 to 17. Its strategy         their children's primary sex  sexually transmitted          teens to prevent      programs.              multiservice youth    delaying the start of
provides comprehensive and     educators; campaign           diseases.                     repeat pregnancies.   --Male Involvement     programs, including   sexual activity and
multidimensional programs      materials approved for use    --Title X family planning     --TANF-funded home    Task Force advises     abstinence programs   abstinence;
that encourage delaying the    in all school districts.      clinics (98 statewide)        visiting program for  the Governor's         and prevention        encouraging
start of sexual activity,      --Adult and Children Talking  served about 23,000 teens in  unwed mothers and     Council on Adolescent  programs for          responsible behaviors
promote parents as the         program encourages parent     1997.                         fathers 16 and over   Pregnancy on           siblings of pregnant  among teens; and
primary sex educators, and     and adult-child               --Three for Free, a condom    provides services,    strategies and         teens.                increasing parent-
support positive outcomes for  communication on sexuality.   distribution program,         including family      policies to promote    --After-school        child communications
pregnant and parenting teens.  State provides training to    implemented at 200 sites      planning to prevent   responsible            programs funded by    about sex, values, and
In addition to increasing      Interagency Committees on     across state.                 repeat teen           behavior.              the Governor's        pregnancy prevention.
family planning services for   Adolescent Pregnancy          --Medicaid expansion allows   pregnancies and out-  --Young Fathers,       Office of Crime       --State-supported
sexually active teens, the     Prevention and Parenting at   for family planning coverage  of-wedlock            Responsible Fathers,   Control and           Interagency Committees
state involves communities in  the local level for parents   for postpartum women,         pregnancies.          a statewide program,   Prevention aim to     on Adolescent
prevention and parenting       and community members on      including teens.                                    provides services to   prevent crime and     Pregnancy Prevention
efforts by funding local       communication and sexuality   --Minors over age 13 can                            unwed, expectant, and  substance abuse and   and Parenting provides
coalitions and offering        issues.                       consent to reproductive                             noncustodial           to reduce             communities
grants to local communities.   --Comprehensive health        health services with                                fathers.               delinquency in 35     information on teen
                               education, including family   parental notification at the                        --Maryland Regional    areas with high       pregnancy and
                               life and sexuality, in        provider's discretion.                              Practitioners Network  crime.                prevention.
                               kindergarten through grade                                                        maintains a statewide                        --Over 600 school,
                               12 is mandated. Local                                                             representation of                            health care, and
                               jurisdictions select                                                              advocates concerned                          community
                               curricula.                                                                        with issues facing                           professionals attend
                                                                                                                 men and fathers and                          an annual statewide
                                                                                                                 hosts an annual male                         TPP conference to
                                                                                                                 involvement                                  receive information on
                                                                                                                 conference.                                  planning,
                                                                                                                                                              implementing, and
                                                                                                                                                              evaluating programs
                                                                                                                                                              and services.

Oregon
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Oregon's goal is to reduce     --STARS (Students Today       --Preliminary approval for    --Case management     --Initiative under     --Skills-for-Life     --Statewide public
teen pregnancy to 15 per       Aren't Ready for Sex), a      Medicaid expansion to allow   for teen parents in   way to study the role  instructional         awareness campaign
1,000 females aged 10 to 17    teen-taught abstinence        coverage of family planning   state welfare system  of older men's         program with youth    supported by local
by the year 2000--an official  curriculum with resistance    services up to 185 percent    includes family       involvement in teen    development approach  community efforts
state benchmark. Its strategy  skills, has been taught to    of the federal poverty        planning.             pregnancy.             aims to prevent teen  delivers state
is to address the causes of    45 percent of the state's     level.                        --Local coalitions    --Public awareness     pregnancy and other   strategy messages
teen pregnancy through         sixth-and seventh-graders.    --Medicaid expansion covers   may target teen       program and local      youth problems.       regarding sexual
coalitions sensitive to local  --Comprehensive sex           family planning services,     parents for           coalition activity                           abstinence, sexual
needs, character, and          education is encouraged in    including vasectomies.        subsequent pregnancy  includes efforts to                          postponement, access
attitudes and through          grades 5 through 12, but      --Title X family planning     prevention            inform males about                           to contraceptives for
statewide efforts to provide   local school districts make   clinics served about 17,700   activities.           teen pregnancy                               sexually active teens,
leadership, data, technical    final decision.               teens in 1997.                                      prevention and to                            male responsibility,
aid, policy development, and   --School-based health         --School-based health                               involve them in these                        family communication,
resources to support local     centers reinforce abstinence  centers (39 currently, 14                           efforts.                                     and parental
efforts. Local coalitions      goals and sex education       state-funded), if locally                                                                        involvement.
have autonomy to develop       through counseling services   permitted, provide high-                                                                         --Statewide private
their own plans but are        and provide preventive        risk teens family planning                                                                       media campaign
encouraged to integrate their  services in high-risk areas   counseling and services.                                                                         targeting teens and
efforts with statewide public  to improve access to          --Skills-for-Life program                                                                        their parents is
awareness efforts.             reproductive health           provides family planning                                                                         planned.
                               information and service       instruction for youth whose
                               intervention.                 families come in contact
                                                             with state welfare system.

