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EVALUATION: IT MAKES A DIFFERENCE* MARION HOWARD, PH.D. Professor of Gynecology and Obstetrics Emory University School of Medicine Clinical Director, Teen Services Program Grady Memorial Hospital Atlanta, Georgia
T HIS CONFERENCE EXPLORES the strengths and potentials of adolescence. As a case history, this presentation deals with the very important role that evaluation has played in one community's attempt to help youth build on their strengths and potentials with respect to managing their sexuality. Since the focus of the effort has been low income black youth throughout this presentation, one must keep in mind that poverty and racism are both pervasive and invasive in our society. These social ills place additional burdens on such youth when it comes to handling almost any aspect of their lives. The evaluations and the subsequent programmatic efforts discussed are those carried out by Emory University Department of Gynecology and Obstetrics in conjunction with the Teen Services Program at Grady Memorial Hospital, a large public hospital in Atlanta. The case history begins in the late 1960s when data on mortality and morbidity rates of infants born at Grady Hospital showed that, in general, the younger the age of the girls who gave birth, the poorer the pregnancy outcome. However, at greatest risk for giving birth to a sick or dead baby were those girls who had babies too soon after their first, even though they were older at the time of their second child's birth. In the 1960s, according to a 10-year fertility study conducted elsewhere, 60% of all girls who gave birth to a first baby under age 16 were likely to give birth to another baby while still of school age. 1 Similar rates were experienced at Grady Hospital. It was clear that family planning services as delivered at Grady did not meet the needs of such girls. Indeed, some girls returned to the hospital for their six-week postpartum checkup already pregnant again. *Presented as part of a Conference on Strengths and Potentials of Adolescence held by the Committee on Public Health of the New York Academy of Medicine March 8, 1991
Address for reprint requests: Emory/Grady Teen Services Program, Grady Hospital, P.O. Box 26158, 80 Butter Street S.E., Atlanta, GA 30335
Vol. 67, No. 6, November-December 1991
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M. HOWARD~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ HOWARD
This data-based recognition that younger adolescents do not function well in the regular system of care led to the establishment of a special hospital program that was able to keep 80% of younger mothers pregnancy free until they were through their teen years.2 Called the Emory/Grady Teen Services Program, this special ongoing program for adolescents uses a casemanagement approach in the delivery of family planning services to adolescents. Although aimed at caring for young people interconceptionally-that is, between pregnancies-the program services start while the young person is pregnant. Family planning counselors from the Teen Services Program participate in the hospital's prenatal education program for pregnant adolescents. Further, a family planning counselor from the program visits young mothers following childbirth while they are still in the hospital to assure that each young person knows about contraception and leaves the hospital with a chosen method. Another program service is to give postpartum or postabortion check-ups in the Teen Services Program clinic rather than the regular hospital clinics. More education can be provided about birth control then, and young mothers can be educated about enrolling in the Teen Services Program for interconceptional care services. All these activities provide important contacts with pregnant/postpartum young adolescents to help them begin thinking about how they will handle their sexual involvement following the birth of their babies and to link them to a service designed to help them carry out their decisions. Similar services are provided for those young girls whose baby is stillborn or who have had miscarriages or abortions. Once enrolled in the Teen Services Program (through a return visit), all young mothers, along with the other young postpartum patients, are given their very own family planning counselors whom they see each time they come. Rather than using standard procedures for family planning follow-up, counselors always arrange to see their young patients at least every three months, but more often if necessary. This is because these are growing young people and they, and their lives, can change quickly. It also is based on the recognition that relationships are important to adolescents. Frequency of contact with each youth by the same counselor is one important way to build trust and confidence and to demonstrate caring. Being a parent creates special problems in living for adolescents. The young mothers in the Teen Services Program along with the other young patients are assigned their family planning counselor based on the school they attend. These case management counselors may have either a nursing or social work/social welfare background. Counselors try to learn about the Bull. N.Y. Acad. Med.
