Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program

During the last decade, state, local, and Federal governments have implemented a large number of new evidence-based practices, the largest number during the last 5 years in particular []. The Obama Administration has cultivated what many consider the greatest opportunity for rigorous evidence to shape social policy in the history of the U.S. government []. The plan originally designed at the Office of Management and Budget (OMB) was to create evidence-based social policy initiatives to improve policymaking and program outcomes, thereby using an evidence-based approach as a key part of the President's legislative agenda. Former OMB Director Peter Orszag called for designing new initiatives to build rigorous data, rather than treating evaluation as an afterthought, and using the evidence that emerges for action [].

President Obama's Fiscal Year (FY) 2010 budget proposed funds to support evidence-based approaches to more effectively target teen pregnancy prevention funds, utilizing evidence-based models and promising practices []. As part of that effort, the Health and Human Services (HHS) FY 2010 budget requested $110 million for a two-tiered evidence-based program []. The budget request redirected funding from the Health and Human Services (HHS) Administration on Children and Families (ACF) abstinence-only until marriage education programs to evidence-based and promising teen pregnancy prevention programs. Under this new initiative, the majority of funds were to support programs using models whose effectiveness has been demonstrated through rigorous evaluation, which came to be known as “Tier 1.” A smaller portion of funds was to be available to develop and test promising or innovative teen prevention programs, referred to as “Tier 2.”

The final spending bill included funding for a new Teenage Pregnancy Prevention (TPP) Program within the Office of the Secretary of Health and Human Services, and provided specific guidance regarding administration of the program. The conferees directed the Secretary to establish an Office of Adolescent Health (OAH) within the Office of the Assistant Secretary for Health. Congress also expressed its intent that the OAH be responsible for implementing and administering the TPP program, and that it coordinate its efforts with ACF, the Centers for Disease Control and Prevention (CDC), and other appropriate HHS offices and operating divisions.

By the end of the second year of the Obama Administration, six new Federal evidence-based initiatives were underway to advance the use of evidence-based program models and to generate high-quality evidence on program models that were either new or had no rigorous evaluation previously. This includes the Teenage Pregnancy Prevention Program, housed in OAH.

As the budget proposal for a new teen pregnancy prevention initiative was being considered on the Hill, an HHS workgroup was established with staff representatives from various offices. The workgroup was tasked with reviewing major issues to be considered in the development and shaping of this new program and a funding opportunity announcement (FOA). The FOA would be the public vehicle for announcing the major components and expectations for this new program effort. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) served as the convener of the workgroup, which had representatives from ASPE, ACF, CDC, and the Office of Public Health and Science (now the Office of the Assistant Secretary for Health).

The workgroup addressed the key topics originally believed HHS would have the authority to undertake, and later examined the final appropriations language. The workgroup considered a wide range of questions on critical topics that would guide the structure and implementation of this new program, such as: (1) How would HHS identify the evidence base of programs proven to be effective through rigorous research? (2) Should the focus be on outcomes and if so, which outcomes should be included? (3) What standards would this new program require for the replication of evidence-based interventions? (4) What would it mean to replicate with fidelity and how would the program manage any adaptations? (5) What should be the scale of grants awarded under Tier 1? (6) What entities should be eligible to apply for grants under Tier 1? There were similar questions about the scope and shape of the Tier 2 efforts as well as what would be considered innovative or promising for potential funding?

Additional questions addressed by the workgroup included: What are the general Federal and grantee-level evaluation strategies that should be utilized to demonstrate the initiative's effectiveness? What performance measures would be required of grantees to obtain and track? How would staff monitor grantee performance? How should the target population be defined? How should program planning and implementation readiness be assured for Tier 1 and 2 grantees and should a planning/needs assessment/training and technical assistance start-up period be required in Year 1 of the grants? The legislation required funded programs be medically accurate and age appropriate. How would OAH assess medical accuracy and age appropriateness of materials used by grantees?