Vermont
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Vermont's goal is to reduce    --Comprehensive health        --Title X family planning     --Support services    --Programs offered     --Network of 16       --Statewide primary
teen pregnancies among girls   education in the schools      clinics (13 sites) have       for pregnant and      are determined by      parent-child centers  prevention plan guides
aged 17 and younger to no      requires instruction in age-  special teen initiatives,     parenting teens--     local need through     statewide offers      how state resources
more than 25 per 1,000 and to  appropriate sexual            including special hours and   including parenting   state network of       integrated health,    are to be used to help
delay parenthood until         development, HIV and          walk-in appointments.         classes, family       parent-child centers.  education, and        local communities
couples are emotionally and    sexually transmitted disease  --Expanded Medicaid           planning to prevent                          social services,      alter conditions that
financially stable. Its        prevention, and drug and      eligibility to 225 percent    a second pregnancy,                          including, parenting  contribute to problem
strategy includes health,      alcohol abuse.                of poverty increases access   and assistance to                            education, child      behaviors, such as
education, and social          --Health educators provide    to family planning services,  complete school--                            abuse and neglect     teen pregnancy.
services programs offered      technical assistance to       which are available out-of-   are available.                               prevention, early     --Media campaign
through a statewide network    schools.                      plan so that a referral from  --Public education                           child development     targets parents to
of integrated services--       --Information on resources    a primary care provider is    for pregnant teens                           programs, mentoring,  help them address with
services provider by parent-   is available to youth,        not required.                 is state-mandated.                           male responsibility,  their middle-school-
child centers, public home     sexual harassment policies                                                                               teen mother panels    aged children the
health visiting programs,      in schools are mandated, and                                                                             who visit schools to  relationship between
family planning clinics, and   sex education for children                                                                               speak about the       drug and alcohol use
school-based education.        in foster care is provided.                                                                              realities of          and sexual activity.
Community-state partnerships   --Family planning clinic                                                                                 pregnancy and
promote healthy behaviors and  providers are available to                                                                               parenting at a young
self-reliance among Vermont    work with schools to provide                                                                             age, school success
children and families.         training for teachers and                                                                                programs, and mental
                               review curricula and to                                                                                  health services.
                               present classes on topics
                               such as sexual violence.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

--------------------
\9 At the time of our review, Louisiana did not have a public
awareness component in its strategy, but the state is in the process
of developing one.

\10 Funded by the National Institute of Child Health and Human
Development and HHS' Office of Population Affairs, the survey
combines longitudinal data collection and individual research.

\11 Since 1980, Chapters of Alpha Phi Alpha Fraternity, Inc., and the
March of Dimes Birth Defects Foundation have collaboratively
conducted "Project Alpha"--a longstanding national program to provide
men with information about teen pregnancy.

      TARGETING HIGH-RISK GROUPS
      IS A KEY OBJECTIVE OF
      STATES' STRATEGIES
---------------------------------------------------------- Letter :3.2

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)\12 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.

--------------------
\12 YRBS is a school-based survey undertaken by CDC that collects
data on often interrelated adolescent health risk behaviors, such as
sexual activity, substance abuse, behaviors that result in
intentional and unintentional injuries, diet, and physical activity.
In 1997, five of the eight states we visited participated in
YRBS--California, Georgia, Maine, Oregon, and Vermont.  Illinois,
Louisiana, and Maryland did not participate in the most recent survey
because of the controversy surrounding the questions on sexual
activity or they lacked the resources needed to conduct the survey,
according to state officials.

      PROGRAM IMPLEMENTATION
      VARIED AT THE LOCAL LEVEL
---------------------------------------------------------- Letter :3.3

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.

      MOST STATES REPORT THAT
      FEDERAL FUNDING IS A MAJOR
      SOURCE OF SUPPORT FOR THEIR
      TPP PROGRAMS
---------------------------------------------------------- Letter :3.4

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.