EVALUATION
597
597~~~~~~~~~~~~~~~~~
schools attended by youth in their caseloads, develop contacts at those schools, and provide actual outreach human sexuality education targeted to 13 and 14 year olds in some of the schools. Clinics are held twice weekly after school at the hospital. A separate waiting area for young teens only, medical care by nurse-midwives who like to work with adolescents, and, of course, counseling by their own counselor about contraceptives or problems that may interfere with their use of contraceptives all contribute to timely ageappropriate intervention. As needed, young mothers are referred by their counselor to other hospital or community services. Many times, however, the Teen Services Program counselor is able to help the young mother with problems such as smoothing out relationships with schools, parents, or boyfriends, or even simply scheduling time for themselves in the midst of time needed for their babies and for their studies. The Teen Services Program first transferred young mothers to the regular system of care after a one-year follow-up; later it waited two years. Now young mothers are allowed to remain in the program until they graduate from high school. The evaluation in the mid-70s that confirmed the effectiveness of this programmatic intervention for young mothers, however, could not ignore that the best way to prevent a second pregnancy was to prevent the first. Never-pregnant teens age 16 and younger always were welcomed to the Teen Services Program, and the program did receive many community referrals. However, often such young people first came when they needed a pregnancy test; thus, many were pregnant before the program had a chance to help them avoid early childbearing. As a result, the total numbers of young people giving birth at the hospital remained too high despite the reduction in rapid repeat childbearing. Further, data began to indicate that starting to have sexual intercourse at an early age, and then continuing over time with a variety of partners, was associated with later infertility. Too many young women also first came to the Teen Services Program when they had contracted a sexually transmitted infection, a prime risk factor in infertility. Young men could come for condoms and counseling but were referred elsewhere for medical services. OUTREACH ATTEMPTS THAT ONLY HALF MET THE NEED
The chosen solution was for the Teen Services Program, in the later 1970s, to work out a formal agreement with the Atlanta public schools to build on the learning strengths of young people. It was felt that if young people were given information covering such areas as decision-making, maturation and hygiene, anatomy and physiology of the reproductive system, becoming a Vol. 67, No. 6, November-December 1991
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parent, sexually transmitted diseases, along with methods of protection against pregnancy and sexually transmitted infections they would be more likely either to abstain from sex at a young age or use protection when they did start having sexual intercourse. To accomplish this, the Atlanta public schools agreed to provide five classroom periods in which such information could be given in the eighth grade. The content was developed by the Emory/Grady Teen Services Program and approved by the Public Schools. One of the great advantages of entering the schools was the ability to reach male as well as female students. Over a four-year period, acting as instructional resources, the Teen Services Program nurses and counselors provided classroom based instruction using the approved curriculum to nearly 30,000 young people. This was done by educating all eighth graders each year-in essence, providing a human sexuality educational net that all students passed through on their way to upper level classes, increased- sexual maturity, and potentially more sexual involvement. Nurses and counselors soon learned that much time in the classrooms had to be spent on correcting misinformation. For example, a national sample study conducted in the 1970s by Kantner and Zelnick3 showed that only 2% of teen-age girls said they did not know at which time of the month they were most likely to become pregnant, but nearly half gave the wrong answer. Although opponents of sex education even today indicate it is wrong to "fill empty bowls," the explosion of sexual coverage and content in the media, plus ideas and attitudes passed from peers meant that most young people already had sated their curiosity with many falsehoods. An Emory University evaluation in the early 1980s showed that the Teen Services Program outreach education effort, indeed, was tapping the learning strengths of young people.4 Students who had the Human Sexuality education program in the 8th grade in Atlanta public schools were found, in the tenth grade, to be much more knowledgeable about their bodies and the risks of sexual involvement than students in neighboring school systems who had not had the program. This was true, even though many of those in neighboring school systems were of higher socioeconomic status. However, it was clear that the program had not keyed into the potential that young people had for applying the knowledge to behaviors. It was disappointing for the Teen Services Program to learn that students who had the knowledge-based decision-making program were not less likely to have sexual intercourse. Moreover, students who had the program were only slightly more likely to use contraception at first intercourse, even though male and female methods for doing so had been brought into the classroom, shown to Bull. N.Y. Acad. Med.
EVALUATION ~~~~~~EAUTO
-~
599 9
them, and their correct usage discussed. Each student also had been taught the name of the health facility nearest her home and/or school where she could find family planning services. Over time, there was no difference in usage between groups. Finally, it was found that more young people who had the program were involved in a pregnancy than those who did not have the program. REDESIGNING THE OUTREACH EDUCATION PROGRAM
Common sense said that no one operates intelligently in a vacuum and that once they became fertile young people needed to be given information about their bodies and care of their reproductive capacity. But, also, it was clear that the kind of information currently being given young people, although necessary, was not sufficient. Ultimately, the Teen Services Program decided that it needed to give young people skills to support their potential for better use of such information. Further, such skills needed to take into account that adolescents are not just short adults, that there is something inherently different about being an adolescent. For example, adolescents have not completed some of the most important phases of their growth and development. Their cognitive functioning is, to a great extent, still concrete. Young people who are in the eighth grade, when thinking ahead, most often are thinking "What am I going to do on the weekend?" If they are really farsighted, they may be thinking "Am I going to make it through the eighth grade?" They generally are not thinking in ways that enable them to ask themselves, "If I have unprotected sex, how might my life be affected five years from now?" Young people become very egocentric in early adolescence. They have the feeling of being "on stage"-everyone is watching me, everything I do, everything I say. In trying to fit in and to belong, often young people will use behaviors to try to fit in if they cannot do it other ways. Also they carry with them a personal fable-a feeling of being so different, so unique, that what happens to others cannot happen to them. "This wonderful girl I'm going with can't possibly have a sexually transmitted disease," or "I didn't think I could get pregnant -after all, we didn't do it that often." The moral development of young people also is incomplete. Adolescents are more likely to take into account their intentions or the behavior of their peers in making moral choices, as though that excuses a behavior. "We didn't mean to have sex: we just got carried away." "I didn't mean to get pregnant." Young people often say, "Everybody is doing it [having sexual intercourse]. It's just a part of a dating relationship. It's just a part of growing Vol. 67, No. 6, November-December 1991
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up." In the low-income population served by Grady Hospital, young people also say, "My mother had her first baby at 15 so why can't I?" The "everybody's doing it" is part of their immediate environment. Thus, the Teen Services Program felt that it was inappropriate to rely solely on a decision-making model, as has been done in the previous educational program. Decision-making involves weighing alternatives, conceptualizing the future at a time when young people, naturally, are focused more on the immediate. Also, knowledge by itself most often does not change behavior. In our society today there are doctors and nurses who still smoke. Of extreme help at this juncture were two evaluations: one was an evaluation of patient satisfaction with the in-hospital services offered to its clinic population by the Teen Services Program, and the other was an evaluation done in the field of youthful smoking prevention. In an attempt to strengthen clinic services, a random sample of the 1,200 young girls seen each year by the Teen Services Program were asked what they most needed more information on. To the surprise of nearly everyone, the most frequently checked item (and 84% of the youth checked it) was "How to say 'no' without hurting the other person's feelings." Thus, it was clear that many young patients were not comfortable or happy with the sexual intercourse they were having. It also was clear that they had not been given skills to negotiate behaviors in their personal relationships. The evaluation in the field of smoking prevention was of a programmatic application of the social influence theory in 7th grade classrooms. The social influence theory holds that young people are inclined to engage in negative health behaviors more because of social and peer pressures than lack of knowledge. The particular application was found to reduce smoking by half in targeted classrooms. Teens slightly older than those being given the program presented the antismoking information, built skills, and role-modeled positive health behavior. It thus became clear that although Grady Hospital had institutionalized both prenatal services for pregnant girls, and family planning/ interconceptional care services for girls having sexual intercourse, there were no institutionalized services or even explicit support for young people who did not want to have, and/or were not having, sexual intercourse. Not even in its outreach education program did the hospital do more than discuss abstaining from sexual behavior as one of the ways to avoid pregnancy and sexually transmitted infections. HELPING YOUNG PEOPLE POSTPONE SEXUAL INVOLVEMENT
By the mid 1980s these evaluative findings had led to field tests of new material, the addition of five classroom periods to the existing human sexuBull. N.Y. Acad. Med.
