The School/Community Initiative to Reduce Risk for Adolescent Pregnancy in Three Kansas Communities. 1
BACKGROUND AND CONTENT
The School/Community Sexual Risk Reduction Replication Initiative was a model for adolescent pregnancy prevention developed in South Carolina 2 and replicated in several Kansas communities 3. This example describes the evaluation of the School/Community Initiatives implemented in the replication, their effectiveness, and uses of the findings for improvement.
The School/Community Sexual Risk Reduction Replication Initiative is a comprehensive approach to reducing teenage pregnancy by implementing a multiple component intervention through the community and school systems. Its goals included not only reducing teenage pregnancy, but also delaying the onset and reducing the prevalence of sexual activity among teens. Goals of the comprehensive initiative included improving access to health services for adolescents, increasing the role of schools in improving adolescent health, and forming community alliances to promote adolescent health.
IDENTIFY STAKEHOLDERS:
Stakeholders in the process included the youth of the communities involved, parents, local school and health organizations, and residents and taxpayers in the community. The Kansas Health Foundation provides grants to support the work. School/Community Initiatives were funded in Geary County, Franklin County, and selected neighborhoods of Wichita, Kansas. The University of Kansas Center for Community Health and Development provided technical assistance evaluation support.
DESCRIBE THE PROGRAM INITIATIVE:
The School/Community Initiative was created to reduce teenage pregnancy in Kansas communities. Adolescent pregnancy has negative outcomes for the teenage mother, her children, and may result in considerable financial and social costs to the broader community. As adolescent pregnancy is a complex issue, it is unlikely that any single intervention (e.g., sexual education) will be sufficient to effect community-level outcomes. A teenage pregnancy risk reduction model had been previously implemented in two rural South Carolina communities. The multiple component intervention was found to be effective in decreasing the estimated pregnancy rate in those communities. The replication initiative, beginning in 1994, was an attempt to repeat that success in three Kansas communities. Geary County, a military community had the highest teen pregnancy rate in Kansas, a 5-year estimated pregnancy rate among women aged 15-19 years of 159.7 per 1,000. The lead agency in the program was the county school district. Franklin County, a rural community, had a 5-year estimated pregnancy rate among women aged 15-19 years of 80.5 per 1,000. The lead agency in their program was a satellite office of a regional drug and alcohol prevention center. The low-income neighborhoods in Northeast Wichita served in this project had birthrates (births and fetal deaths) for women aged 15-19 years of 141.9 per 1,000. (Estimated pregnancy rates were unavailable due to lack of abortion data in the target area.) The lead agency in the Wichita neighborhood was a grassroots community organization based by and for members of the Black Community. The initiative's broad objectives included: a) reducing teenage pregnancy, b) delaying the age of first intercourse, and c) increasing contraceptive use among sexually active teenagers. Intervention components chosen to accomplish those goals were to a) enhance sexuality education for teachers and parents; b) provide comprehensive, age appropriate sexuality education from kindergarten through 12th grade (K-12); c) increase access to health services; d) collaborate with school administrators to promote communication about school health decisions and assess student knowledge, attitudes, and behaviors; e) a increase awareness and involvement of the entire community in the prevention initiative through mass media and other means; f) provide training to create peer support and education programs; g) provide alternative activities for youth; and h) promote involvement of the faith community. The Kansas Health Foundation provided approximately $400,000 over four years to the three communities to reduce the risks associated with teenage pregnancy. In addition, they funded research and evaluation teams at the University of Kansas and University of South Carolina to support and evaluate the initiative. Broad objectives and the activities chosen to accomplish them are based on a logic model that hypothesizes that there is a relationship between environmental change (implementation of components and community/systems change) and more distant outcomes (estimated pregnancy rate). Specifically, it is assumed that environmental changes and interventions, such as increasing sexual education and extending health clinic hours to increase access will effect wide spread behavior change (i.e. abstinence, safe sex) and population-level outcomes (i.e. extinguished pregnancy rate).
FOCUS THE EVALUATION DESIGN:
The focus of the current evaluation is to determine if the School/Community Initiatives implemented in the three communities were effective in accomplishing the broad objectives the initiative set out to achieve after a four year time period (1994-1997). In order to assess this, data were collected on services provided and new programs, practices and/or policies established to reduce risk or enhance protection. In addition, survey information was collected on sexual knowledge, attitudes, and behavior among adolescents. Estimated pregnancy rates were obtained from the state health department. The findings from each of the three communities were compared to zip codes or counties with similar estimated pregnancy rates or birthrates for 14-17 year old female adolescents. Two target areas or district neighborhoods were identified in Northeast Wichita. Comparisons to rates prior to the intervention were compared to those during the intervention. Results of the evaluation were released to the community, the grant making agencies, and used by the research and evaluation teams in examining how adaptation of the original model of risk reduction according to the communities? needs and preferences affected replication and effectiveness. The evaluation used a pretest-posttest comparison group design to assess the overall impact of the program components/changes put into practice on the broader objectives in the three communities.