                                         Table 3

                            Key Funding Sources States Use to
                            Support Teen Pregnancy Prevention
                              Initiatives, Fiscal Year 1997

                   California   Georgia\a    Illinois       Maine    Maryland     Vermont
-----------------  ----------  ----------  ----------  ----------  ----------  ----------
Federal funding    $11,806,39  $11,151,76  $11,581,13  $2,465,119  $2,984,133    $433,239
 (total)                    7           9           7
Medicaid\b          7,405,397  5,089,878\   1,830,887     595,749   1,395,080     110,392
                                        c
Title V Maternal           \d  1,123,604\   2,644,300     625,970     598,528     130,432
 and Child Health                       e
 Services Block
 Grant
Title X Family      4,401,000   1,638,287   1,914,000     920,000     990,525     161,646
 Planning
Social Service              0           0   5,191,950     273,400           0      30,759
 Block Grant
TANF                       \f   3,300,000          \f          \f          \f          \f
Preventive Health           0           0           0      50,000           0           0
 and Health
 Services Block
 Grant
State funding      84,310,000   3,866,993   6,635,290   1,806,541   3,543,000     193,786
=========================================================================================
Total federal and  $96,116,39  $15,018,76  $18,216,42  $4,271,660  $6,527,133    $627,015
 state funding              7           2           7
-----------------------------------------------------------------------------------------
Note:  State fiscal years vary.

\a Funding is for fiscal year 1998.

\b Medicaid costs for family planning for ages 19 and under.

\c Total is Medicaid funds for family planning for ages 19 and under
and ICTF funds used to support the TPP strategy.

\d Unable to isolate.  Total block grant was $7.5 million.

\e Includes carryover for fiscal year 1997.

\f Could not isolate TANF funds for services to teen parents, which
could include services relating to the prevention of a subsequent
pregnancy or prevention counseling to nonparent teens in the
household.

Source:  State-reported data, except for Medicaid funding obtained
from the Health Care Financing Administration.  Louisiana and Oregon
did not report financial data by funding source.

   FEDERAL WELFARE REFORM HAD A
   LIMITED EFFECT ON EIGHT STATES'
   TPP STRATEGIES
------------------------------------------------------------ Letter :4

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.

      STATES BEGAN REQUIRING TEEN
      PARENTS TO STAY IN SCHOOL
      AND LIVE AT HOME BEFORE
      FEDERAL WELFARE REFORM
---------------------------------------------------------- Letter :4.1

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.

      NOT ALL STUDY STATES PLAN TO
      SEEK BONUS FOR REDUCING
      OUT-OF-WEDLOCK BIRTHS
---------------------------------------------------------- Letter :4.2

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.\13 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.\14

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.

--------------------
\13 HHS will determine the rates of abortions for the most recent
calendar year compared to 1995--the base year.

\14 The amount of the award will depend on the number of recipients.
HHS is expected to issue the final rules no later than January 1999.
Guam, American Samoa, and the Virgin Islands are also potentially
eligible for the bonus if they have a decrease in their
out-of-wedlock ratios that is comparable to that of the top five
states.  While these territories face similar eligibility criteria,
their eligibility is determined separately (that is, they could be
potentially eligible in addition to the five states) and the amount
of their bonus is less.

      SOME STATES CONCERNED ABOUT
      THE PRESCRIPTIVE NATURE OF
      ABSTINENCE-ONLY EDUCATION
      PROGRAMS
---------------------------------------------------------- Letter :4.3

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.\15 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.)

                                         Table 4

                          State Initiatives for Abstinence-Only
                                        Education

                                                                     Amount and source of
State        Type of program                          Federal funds        matching funds
-----------  --------------------------------------  --------------  --------------------
California   Local community programs targeted to        $5,764,199            $4,323,149
              youth aged 17 and under to motivate                      (state, local, and
              them to avoid sexual activity and to                               in-kind)
              resist media, peer, and partner
              pressure.
Georgia      Grants to local coalitions for various       1,450,083             1,087,562
              programs for 10-to 19-year-olds and                        (local grantees)
              their parents, including mentoring,
              parent involvement, after-school
              programs, and media campaigns.
Illinois     Programs for at-risk communities to          2,095,116               161,416
              form coalitions to link existing                                    (state)
              abstinence-only programs targeted at                              1,467,191
              9-to 14-year-olds.                                         (local grantees)
Louisiana    Multifaceted approach, including             1,627,850             1,220,867
              community projects, pilot project,                       (state, local, and
              public awareness campaigns, and a                                  in-kind)
              state clearinghouse on abstinence
              programs.
Maine        TV campaign targeted to children 14            172,468               129,351
              and under to improve parent and child                             (in-kind)
              communication on issues of sexuality,
              life aspirations, and refusal skills.
Maryland     Funds 16 after-school abstinence-only          535,712               410,784
              programs for 9-to 18-year-olds (2                        (state, local, and
              focus on male involvement) and                                     private)
              expanded TV campaign.
Oregon       Expand abstinence curricula for sixth          460,076               345,657
              and seventh grades throughout the                       (state and private)
              state.
Vermont      Media campaign targeted at parents to           69,855                52,698
              address with their middle-school-                                   (state)
              aged children the relationship
              between drug and alcohol use and
              sexual activity.
-----------------------------------------------------------------------------------------
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.