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ality program in the schools, and greatly reduced sexual involvement among the target population.5 Indeed, the evaluation conducted by the Emory/Grady Teen Services Program showed that low-income Grady Hospital youth in neighboring school systems who did not have the revised program (a total of ten classroom periods in all) were five times more likely to become sexually involved in the eighth grade than those who had the program. By the end of the ninth grade (a year to a year and a half after having had the revised program), there was still a one third reduction in the rate of sexual involvement. Further, the reduction in sexual involvement held true for both boys and girls who had not had sex before the eighth grade. This evaluation affirmed the potential young people had for better managing their sexual behavior. Further support for this notion was found in data showing that, among those who had intercourse, those who had the revised program were more likely at the end of the ninth grade to report, "I tried it once or twice" or "I used to have sex but don't anymore" as opposed to youth who didn't have the program who were more likely to report they had sex "often" or "sometimes." The evaluation of the revised program also showed that giving young people skills to postpone sexual involvement was not incompatible with giving young people information about contraceptives. Those low income youth who had the revised program were both more likely to postpone sexual intercourse and to use contraceptives if they did have sex (80% of those who used contraceptives said they did so because of what they learned in school). Finally, it appeared through hospital record research aimed at validating the information given by youth that the revised program had reduced births by one third among low income youth who had the program as well. USING THE POTENTIAL OF OLDER YOUTH POSITIVELY TO INFLUENCE YOUNGER YOUTH
One unique aspect of the revised program is that new material added to the existing program utilizes the strengths and potentials of youth to influence one another positively. The new material (a separate curriculum called Postponing Sexual Involvement) is presented to eighth graders by students who are juniors and seniors in high school, working under the supervision of the Emory/Grady Teen Services Program counselors. These teen leaders are given 20 hours of initial training and then once a month two-hour in-services throughout the school year. They are paid for each classroom session. Approximately 30 teen leaders are needed each year to reach the nearly 5,000 eighth grade students in the Atlanta public schools. The teen leaders themselves gain in leadership, presentation skills, and self-esteem because of their meaningful contribution to the community. Vol. 67, No. 6, November-December 1991
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The Postponing Sexual Involvement Educational Series is experiential for the eighth graders to whom it is given. The Series helps youth understand where social pressures to have sex come from and how to deal with them. The Series teaches youth assertiveness techniques for saying no to peer pressures as well. Indeed, the Series turns around peer pressure toward sexual involvement and replaces it with group and individual pressure to postpone sexual involvement. The Series helps young people to think about levels of physically expressing affection, stopping points, and alternative ways of showing another person that they care. Special emphasis in the Series is given to practice in handling problem situations. The Teen Services Program has disseminated the curriculum and training materials for the Postponing Sexual Involvement Educational Series to youth clubs, church groups, health agencies, and school systems throughout Georgia. That others have decided that such a program fills a needed void in their efforts is best illustrated by the fact that one third of the schools in Georgia are now using the Postponing program in some fashion. A companion program for parents which enables them to reinforce the skills being given their offspring also is being widely used. However, other lessons were to be learned from the revised program evaluation data. One was the importance of follow-through efforts to sustain program gains. Funds from a local department store aided in the development and presentation of a play designed to reinforce the information given in the eighth grade. This play, Making Responsible Decisions, was given live to 7,000 high school students over a two year period. Ultimately, a videotape of the play was made and a discussion guide developed. Copies of these were given to all senior high schools in the Atlanta Public Schools for use by teachers. Of great importance, the revised program evaluation showed that an uncomfortably high number of young people said they had had sexual intercourse before the eighth grade-more than one out of every 10 girls and an even higher proportion of boys. This highlighted the importance of reaching young people earlier, particularly since by the mid 80s data showed that half of all girls were becoming fertile before the age of 13. The Teen Services Program decided that it was important to reach down to young people at an age when they were initially beginning to decide about how they would behave as teen-agers. An age-appropriate version of the postponing material (Postponing Sexual Involvement for Preteens) was developed for use with 10-12-year olds. It was field tested with fifth grade students in the Atlanta Public Schools. Staffing and funds preclude this program from being given by Bull. N.Y. Acad. Med.
