Without warning, the Trump administration has yanked funding for four teen pregnancy prevention programs serving American Indian youth.
On July 1, the Department of Health and Human Services (HHS) told the 80-plus Teen Pregnancy Prevention (TPP) program grantees that their funding would end two years early, in June 2018 instead of June 2020, as scheduled.
Teen birth rates in the U.S. have been declining for more than two decades, and were down 67 percent in 2016 from a high of 61.8 births per 1,000 females in 1991. The birth rate for AI/AN teens was 26 births per 1,000 in 2014, a 17 percent decline from 2013 and a 69 percent decline since 1991, according to the National Campaign to Prevent Teen and Unplanned Pregnancy.
The decline in the teen birth rate is not due to teens having more abortions. Instead, they are having less sex, using more effective contraception more often when they do have sex, and have more information on how to prevent pregnancy, reports the Pew Research Center. “It’s a mistake to think that sex education has to make abstinence and the use of contraception mutually exclusive,” said Jennifer Hettema, project director of a TPP-funded initiative serving 13- to 19-year-old Native Americans and Hispanics run by the University of New Mexico’s Health Sciences Center.
TPP funds implementation of evidence-based programs and the development, evaluation and dissemination of new approaches to preventing teen pregnancy.
The University of New Mexico program is investigating whether a brief patient-centered interview, conducted in a medical setting, that asks a teen who is already having unprotected sex to think about the impact an unintended pregnancy would have on his or her life goals and values and then offers, to those who are interested, information about how to prevent pregnancy. The hypothesis is that the interviews, each based on a protocol but modified to meet the needs of the individual teen, will decrease the rate of unprotected sex among the participants. The model comes from a proven intervention technique that offers people who might be drinking too much, but do not have an alcohol use disorder, information about risky drinking.
“Most interventions for teen pregnancy are more intensive. We’re the first to ask whether a brief intervention in a medical setting is effective,” explained Hettema. If it is, the intervention is extremely cost-effective from a public health standpoint, she said.
There is a correlation between these federally-funded programs and the declining teen birth rate, noted Andrea Kane, VP of Policy & Strategic Partnerships at the National Campaign to Prevent Teen and Unplanned Pregnancy. Since the federal TPP and PREP (Personal Responsibility Education) programs were implemented in 2010, the national teen birth rate has dropped an astounding 41 percent. A correlation does not prove causation, but it does suggest, she said, that the programs may be having a significant effect on dealing with this public health issue that cost taxpayers upwards of $9 billion in 2010, according to the CDC.
Despite the progress that has been made, the “U.S. teen birth rate remains higher than in other developed countries,” and “geographic, socioeconomic, and racial/ethnic disparities in teen birth rates persist,” according to a 2015 Public Health Report. The research component of the TPP is intended to determine what strategies work best for which teens. To date, very little other research has been conducted to identify effective evidence-based teen pregnancy prevention programs for AI/AN populations.
In Arizona, The Johns Hopkins Center for American Indian Health is working with a tribe to evaluate the effectiveness of the Respecting the Circle of Life program in reducing teen pregnancy and the occurrence of sexually transmitted diseases. The program was developed and piloted as a collaboration between the center and the tribe, said Lauren Tingey, the center’s director. “The nine-session program teaches every method of avoiding unintended pregnancy, including abstinence, contraceptive use, and condom use to prevent a pregnancy or a sexually transmitted infection,” said Tingey. The first eight sessions are conducted as part of a basketball camp, with the ninth session, which includes the teen’s parent, following.
The pilot program, Tingey said, “was shown to improve youth’s HIV prevention and transmission knowledge, their confidence in their ability to use condoms, their belief that condoms were effective, and the frequency with which they spoke to their families about topics like HIV and AIDS.” This TPP-funded research was designed to include a very large randomized sample and look at whether the intervention changed actual behavior, such as condom or contraceptive use, the number of partners a teen had, and, ideally, pregnancy rates.
“There are not very many programs that have this kind of content, developed for and evaluated with Native American communities. There are programs with African American and Latino communities, but very, very few developed for and rigorously evaluated for Native American communities,” she said.
Ending these projects two years early means that researchers will not be able to answer the questions they set out to answer because their samples will not be large enough to get statistically valid results and the follow-up periods will not be long enough to find out if the results persist. And the year at the end of the grant period – time necessary to evaluate the data and transfer it from the laboratory to the people who actually work with teens – will be gone, explained Hettema and Tingey.
TPP has won accolades from many organizations, including the National Conference of State Legislatures, which wrote in 2016: “The Teen Pregnancy Prevention Program (TPP), administered by the U.S. Department of Health and Human Services’ (HHS) Office of Adolescent Health, is among the first examples of federal evidence-based policymaking.”
A U.S. Health and Human Services Department spokesperson, however, told ICMN that the evaluation of the first round of 5-year TPP grants, awarded in 2010, showed disappointing results. “Of the 37 projects for which evaluation results have been reported, fully 73 percent were found to have no or negative impact on the behavior of the teens who participated in the program compared to teens who did not participate. Three programs demonstrated negative effects on teen behavior, including an increased likelihood to begin having sex, increased likelihood to engage in unprotected sex, and an increased likelihood of becoming pregnant. While some programs did show positive effects, most positive impacts either dissipated within 6-12 months or were evident in only specific sub-groups of teens. Only four of the 37 programs studied showed sustained and positive impacts,” the department wrote in an email.
In its budget process for 2018, and in agreement with President Donald Trump’s proposed budget, the House has eliminated TPP altogether, but that is par for the course. In previous years the Senate has gone ahead and funded the program in its appropriations process; however, exactly what happens if the Senate funds a program HHS has cut is not clear, said Kane.
HHS said: “Given the very weak evidence of positive impact of these programs, the Trump administration, in its FY 2018 budget proposal did not recommend continued funding for the TPP program. Current TPP grantees were given a project end date of June 30, 2018. During this time HHS will continue to review the evidence and determine how to better structure this program, should the U.S. Congress decide to continue its funding.”