--------------------
\15 As of June 1998, all 50 states and the territories had applied
for and received federal funding.  New Hampshire returned its federal
funds because state agencies were unable to come to an agreement on
the best program for the state.

   FEW STATE ASSESSMENTS OF TPP
   PROGRAMS ADEQUATELY MEASURE
   THEIR EFFECT ON TEEN PREGNANCY
------------------------------------------------------------ Letter :5

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.

      PROGRAM EFFECTS ON TEEN
      PREGNANCY NOT GENERALLY
      CAPTURED BY CURRENT PROGRAM
      EVALUATIONS
---------------------------------------------------------- Letter :5.1

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.\16 (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.\17 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.

                                         Table 5

                         Evaluations of the Various Activities in
                               the Eight States' Strategies

                                                     Type of program evaluation
                                           ----------------------------------------------
                                                                         Outcome
                                                                 ------------------------
                                                                 Moderate or
                                                                 weak          Strong
State and activity                         None      Process     relation      relation
-----------------------------------------  --------  ----------  ------------  ----------
California
-----------------------------------------------------------------------------------------
Adolescent and Family Life program                   x
(statewide)

Community Challenge grants (112 sites)               x           x             x

Education Department TPP grants (37                  x           x             x
programs)

Information and education services for               x           x
teens (31 sites)

Male involvement (23 projects)                       x           x

Media campaign (statewide)                           x           x

Mentoring (statewide)                      x

Teen Smart (56 clinics)                              x           x             x

Georgia
-----------------------------------------------------------------------------------------
Abstinence education                                                           x

Comprehensive family life education        x

Family connection collaboration                      x

Male responsibility program (23 sites)               x

Media campaign (statewide)                           x

Micro Enterprise program                   x

Nontraditional clinics                               x

Peer counseling program (23 sites)         x

Postponing sexual involvement\a                      x

Resource mothers                           x

Teen Plus (27 centers)                               x           x             x

Teen Plus nonclinical (17 sites)                     x

Illinois
-----------------------------------------------------------------------------------------
Abstinence-only program                                          x             x

Adolescent health program (42 sites)                 x

Family planning program (60 clinics)                 x

Help-Me-Grow helpline (statewide)          x

Parents Too Soon (20 prevention sites; 45            x           x             x
teen mother sites)

School-based health (22 centers)                     x           x             x

Subsequent pregnancy project (10 sites)              x                         x

Teen parent services (statewide)           x

Teen REACH after-school program (13                  x           x             x
sites)

Louisiana
-----------------------------------------------------------------------------------------
Abstinence-based curriculum                x

Pilot area programs\b
--Abstinence-based, simulating demands of
parenthood (3 programs)
--Sex education in pilot area schools
--Cable TV teen talk show
--Male involvement program (4 sites)
--Community-based youth development
program (3 sites)

Pregnant and parenting teens (2 clinics)             x

School-based health (31 centers)                     x

Teen male peer counseling program          x

Maine
-----------------------------------------------------------------------------------------
Abstinence education media campaign                  x
(statewide)

Family life education program                        x           x

Family planning (34 clinics)                         x

Peer leader program (130 sites)            x

Primary prevention (2 programs)                      x           x

School-based health (11 centers)                     x           x

Teen pregnancy and parenting services                x           x
(every county)

Maryland
-----------------------------------------------------------------------------------------
Abstinence-only after-school program                 x                         x

Community incentive grants\c (15                     x           x             x
programs)

Family planning (98 clinics)                         x

Media campaign (statewide)                                       x

Teen outreach (3 clinics)                            x

Oregon
-----------------------------------------------------------------------------------------
Contraceptive access--title X clinics                x

Public awareness program (statewide)       x

Responsible sex education in schools                 x

School-based health (33 centers)                     x

Sex education in school-based health                 x
center preventive services

Skills-for-Life program                    x

STARS abstinence education curricula\e               x           x

Vermont
-----------------------------------------------------------------------------------------
Abstinence education media campaign                  x           x
(statewide)

Family planning (13 clinics)                         x

Parent-child (16 centers)                  x

School-based health (4 centers)                      x
-----------------------------------------------------------------------------------------
\a Although only process evaluation is required, Georgia expanded
this program after a privately funded outcome evaluation showed
positive effects on outcomes closely related to teen pregnancy.  A
follow-up showed that these gains diminished by grade 12.