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the counselors from the Hospital's Teen Services Program so the Preteen Postponing program was designed to be given by teachers. No long-term evaluation yet has been carried out, but it is hoped that implementation of such a program will help more young people refrain from sex. Immediate reactions of the younger students were extremely positive. Yet another outcome from the evaluation of the revised program was increased awareness that young people who become sexually involved are also much more likely to be experimenting with smoking and drinking. The hospital's neonatal units held many babies whose low-birth weight had been caused by smoking, along with other babies who suffered from fetal-alcohol syndrome or were "crack babies." The negative health behaviors of the mothers of these babies often had their antecedents in the early teen years. Funds from the Office of Substance Abuse Perinatal Division are now enabling the Teen Services Program to learn if, by adding no more than five minutes to a regular family planning visit, young people can be helped to understand the relationship between substance use and reproductive health in such a way as to change behavior. Evaluations continue to point out to us that we still do not know enough about how to build on the strengths and potentials of youth. For example, currently we find at least a third of the young girls who give birth at the hospital, at one time or another, have used contraceptives. So it is not that they did not know about birth control. Younger sisters of girls who have had a baby are at unusually high risk for becoming pregnant themselves. We are now experimenting with models that enable us to provide parents with more information about how to help their children have healthy babies when they are older. Our goal is to assist parents in affecting not only the life of the girl who already has one baby but younger brothers and sisters as well. Part of this approach is linking, in particular, younger sisters of girls who have had a baby with the Big Brothers/Big Sisters organization in Atlanta. Our hope is that the attention given the younger sister will counteract some of the extra attention the young mother and her new baby receive from family and friends. It also will give the younger siblings a one-on-one adult relationship through which to explore options for their lives. THE IMPORTANCE OF EVALUATION
What has been learned by the evaluations just discussed (and others space here does not permit us to discuss)? Much. Some interventions the Emory/Grady Teen Services Program thought were working wonderfully were not. Other efforts actually were working better than imagined and, Vol. 67, No. 6, November-December 1991
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therefore, not only were deemed worthy of continuation but dissemination as well. Essentially, it was learned that continuing programs merely on the basis of good feelings about what is being done can do a tremendous disservice to young people. An unevaluated effort can be taking precious community resources and applying them in a way that is not achieving desired goals or truly helping youth. If, programmatically, a community tries to build on the strengths and potentials of young people, evaluations must be used to find out whether that is being done. In the case history just discussed, evaluation also accomplished several other things. It increased interagency cooperation. The schools were much more willing to let the Teen Services Program continue active intervention with youth in the schools because the interventions were constantly evaluated and revised as indicated. The schools also were more willing to provide funding in lean years to continue such mutual efforts. It increased commitment to innovative solutions and multiple approaches. Often people become interested in a problem, try one program, and then move on to a different area. Evaluation led Grady Hospital's Teen Services Program to understand how it could do things better and helped it to recognize unmet needs. Therefore it was easier for the hospital not to abandon the problem but try to build on what it had learned in a variety of ways. It increased commitment to "staying power." Learning from the evaluations gave the Teen Services Program a keen sense of wanting to continue to improve. It could only do so by "living to fight another day." Anyone who has worked in a community knows that funding often follows the "hot" topic. One year it is child abuse, another it is AIDS, another it is welfare dependency. Working around these topical shifts meant having actively to expand support beyond federal title funding. For example, funding and other help was obtained from such widely diverse sources as a local department store, the Medical Association of Georgia and its Auxilliary, several foundations, and business/individual donations. Staying power commitment also involved a recognition that although the lives of one group of young people are affected by programmatic intervention, that group moves on only to be replaced immediately by another group with the same set of needs to be met. It increased the understanding of the breadth and depth of issues and the need for total community involvement. There is no one solution. The young person the schools call their student, a youth club calls their member, a social service agency calls their client, a parent calls their child, and we call our patient is still the same young person. Evaluations pointed up the need to Bull. N.Y. Acad. Med.
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recognize that multiple community organizations/groups and individuals must bring to bear what each can to help young people use their strengths and work toward their potential. CONCLUSION In sum, evaluation has helped one segment of the Atlanta community move from a single focus on helping adolescent mothers to prevent rapid repeated pregnancy to one of multiple strategies. One ongoing important and successful focus is to help both young men and young women to postpone sexual involvement. Another is to provide contraceptive services on a case management basis to very young adolescents until they are older and can function better in the regular system of care. A third effort is to reach out to young people as early as the fifth grade around the time they are beginning to decide how they will behave sexually when they become teenagers. Overall, evaluations have been critical in enabling Grady Memorial hospital and its community to make significant strides in their efforts to support the strengths and potentials of young people in better managing their sexuality. REFERENCES 1. Keeve, J.P., Schesinger, E.R., and and contraceptive experience of young Wight, M.S.: Fertility experience of juveunmarried women in the United States, nile girls: a community-wide ten-year 1976 and 1971. Family Plan. Persp. study. Maternal and Child Health Section 9:55-71, 1977. at the American Public Health Associa- 4. Howard, M.: Helping Youth Postpone tion. Detroit, November 12, 1968. Sexual Involvement. In: New Universals, 2. Jevitt, C.M.: A Study Of Repeated PregAdolescent Health in a Time of Change, nancy Among Adolescents Enrolling in a Bennett, D. and Williams, M., editors. Teen Services Program, School of NursCurtin, Australia, Brolga Press, 1988. ing. Atlanta, GA., Emory University, 5. Howard, M.: Helping teenagers postpone 1983. sexual involvement. Family Plan. Persp. 3. Zelnick, M. and Kantner, J.F.: Sexual 22:21-26, 1990.