GATHER CREDIBLE EVIDENCE:
A multiple case design study was used to examine the effects on measure of process and intermediate outcome. Process measures (and related methods) included the importance of goals as rated by the constituents (identified through surveys), member satisfaction with project functioning (survey), and measures of project implementation (documentation of the number/rate community actions, media coverage, services provided, health and sexuality education, resources generated) ascertained through a monitoring/feedback system and semi-structured interviews. Those surveyed included community members who had participated in project activities, or served on boards or committees, and those whom staff wanted to inform or had a history of being supportive. Intermediate outcome measures included the rate of community changes (the onset of new or modified programs, policies, or practices consistent with the mission that were facilitated by the project; monitored on a monthly basis). They also included the importance of changes as rated by constituents (survey), and critical events identified as important to the initiative?s development (related through semi-structured interviews). More distant outcome measures included reported behavior changes in sexual activity, condom usage, and age of first intercourse, and estimated pregnancy rates or birthrates (behavioral surveys) for females aged 14-17 years. Data on behavior change was collected through the Youth Risk Behavior Survey and Adolescent Curriculum Evaluation in Geary and Franklin County. The Wichita sites declined to participate in the survey, so no data were available for behavior change in those neighborhoods. Estimated pregnancy and birthrates were obtained from archival records available from the state health department. These measures were judged as credible evidence to evaluate the comprehensive community initiative.
JUSTIFY CONCLUSIONS
Overall, findings from the replication of the school and community model in Kansas were encouraging. Although most values were not statistically significant, small decreases in estimate pregnancy and birthrates were detected. There were changes in self-reported behavior in adolescents, and rates of community and system change in all communities were strong throughout the length of the intervention. The lack of statistical significance in the level of change is not unanticipated after such a short time period for intervention. It is encouraging that change was seen in the desired direction for most outcome measures in many of the communities. Those changes that were statistically significant included the proportion of ninth and tenth graders reporting that they had ever had sex in Geary County, with a decrease from 51% to 38% among females and a decrease from 63% to 43% in males. In Franklin County, more 11th and 12th grade males reported using condoms in 1996 (55%) than had done so in 1994 (39%). Among more distant outcome measures, estimated pregnancy rates decreased in both Geary and Franklin County and estimated birthrates decreased at one of the Wichita sites, while comparison sites were mixed. By comparison, on the state level, estimated pregnancy rates rose in Kansas between pre-intervention and intervention periods. Process measures indicated different communities found different goals more important, with response rates for surveys varying between 23% and 50%. Satisfaction surveys were distributed one and a half to three years after intervention projects were initiated, with response rated varying between 35% to 58%. It is unclear if those who chose not to respond felt significantly differently than those who did or simply if survey methods (e.g., length of survey) may have influenced response rates. In addition, surveys were sent to community members identified as active in the initiative as opposed to random community members, which may have influenced ratings. In general, community satisfaction with project functioning was high, and changes facilitated by each project were considered important. Overall, projects were well received in their respective communities although opposition regarding the controversial nature of some strategies (e.g., increasing access to contraceptives for young people and providing comprehensive sexuality education) was encountered.
ENSURE USE AND SHARE LESSONS LEARNED:
The current comprehensive evaluation was designed to support and assess the process, intermediate outcome and more distant outcomes of three multicomponent school and community-based projects. Ongoing evaluation was utilized at multiple stages of the intervention. It was used in early phases to set the future direction of the project, identify strengths and challenges to project functioning, and track the progress of the unfolding replication effort. Later, evaluation of community and system change data steered the direction of new efforts, especially toward areas that had been neglected by previous efforts. Finally, evaluation provided feedback about whether the initiative was being effective and whether it had replicated the success experienced in South Carolina, despite significant changes made to accommodate the differences in communities. The evaluation was designed to track complex multicomponent initiatives responsive to local contexts and issues and which would meet the needs of both the initiative and the stakeholders. Evaluation questions were created to specifically address the interest of community members, the initiative's leadership, and funders. Evaluation started early in the process to be useful in understanding and improving the effort as it unfolded and changed. Data from the evaluation were used to sustain the initiatives, helping them garner additional resources to continue their efforts. Finally, the evaluation was part of a larger support system designed to build local capacity for reducing risks for adolescent pregnancy in that community. As a result of the promising changes in intermediate and more distant outcome measures evidenced in the findings, the Kansas Health Foundation provided additional funds for a second generation of School/Community Initiatives in three additional Kansas communities.
RESOURCES
- Paine-Andrews, A., Harris, K.J., Fisher, J.L., Lewis, R.K., Williams, E.L., Fawcett, S.B., & Vincent, M.L. Effects of a replication of a multicomponent model for preventing adolescent pregnancy in three Kansas communities. Family Planning Perspectives. 1999; 31(4): 182-189.
- Vincent, M.L., Clearie, A., & Schluchter, M. Reducing adolescent pregnancy through school and community-based education. Journal of the American Medical Association. 1987; 257(24): 3382-3386.
- Paine-Andrews, A., Vincent, M.L., Fawcett, S.B., Campuzano, M.K., Harris, K.J., Lewis, R.K., Williams, E.L., & Fisher, J.L. Replicating a community initiative for preventing adolescent pregnancy: From South Carolina to Kansas. Family and Community Health. 1996; 19(1): 14-30.