\b According to Louisiana officials, the evaluation plan for
activities in the pilot area is not yet complete.

\c Evaluation requirements vary by grantee.

\d Outcome evaluation of program effect on attitudes and behavior is
planned for the 1998-99 school year.

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.\18 Also, some program staff are reluctant to spend
program dollars on evaluations.

--------------------
\16 Douglas Kirby, No Easy Answers:  Research Findings on Programs to
Reduce Teen Pregnancy, commissioned by the National Campaign to
Prevent Teen Pregnancy Task Force on Effective Programs and Research
(Washington, D.C.:  Mar.  1997).

\17 "National Campaign to Prevent Teen Pregnancy," memo to HHS from
the Task Force on Effective Programs and Research (Washington, D.C.:
Jan.  14, 1998), and K.  A.  Moore and others, Adolescent Pregnancy
Prevention Programs:  Interventions and Evaluations.

\18 National Research Council, Risking the Future:  Adolescent
Sexuality, Pregnancy, and Childbearing (Washington, D.C.:  1987), and
Douglas Kirby, No Easy Answers:  Research Findings on Programs to
Reduce Teen Pregnancy.

      SOME STATES ARE IMPLEMENTING
      PERFORMANCE MEASUREMENT
      SYSTEMS TO ASSESS PROGRESS
      TOWARDS TPP GOALS
---------------------------------------------------------- Letter :5.2

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.

   HHS PROVIDES KEY FEDERAL
   SUPPORT FOR TPP INITIATIVES
------------------------------------------------------------ Letter :6

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,\19
HHS established performance measures against which the performance of
HHS-funded activities will be assessed.

--------------------
\19 Under the Results Act, federal agencies are required to set
goals, measure performance, and report on the degree to which the
goals are met.  The legislation was enacted to increase program
effectiveness and public accountability by having federal agencies
focus on results and service quality.

      MULTIPLE FEDERAL PROGRAMS
      SUPPORT STATE EFFORTS
---------------------------------------------------------- Letter :6.1

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.

                                         Table 6

                          HHS Programs and Funding Streams That
                            Support Teen Pregnancy Prevention

Program or funding                                          Fiscal year      Administerin
stream              Description                             1997 funding     g agency
------------------  --------------------------------------  ---------------  ------------
TPP-specific programs
-----------------------------------------------------------------------------------------
Adolescent Family   Directly funds local abstinence-based   $14.2 million    Office of
Life Demonstration  programs that emphasize abstinence but  through Office   Population
and Research        include information on reproductive     of Secretary     Affairs
Program             health; beginning fiscal year 1997,     (up to $8        (OPA)
                    provides funding for abstinence-only    million may be
                    programs following the welfare law's    awarded to
                    abstinence definition.                  state or local
                                                            grantees, with
                                                            the remainder
                                                            awarded to
                                                            localities)

Community           CDC's 5-year program (now in its third  $13.7 million    CDC
Coalition           year) funds 13 communities to
Partnership         demonstrate that they can mobilize
Program for the     community resources to support
Prevention of Teen  comprehensive prevention programs. CDC
Pregnancy           also provides support for national
                    nongovernmental education
                    organizations to help schools
                    implement TPP programs. This effort is
                    just beginning.

Abstinence          Legislated under welfare reform,        $50 million a    Health
Education Program   awards grants to states for             year for 5       Resources
                    abstinence-only programs. The           years,           and Services
                    legislation prescribes the parameters   beginning        Administrati
                    of acceptable abstinence-only           fiscal year      on (HRSA)
                    programming. There is a required match  1998 ($250
                    of 3 nonfederal dollars for every 4     million total);
                    federal dollars awarded.                additional $6
                                                            million for
                                                            evaluation

Block grant funding
-----------------------------------------------------------------------------------------
Maternal and Child  Funding to monitor and improve the      $681 million     HRSA
Health Services     health status of women, infants,        total (could
Block Grant         children, and teens. States receive     not isolate
                    funding directly from the federal       TPP)
                    government to fund various programs,
                    including TPP programs.