Vol. 67, No. 6, November-December 1991
EVALUATION: IT MAKES A DIFFERENCE* MARION HOWARD, PH.D. Professor of Gynecology and Obstetrics Emory University School of Medicine Clinical Director, Teen Services Program Grady Memorial Hospital Atlanta, Georgia
T HIS CONFERENCE EXPLORES the strengths and potentials of adolescence. As a case history, this presentation deals with the very important role that evaluation has played in one community's attempt to help youth build on their strengths and potentials with respect to managing their sexuality. Since the focus of the effort has been low income black youth throughout this presentation, one must keep in mind that poverty and racism are both pervasive and invasive in our society. These social ills place additional burdens on such youth when it comes to handling almost any aspect of their lives. The evaluations and the subsequent programmatic efforts discussed are those carried out by Emory University Department of Gynecology and Obstetrics in conjunction with the Teen Services Program at Grady Memorial Hospital, a large public hospital in Atlanta. The case history begins in the late 1960s when data on mortality and morbidity rates of infants born at Grady Hospital showed that, in general, the younger the age of the girls who gave birth, the poorer the pregnancy outcome. However, at greatest risk for giving birth to a sick or dead baby were those girls who had babies too soon after their first, even though they were older at the time of their second child's birth. In the 1960s, according to a 10-year fertility study conducted elsewhere, 60% of all girls who gave birth to a first baby under age 16 were likely to give birth to another baby while still of school age. 1 Similar rates were experienced at Grady Hospital. It was clear that family planning services as delivered at Grady did not meet the needs of such girls. Indeed, some girls returned to the hospital for their six-week postpartum checkup already pregnant again. *Presented as part of a Conference on Strengths and Potentials of Adolescence held by the Committee on Public Health of the New York Academy of Medicine March 8, 1991
Address for reprint requests: Emory/Grady Teen Services Program, Grady Hospital, P.O. Box 26158, 80 Butter Street S.E., Atlanta, GA 30335
Vol. 67, No. 6, November-December 1991
596
M. HOWARD~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ HOWARD
This data-based recognition that younger adolescents do not function well in the regular system of care led to the establishment of a special hospital program that was able to keep 80% of younger mothers pregnancy free until they were through their teen years.2 Called the Emory/Grady Teen Services Program, this special ongoing program for adolescents uses a casemanagement approach in the delivery of family planning services to adolescents. Although aimed at caring for young people interconceptionally-that is, between pregnancies-the program services start while the young person is pregnant. Family planning counselors from the Teen Services Program participate in the hospital's prenatal education program for pregnant adolescents. Further, a family planning counselor from the program visits young mothers following childbirth while they are still in the hospital to assure that each young person knows about contraception and leaves the hospital with a chosen method. Another program service is to give postpartum or postabortion check-ups in the Teen Services Program clinic rather than the regular hospital clinics. More education can be provided about birth control then, and young mothers can be educated about enrolling in the Teen Services Program for interconceptional care services. All these activities provide important contacts with pregnant/postpartum young adolescents to help them begin thinking about how they will handle their sexual involvement following the birth of their babies and to link them to a service designed to help them carry out their decisions. Similar services are provided for those young girls whose baby is stillborn or who have had miscarriages or abortions. Once enrolled in the Teen Services Program (through a return visit), all young mothers, along with the other young postpartum patients, are given their very own family planning counselors whom they see each time they come. Rather than using standard procedures for family planning follow-up, counselors always arrange to see their young patients at least every three months, but more often if necessary. This is because these are growing young people and they, and their lives, can change quickly. It also is based on the recognition that relationships are important to adolescents. Frequency of contact with each youth by the same counselor is one important way to build trust and confidence and to demonstrate caring. Being a parent creates special problems in living for adolescents. The young mothers in the Teen Services Program along with the other young patients are assigned their family planning counselor based on the school they attend. These case management counselors may have either a nursing or social work/social welfare background. Counselors try to learn about the Bull. N.Y. Acad. Med.
EVALUATION
597
597~~~~~~~~~~~~~~~~~
schools attended by youth in their caseloads, develop contacts at those schools, and provide actual outreach human sexuality education targeted to 13 and 14 year olds in some of the schools. Clinics are held twice weekly after school at the hospital. A separate waiting area for young teens only, medical care by nurse-midwives who like to work with adolescents, and, of course, counseling by their own counselor about contraceptives or problems that may interfere with their use of contraceptives all contribute to timely ageappropriate intervention. As needed, young mothers are referred by their counselor to other hospital or community services. Many times, however, the Teen Services Program counselor is able to help the young mother with problems such as smoothing out relationships with schools, parents, or boyfriends, or even simply scheduling time for themselves in the midst of time needed for their babies and for their studies. The Teen Services Program first transferred young mothers to the regular system of care after a one-year follow-up; later it waited two years. Now young mothers are allowed to remain in the program until they graduate from high school. The evaluation in the mid-70s that confirmed the effectiveness of this programmatic intervention for young mothers, however, could not ignore that the best way to prevent a second pregnancy was to prevent the first. Never-pregnant teens age 16 and younger always were welcomed to the Teen Services Program, and the program did receive many community referrals. However, often such young people first came when they needed a pregnancy test; thus, many were pregnant before the program had a chance to help them avoid early childbearing. As a result, the total numbers of young people giving birth at the hospital remained too high despite the reduction in rapid repeat childbearing. Further, data began to indicate that starting to have sexual intercourse at an early age, and then continuing over time with a variety of partners, was associated with later infertility. Too many young women also first came to the Teen Services Program when they had contracted a sexually transmitted infection, a prime risk factor in infertility. Young men could come for condoms and counseling but were referred elsewhere for medical services. OUTREACH ATTEMPTS THAT ONLY HALF MET THE NEED
The chosen solution was for the Teen Services Program, in the later 1970s, to work out a formal agreement with the Atlanta public schools to build on the learning strengths of young people. It was felt that if young people were given information covering such areas as decision-making, maturation and hygiene, anatomy and physiology of the reproductive system, becoming a Vol. 67, No. 6, November-December 1991
598 598
HOWARD M. HOWARD M.