Social Services     Funding directly to states for social   $2.5 billion     Administrati
Block Grant         services. Up to 10% of the grant may    total (could     on for
                    be transferred to other block grant     not isolate      Children and
                    programs, including those that support  TPP)             Families
                    health services.                                         (ACF)

Preventive Health   Funds state activities to meet Healthy  $148 million     CDC
and Health          People 2000 goals. States can use the   total, with
Services Block      funds for programs to reduce teen       $2.8 million
Grant               pregnancy for ages 15 to 17 and to      used for TPP
                    reduce unintended pregnancies. In
                    1997, 9 states funded teen pregnancy
                    prevention.

Community Services  Funding for states to address poverty.  $487 million     ACF
Block Grant         Teen pregnancy prevention is not a      total (could
                    specific activity, but programs can     not isolate
                    fund family planning, job counseling,   TPP)
                    substance abuse treatment, and general
                    equivalency diploma education.

TANF                Funding directly to states to serve     $13 billion      ACF
                    needy families and children (replaces   total (could
                    Aid to Families With Dependent          not isolate
                    Children). Funds can be used for        TPP)
                    preventing out-of-wedlock births,
                    especially to teens.

Key categorical and entitlement programs
-----------------------------------------------------------------------------------------
Title X Family      Family planning education, counseling,  $198 million     OPA
Planning Program    and clinical services, with priority    total through
                    given to ensuring services are          HRSA, with an
                    available to individuals up to 250      estimated
                    percent of the federal poverty level.   $59 million for
                    The prevention of unintended pregnancy  teens\a
                    is a major program goal. About 30% of
                    clients are under age 20, and clinics
                    can have programs that target teens.

Male research       Grants awarded to 10 local              $1.8 million     OPA
grants              organizations in 8 states to support    through HRSA
                    male-oriented organizations in          (fiscal year
                    developing, implementing, and testing   1998)
                    approaches to involve young men in
                    family planning and reproductive
                    health programs.

Medicaid            Provides medical assistance for low-    $67,181,220      Health Care
                    income individuals, and requires        (family          Financing
                    states to provide family planning       planning for     Administrati
                    services to eligible individuals of     ages 19 and      on
                    childbearing age (including sexually    under)
                    active minors).

Other programs or funding sources related to TPP
-----------------------------------------------------------------------------------------
Health education    Provides funding to all states, 19 of   $38 million      CDC
in schools          the nation's largest cities, and        total (could
                    relevant national nongovernmental       not isolate
                    organizations to support schools and    TPP)
                    other agencies that serve youth to
                    provide HIV prevention education,
                    including training teachers and
                    developing and distributing
                    educational materials. The goal is to
                    prevent HIV, but sexual risk behaviors
                    that also put teens at risk of
                    unintended pregnancy are targeted.

Healthy Schools,    Grants to local communities to          $5.1 million     HRSA
Healthy             establish school-based health centers   for 26 centers
Communities         that provide comprehensive primary      in 20 states
                    health care services to at-risk youth.  (could not
                    Reproductive health services could be   isolate TPP)
                    included.

Community Schools   Funds after-school programs in          $13 million      ACF
Program             communities with high poverty and       total (could
                    delinquency to help youth aged 5 to 18  not isolate
                    achieve academic and employment         TPP)
                    success.

Girl Neighborhood   Targets girls aged 10 to 14 to promote  $1 million       HRSA
Power               successful futures; teaches prevention  total through
                    for multiple risks, including           the Maternal
                    pregnancy. Nationally, there are 4      and Child
                    projects in low-income neighborhoods.   Health Services
                                                            Block Grant
                                                            (could not
                                                            isolate TPP)

Direct health care  Provides direct care to native          $5.6 million     Indian
services for        American Indians and Alaskans,          estimated        Health
American Indian     including teen pregnancy prevention     for TPP and      Service
and Alaskan         and family planning services.           family planning
Natives                                                     services

High-Risk Youth     Supports 117 projects focusing on       $15 million      Substance
Program             female teen drug prevention. Teen       total, with      Abuse and
                    pregnancy is a risk factor associated   $750,000 for     Mental
                    with drug use; teen pregnancy           TPP              Health
                    prevention is a goal of some of the                      Services
                    projects.                                                Administrati
                                                                             on (SAMHSA)

Pregnant and        Program for pregnant and postpartum     $883,000 total,  SAMHSA
Postpartum          women also provides services for girls  with $45,000
Substance Abuse     and women of childbearing age to        for TPP
Prevention          prevent unwanted pregnancies that
                    could result in a drug-exposed infant.

Independent Living  Assists teens in transitioning from     $70 million      ACF
Initiatives         foster care to independent living.      total (could
Program             Pregnancy prevention is not             not isolate
                    specifically addressed in the           TPP)
                    legislation, but some programs fund
                    teen pregnancy prevention.

Healthy Start       Demonstration to reduce infant          $96 million      HRSA
                    mortality. Teen pregnancy contributes   total (could
                    to higher rates of infant mortality,    not isolate
                    so projects have developed approaches   TPP)
                    to prevent teen pregnancy.

Community health    Provide health services (including      $645 million     HRSA
centers             family planning) to low-income          total (could
                    individuals in medically underserved    not isolate
                    areas. Teen pregnancy prevention is     TPP)
                    not an explicit goal.

Migrant health      Provide medical and support services    $69 million      HRSA
centers             to migrant farmworkers and their        total (could
                    families in about 400 clinics,          not isolate
                    including family planning services.     TPP)

National Youth      National Collegiate Athletic            $12 million      ACF
Sports Program      Association sports program for 70,000   total (could
                    low-income youth aged 10 to 16.         not isolate
                                                            TPP)

Basic Center        Supports local agencies that provide    $43.7 million    ACF
Program for         crisis intervention services and        total (could
Runaway and         social and health services to runaway   not isolate
Homeless Youths     and homeless youth outside the          TPP)
                    traditional juvenile justice and law
                    enforcement systems.

Street Outreach     Sexual abuse and exploitation           $8 million       ACF
Program             prevention program for runaway,         total (could
                    homeless, and street youth.             not isolate
                                                            TPP)

Transitional        Provides services for homeless youth    $14.9 million    ACF
Living for Older    aged 16 to 21 to transition to self-    total (could
Homeless Youth      sufficiency.                            not isolate
                                                            TPP)

Empowerment Zone/   Federal governmentwide effort to        $1 billion       HHS and
Enterprise          enable the self-revitalization and      total in Social  other
Community           growth of distressed urban and rural    Services Block   federal
Initiative          areas; 105 designated communities       Grant funds;     agencies,
                    receive enhanced federal funds through  $2.5 billion in  with the
                    Social Services Block Grant funds, tax  tax incentives   Departments
                    incentives, special consideration for   (could not       of
                    competitive federal grants, and         isolate TPP)     Agriculture
                    technical assistance.                                    and Housing
                                                                             and Urban
                                                                             Development
                                                                             as lead
                                                                             program
                                                                             managers
-----------------------------------------------------------------------------------------
\a Estimate based on the proportion of title X clients under age 20.

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.)

                                         Table 7

                         HHS Surveillance and Research Related to
                                      Teen Pregnancy

                            CDC                                         NIH\a
-----------------------------------------------------------  ----------------------------
                              National Center for Chronic
National Center for Health    Disease Prevention and Health  National Institute of Child
Statistics                    Promotion                      Health and Human Development
----------------------------  -----------------------------  ----------------------------
--Generates national teen     --Generates state-by-state     --National Longitudinal
pregnancy rates by combining  teen pregnancy rates by        Study of Adolescent Health
data on legal induced         combining data on legal        (Add Health) combines
abortion and fetal loss with  induced abortion and fetal     longitudinal data collection
live birth data.              loss with live birth data.     efforts and individual
--Collects national data on   --Collects state-by-state and  investigator-initiated
incidence and trends in teen  national data on incidence,    research using these data.
pregnancies and births.       trends, and causes of teen     The survey is designed to
Collects state data on        pregnancy.                     measure the effects of
trends and variations in      --Youth Risk Behavior          various influences on health
teenage births.               Surveillance System--          behaviors, such as sexual
--Collects state-by-state     national, state, and local     activity and drug and
and national data on trends   school-based surveys (YRBS)    alcohol use, offering
and variations in births to   of representative samples of   insight into the basis for
unmarried teens.              ninth-to twelfth-grade         changes in teen birth rates
--Conducts National Survey    students and a national        over time.
of Family Growth, with other  household-based survey of 12-  --National Survey of
HHS agencies. The 1995        to 21-year-olds--provides      Adolescent Males (with OPA)
survey was released in 1997.  information on sexual          combines longitudinal data
It provides national data on  behavior, contraceptive use,   collection and individual
sexual activity,              substance abuse, and           research.
characteristics of partners,  pregnancy and HIV education.
fertility, contraception,     --School Health Policy and
marriage and cohabitation,    Program Study provides
infertility, adoption,        national data on TPP policies
maternity leave, and other    and programs implemented by
factors that affect teenage   states' departments of
and adult women and the       education, school districts,
health and well-being of      and schools. It provides
their children.               information about state
                              requirements, training
                              provided, and percentage of
                              teachers who taught the
                              subject.
                              --Pregnancy Risk Assessment
                              Monitoring System--an
                              ongoing, state-specific (16
                              states), population-based
                              surveillance system--
                              generates state-specific data
                              for assessing preconception,
                              prenatal and postpartum
                              health status, including
                              information on pregnancy
                              intention and family
                              planning.
-----------------------------------------------------------------------------------------
\a NIH funds a range of research examining intervention programs for
young people to help them abstain from early sex or unprotected sex.
The focus at the NIH level is on theoretically grounded programs with
rigorous evaluation components.  Some interventions are for HIV
prevention, and some are for pregnancy prevention.  In fiscal year
1997, the National Institute of Child Health and Human Development's
Demographic and Behavioral Sciences Branch was examining eight such
interventions and a number of smaller programs for pregnancy
prevention.