parent, sexually transmitted diseases, along with methods of protection against pregnancy and sexually transmitted infections they would be more likely either to abstain from sex at a young age or use protection when they did start having sexual intercourse. To accomplish this, the Atlanta public schools agreed to provide five classroom periods in which such information could be given in the eighth grade. The content was developed by the Emory/Grady Teen Services Program and approved by the Public Schools. One of the great advantages of entering the schools was the ability to reach male as well as female students. Over a four-year period, acting as instructional resources, the Teen Services Program nurses and counselors provided classroom based instruction using the approved curriculum to nearly 30,000 young people. This was done by educating all eighth graders each year-in essence, providing a human sexuality educational net that all students passed through on their way to upper level classes, increased- sexual maturity, and potentially more sexual involvement. Nurses and counselors soon learned that much time in the classrooms had to be spent on correcting misinformation. For example, a national sample study conducted in the 1970s by Kantner and Zelnick3 showed that only 2% of teen-age girls said they did not know at which time of the month they were most likely to become pregnant, but nearly half gave the wrong answer. Although opponents of sex education even today indicate it is wrong to "fill empty bowls," the explosion of sexual coverage and content in the media, plus ideas and attitudes passed from peers meant that most young people already had sated their curiosity with many falsehoods. An Emory University evaluation in the early 1980s showed that the Teen Services Program outreach education effort, indeed, was tapping the learning strengths of young people.4 Students who had the Human Sexuality education program in the 8th grade in Atlanta public schools were found, in the tenth grade, to be much more knowledgeable about their bodies and the risks of sexual involvement than students in neighboring school systems who had not had the program. This was true, even though many of those in neighboring school systems were of higher socioeconomic status. However, it was clear that the program had not keyed into the potential that young people had for applying the knowledge to behaviors. It was disappointing for the Teen Services Program to learn that students who had the knowledge-based decision-making program were not less likely to have sexual intercourse. Moreover, students who had the program were only slightly more likely to use contraception at first intercourse, even though male and female methods for doing so had been brought into the classroom, shown to Bull. N.Y. Acad. Med.
EVALUATION ~~~~~~EAUTO
-~
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them, and their correct usage discussed. Each student also had been taught the name of the health facility nearest her home and/or school where she could find family planning services. Over time, there was no difference in usage between groups. Finally, it was found that more young people who had the program were involved in a pregnancy than those who did not have the program. REDESIGNING THE OUTREACH EDUCATION PROGRAM
Common sense said that no one operates intelligently in a vacuum and that once they became fertile young people needed to be given information about their bodies and care of their reproductive capacity. But, also, it was clear that the kind of information currently being given young people, although necessary, was not sufficient. Ultimately, the Teen Services Program decided that it needed to give young people skills to support their potential for better use of such information. Further, such skills needed to take into account that adolescents are not just short adults, that there is something inherently different about being an adolescent. For example, adolescents have not completed some of the most important phases of their growth and development. Their cognitive functioning is, to a great extent, still concrete. Young people who are in the eighth grade, when thinking ahead, most often are thinking "What am I going to do on the weekend?" If they are really farsighted, they may be thinking "Am I going to make it through the eighth grade?" They generally are not thinking in ways that enable them to ask themselves, "If I have unprotected sex, how might my life be affected five years from now?" Young people become very egocentric in early adolescence. They have the feeling of being "on stage"-everyone is watching me, everything I do, everything I say. In trying to fit in and to belong, often young people will use behaviors to try to fit in if they cannot do it other ways. Also they carry with them a personal fable-a feeling of being so different, so unique, that what happens to others cannot happen to them. "This wonderful girl I'm going with can't possibly have a sexually transmitted disease," or "I didn't think I could get pregnant -after all, we didn't do it that often." The moral development of young people also is incomplete. Adolescents are more likely to take into account their intentions or the behavior of their peers in making moral choices, as though that excuses a behavior. "We didn't mean to have sex: we just got carried away." "I didn't mean to get pregnant." Young people often say, "Everybody is doing it [having sexual intercourse]. It's just a part of a dating relationship. It's just a part of growing Vol. 67, No. 6, November-December 1991
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up." In the low-income population served by Grady Hospital, young people also say, "My mother had her first baby at 15 so why can't I?" The "everybody's doing it" is part of their immediate environment. Thus, the Teen Services Program felt that it was inappropriate to rely solely on a decision-making model, as has been done in the previous educational program. Decision-making involves weighing alternatives, conceptualizing the future at a time when young people, naturally, are focused more on the immediate. Also, knowledge by itself most often does not change behavior. In our society today there are doctors and nurses who still smoke. Of extreme help at this juncture were two evaluations: one was an evaluation of patient satisfaction with the in-hospital services offered to its clinic population by the Teen Services Program, and the other was an evaluation done in the field of youthful smoking prevention. In an attempt to strengthen clinic services, a random sample of the 1,200 young girls seen each year by the Teen Services Program were asked what they most needed more information on. To the surprise of nearly everyone, the most frequently checked item (and 84% of the youth checked it) was "How to say 'no' without hurting the other person's feelings." Thus, it was clear that many young patients were not comfortable or happy with the sexual intercourse they were having. It also was clear that they had not been given skills to negotiate behaviors in their personal relationships. The evaluation in the field of smoking prevention was of a programmatic application of the social influence theory in 7th grade classrooms. The social influence theory holds that young people are inclined to engage in negative health behaviors more because of social and peer pressures than lack of knowledge. The particular application was found to reduce smoking by half in targeted classrooms. Teens slightly older than those being given the program presented the antismoking information, built skills, and role-modeled positive health behavior. It thus became clear that although Grady Hospital had institutionalized both prenatal services for pregnant girls, and family planning/ interconceptional care services for girls having sexual intercourse, there were no institutionalized services or even explicit support for young people who did not want to have, and/or were not having, sexual intercourse. Not even in its outreach education program did the hospital do more than discuss abstaining from sexual behavior as one of the ways to avoid pregnancy and sexually transmitted infections. HELPING YOUNG PEOPLE POSTPONE SEXUAL INVOLVEMENT
By the mid 1980s these evaluative findings had led to field tests of new material, the addition of five classroom periods to the existing human sexuBull. N.Y. Acad. Med.