      FEW HHS EVALUATIONS WILL
      SHOW THE EFFECT PROGRAMS
      HAVE ON TEEN PREGNANCY
---------------------------------------------------------- Letter :6.2

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.\20 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.

--------------------
\20 In addition, states may select state-initiated performance
measures against which program performance will be assessed.

   CONCLUSIONS
------------------------------------------------------------ Letter :7

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.

   AGENCY AND STATE COMMENTS
------------------------------------------------------------ Letter :8

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.

---------------------------------------------------------- Letter :8.1

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.

Sincerely yours,

Marsha Lillie-Blanton
Associate Director
Health Services Quality and
 Public Health Issues

OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

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

Year         Calif.       Ga.      Ill.       La.       Md.     Maine     Oreg.       Vt.
---------  --------  --------  --------  --------  --------  --------  --------  --------
1991             75        76        65        76        54        44        55        39
1994             71        72        63        75        50        36        51        33
1996             63        68        57        67        46        31        51        30
-----------------------------------------------------------------------------------------
Source:  HHS, National Center for Health Statistics.

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.

                         Table I.2

          State Agencies Contacted in Each of the
                        Eight States

State   Agency
------  --------------------------------------------------
Califo  Department of Health Services
rnia    Department of Social Services
        Department of Education
        Department of Alcohol and Drug Programs
        Department of Youth Authority
        Department of Criminal Justice Planning

Georgi  Department of Human Resources
a       Department of Family and Children Services
        Family Connection Initiative
        Department of Juvenile Justice

Illino  Department of Human Services
is      Department of Public Health
        State Board of Education

Louisi  Department of Health and Hospitals
ana     Office of Public Health
        Department of Social Services
        Department of Education

Maine   Department of Human Services
        Department of Education
        Department of Mental Health, Mental Retardation,
        and Substance Abuse
        Office of Data Research and Vital Statistics

Maryla  Governor's Office for Children, Youth, and
nd      Families
        Governor's Council on Adolescent Pregnancy
        Department of Health and Mental Hygiene
        Department of Human Services
        Department of Education

Oregon  Oregon Health Division
        Department of Human Resources
        STARS Program
        Governor's Office

Vermon  Department of Health
t       Department of Social Welfare
        Department of Education
        Department of Social and Rehabilitative Services
        Department of Mental Health and Mental Retardation
----------------------------------------------------------
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.

SELECTED FEDERAL AGENCIES WITH
PROGRAMS THAT MAY IMPACT TEEN
PREGNANCY PREVENTION
========================================================== Appendix II

                                        Table II.1

                          Federal Agencies and Their TPP-Related
                                         Programs

Agency                         TPP-Related Programs
-----------------------------  ----------------------------------------------------------
Department of Agriculture      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.

Department of Defense          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.

Department of Education        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.

Department of Housing and      No specific programs for teen pregnancy prevention;
Urban Development              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.

Department of Justice          Administers programs focused on at-risk youth and designed
                               to reduce juvenile delinquency, which may have a
                               tangential impact on teen pregnancy.

Department of Labor            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.

Corporation for National       Volunteers through the Corporation's volunteer program
Service                        work with communities on various activities, some of which
                               may be TPP activities or youth development programs.

Office of National Drug        Does not provide direct programming on teen pregnancy
Control Policy                 prevention. The Office coordinates substance abuse
                               prevention focus of other federal agencies, with a focus
                               on youth.
-----------------------------------------------------------------------------------------
Source:  HHS and the federal agencies listed.

*** End of document. ***