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ality program in the schools, and greatly reduced sexual involvement among the target population.5 Indeed, the evaluation conducted by the Emory/Grady Teen Services Program showed that low-income Grady Hospital youth in neighboring school systems who did not have the revised program (a total of ten classroom periods in all) were five times more likely to become sexually involved in the eighth grade than those who had the program. By the end of the ninth grade (a year to a year and a half after having had the revised program), there was still a one third reduction in the rate of sexual involvement. Further, the reduction in sexual involvement held true for both boys and girls who had not had sex before the eighth grade. This evaluation affirmed the potential young people had for better managing their sexual behavior. Further support for this notion was found in data showing that, among those who had intercourse, those who had the revised program were more likely at the end of the ninth grade to report, "I tried it once or twice" or "I used to have sex but don't anymore" as opposed to youth who didn't have the program who were more likely to report they had sex "often" or "sometimes." The evaluation of the revised program also showed that giving young people skills to postpone sexual involvement was not incompatible with giving young people information about contraceptives. Those low income youth who had the revised program were both more likely to postpone sexual intercourse and to use contraceptives if they did have sex (80% of those who used contraceptives said they did so because of what they learned in school). Finally, it appeared through hospital record research aimed at validating the information given by youth that the revised program had reduced births by one third among low income youth who had the program as well. USING THE POTENTIAL OF OLDER YOUTH POSITIVELY TO INFLUENCE YOUNGER YOUTH
One unique aspect of the revised program is that new material added to the existing program utilizes the strengths and potentials of youth to influence one another positively. The new material (a separate curriculum called Postponing Sexual Involvement) is presented to eighth graders by students who are juniors and seniors in high school, working under the supervision of the Emory/Grady Teen Services Program counselors. These teen leaders are given 20 hours of initial training and then once a month two-hour in-services throughout the school year. They are paid for each classroom session. Approximately 30 teen leaders are needed each year to reach the nearly 5,000 eighth grade students in the Atlanta public schools. The teen leaders themselves gain in leadership, presentation skills, and self-esteem because of their meaningful contribution to the community. Vol. 67, No. 6, November-December 1991
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The Postponing Sexual Involvement Educational Series is experiential for the eighth graders to whom it is given. The Series helps youth understand where social pressures to have sex come from and how to deal with them. The Series teaches youth assertiveness techniques for saying no to peer pressures as well. Indeed, the Series turns around peer pressure toward sexual involvement and replaces it with group and individual pressure to postpone sexual involvement. The Series helps young people to think about levels of physically expressing affection, stopping points, and alternative ways of showing another person that they care. Special emphasis in the Series is given to practice in handling problem situations. The Teen Services Program has disseminated the curriculum and training materials for the Postponing Sexual Involvement Educational Series to youth clubs, church groups, health agencies, and school systems throughout Georgia. That others have decided that such a program fills a needed void in their efforts is best illustrated by the fact that one third of the schools in Georgia are now using the Postponing program in some fashion. A companion program for parents which enables them to reinforce the skills being given their offspring also is being widely used. However, other lessons were to be learned from the revised program evaluation data. One was the importance of follow-through efforts to sustain program gains. Funds from a local department store aided in the development and presentation of a play designed to reinforce the information given in the eighth grade. This play, Making Responsible Decisions, was given live to 7,000 high school students over a two year period. Ultimately, a videotape of the play was made and a discussion guide developed. Copies of these were given to all senior high schools in the Atlanta Public Schools for use by teachers. Of great importance, the revised program evaluation showed that an uncomfortably high number of young people said they had had sexual intercourse before the eighth grade-more than one out of every 10 girls and an even higher proportion of boys. This highlighted the importance of reaching young people earlier, particularly since by the mid 80s data showed that half of all girls were becoming fertile before the age of 13. The Teen Services Program decided that it was important to reach down to young people at an age when they were initially beginning to decide about how they would behave as teen-agers. An age-appropriate version of the postponing material (Postponing Sexual Involvement for Preteens) was developed for use with 10-12-year olds. It was field tested with fifth grade students in the Atlanta Public Schools. Staffing and funds preclude this program from being given by Bull. N.Y. Acad. Med.
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the counselors from the Hospital's Teen Services Program so the Preteen Postponing program was designed to be given by teachers. No long-term evaluation yet has been carried out, but it is hoped that implementation of such a program will help more young people refrain from sex. Immediate reactions of the younger students were extremely positive. Yet another outcome from the evaluation of the revised program was increased awareness that young people who become sexually involved are also much more likely to be experimenting with smoking and drinking. The hospital's neonatal units held many babies whose low-birth weight had been caused by smoking, along with other babies who suffered from fetal-alcohol syndrome or were "crack babies." The negative health behaviors of the mothers of these babies often had their antecedents in the early teen years. Funds from the Office of Substance Abuse Perinatal Division are now enabling the Teen Services Program to learn if, by adding no more than five minutes to a regular family planning visit, young people can be helped to understand the relationship between substance use and reproductive health in such a way as to change behavior. Evaluations continue to point out to us that we still do not know enough about how to build on the strengths and potentials of youth. For example, currently we find at least a third of the young girls who give birth at the hospital, at one time or another, have used contraceptives. So it is not that they did not know about birth control. Younger sisters of girls who have had a baby are at unusually high risk for becoming pregnant themselves. We are now experimenting with models that enable us to provide parents with more information about how to help their children have healthy babies when they are older. Our goal is to assist parents in affecting not only the life of the girl who already has one baby but younger brothers and sisters as well. Part of this approach is linking, in particular, younger sisters of girls who have had a baby with the Big Brothers/Big Sisters organization in Atlanta. Our hope is that the attention given the younger sister will counteract some of the extra attention the young mother and her new baby receive from family and friends. It also will give the younger siblings a one-on-one adult relationship through which to explore options for their lives. THE IMPORTANCE OF EVALUATION
What has been learned by the evaluations just discussed (and others space here does not permit us to discuss)? Much. Some interventions the Emory/Grady Teen Services Program thought were working wonderfully were not. Other efforts actually were working better than imagined and, Vol. 67, No. 6, November-December 1991
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therefore, not only were deemed worthy of continuation but dissemination as well. Essentially, it was learned that continuing programs merely on the basis of good feelings about what is being done can do a tremendous disservice to young people. An unevaluated effort can be taking precious community resources and applying them in a way that is not achieving desired goals or truly helping youth. If, programmatically, a community tries to build on the strengths and potentials of young people, evaluations must be used to find out whether that is being done. In the case history just discussed, evaluation also accomplished several other things. It increased interagency cooperation. The schools were much more willing to let the Teen Services Program continue active intervention with youth in the schools because the interventions were constantly evaluated and revised as indicated. The schools also were more willing to provide funding in lean years to continue such mutual efforts. It increased commitment to innovative solutions and multiple approaches. Often people become interested in a problem, try one program, and then move on to a different area. Evaluation led Grady Hospital's Teen Services Program to understand how it could do things better and helped it to recognize unmet needs. Therefore it was easier for the hospital not to abandon the problem but try to build on what it had learned in a variety of ways. It increased commitment to "staying power." Learning from the evaluations gave the Teen Services Program a keen sense of wanting to continue to improve. It could only do so by "living to fight another day." Anyone who has worked in a community knows that funding often follows the "hot" topic. One year it is child abuse, another it is AIDS, another it is welfare dependency. Working around these topical shifts meant having actively to expand support beyond federal title funding. For example, funding and other help was obtained from such widely diverse sources as a local department store, the Medical Association of Georgia and its Auxilliary, several foundations, and business/individual donations. Staying power commitment also involved a recognition that although the lives of one group of young people are affected by programmatic intervention, that group moves on only to be replaced immediately by another group with the same set of needs to be met. It increased the understanding of the breadth and depth of issues and the need for total community involvement. There is no one solution. The young person the schools call their student, a youth club calls their member, a social service agency calls their client, a parent calls their child, and we call our patient is still the same young person. Evaluations pointed up the need to Bull. N.Y. Acad. Med.
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recognize that multiple community organizations/groups and individuals must bring to bear what each can to help young people use their strengths and work toward their potential. CONCLUSION In sum, evaluation has helped one segment of the Atlanta community move from a single focus on helping adolescent mothers to prevent rapid repeated pregnancy to one of multiple strategies. One ongoing important and successful focus is to help both young men and young women to postpone sexual involvement. Another is to provide contraceptive services on a case management basis to very young adolescents until they are older and can function better in the regular system of care. A third effort is to reach out to young people as early as the fifth grade around the time they are beginning to decide how they will behave sexually when they become teenagers. Overall, evaluations have been critical in enabling Grady Memorial hospital and its community to make significant strides in their efforts to support the strengths and potentials of young people in better managing their sexuality. REFERENCES 1. Keeve, J.P., Schesinger, E.R., and and contraceptive experience of young Wight, M.S.: Fertility experience of juveunmarried women in the United States, nile girls: a community-wide ten-year 1976 and 1971. Family Plan. Persp. study. Maternal and Child Health Section 9:55-71, 1977. at the American Public Health Associa- 4. Howard, M.: Helping Youth Postpone tion. Detroit, November 12, 1968. Sexual Involvement. In: New Universals, 2. Jevitt, C.M.: A Study Of Repeated PregAdolescent Health in a Time of Change, nancy Among Adolescents Enrolling in a Bennett, D. and Williams, M., editors. Teen Services Program, School of NursCurtin, Australia, Brolga Press, 1988. ing. Atlanta, GA., Emory University, 5. Howard, M.: Helping teenagers postpone 1983. sexual involvement. Family Plan. Persp. 3. Zelnick, M. and Kantner, J.F.: Sexual 22:21-26, 1990.
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