In December 2010 with the enactment of the FY 2010 appropriations, the new Teen Pregnancy Prevention Program had a mandate and funding. The spending bill provided a total of $110 million for the program and stipulated that not less than $75,000,000 would be available for programs that replicate teenage pregnancy prevention programs proven effective through rigorous evaluation, and that a range of evidence-based programs be eligible for these funds. In addition, the spending bill language provided that not less than $25,000,000 was to be available for research and demonstration grants to develop, replicate, refine, and test additional models and innovative strategies for preventing teenage pregnancy; and that the remaining amounts may be used for training and technical assistance, evaluation, outreach, and additional program support.

Multiple efforts were underway simultaneously at HHS—the workgroup examining key issues to shape the TPP program, the establishment of the Office of Adolescent Health, and a group working to define and identify the evidence base—all shaping what would eventually become the Teen Pregnancy Prevention Program. With the final appropriations language and the recommendations of the HHS workgroup, the Office of Adolescent Health focused on writing and issuing the new competitive FOA for the TPP program. At the same time, another workgroup with leadership from ACF, met on a regular basis to define the criteria to be used to identify the evidence base of programs and contracted to conduct an independent, systematic review of the evidence base on programs to reduce teen pregnancy, sexually transmitted infections (STIs), and associated sexual risk behaviors.

Two separate FOAs were issued in April 2010. One defined the parameters of replication efforts and the other laid out the requirements for research and demonstration projects. Tier 1 of the TPP program includes replications of evidence-based program models, those models that have demonstrated impacts, through rigorous evaluation, on key sexual behavioral outcomes including reduction of teen pregnancy, delay of sexual activity, increased contraceptive use, or reduced transmission of STIs. The other FOA set forth the parameters of the Tier 2 projects to test interventions based on (a) some preliminary evidence of effectiveness; (b) a significant adaptation of an evidence-based program; or (c) a new and innovative approach to teenage pregnancy prevention.

Both FOAs stated that the proposed intervention(s) should clearly define the target population by age groups (e.g., 9–14; 15–17; 18–19), and priority populations (e.g., adolescents in foster care) within geographic areas with high teen birth rates. A sound rationale based on statistical data and other community factors was necessary to justify the specified population to be served. Both FOAs explicitly stated that 6–12 months of the first year would be allocated to hiring, training, conducting needs assessments, piloting the program, and otherwise ensuring readiness for full implementation. Applicants were notified that all core curricula materials (e.g., teacher training manuals, student handbooks) for use in the projects must be submitted to the OAH for review and approval prior to full implementation of the project. The review ensured that the materials were medically accurate. Grantees were required to self-certify the age appropriateness of their program and activities. In addition, all grantees were expected to monitor and report on program implementation and outcomes through a common set of performance measures developed by OAH and approved by OMB. All of the projects were funded as cooperative agreements for a 5-year grant period. A cooperative agreement, as opposed to a grant, is an award instrument with substantial involvement of the awarding agency and the recipient. OAH opted to utilize this mechanism to provide for close collaboration with recipients, ensure adherence to project aims, enable review and approval of curricula and educational materials, and assist with ongoing technical assistance and troubleshooting.

To establish the standards of evidence for Tier 1 programs and to describe the evidence base to applicants, a list of program models was developed and the list was published in the FOA. The FOA required applicants to choose one or more of these evidence-based models to implement with fidelity to the original program models with only minimal adaptations allowed for new settings or different youth populations.

The Tier 2 FOA required applicants to choose interventions that could be rigorously evaluated, had the potential to demonstrate evidence, and could eventually be replicated. Funded projects were required to develop a manual that outlines curriculum or intervention instruction and delivery. Grantees were also required to monitor and document ongoing program implementation to facilitate potential future replication.

Prior to awarding $75 million in grants for replicating evidence-based programs, HHS undertook a process to identify programs that would be eligible for TPP funding and had documented positive impact on teen pregnancy and related factors. Within an intensely short period of time, under ACF leadership and with contractor assistance, HHS defined the evaluation standards necessary to be considered “effective based on rigorous evaluation” and conducted a systematic, comprehensive review of the literature on teen pregnancy, STIs, and sexual risk behaviors. A total of 88 studies met the preliminary review criteria and were included in the data extraction and analysis phase of the review. Ultimately, the HHS Pregnancy Prevention Evidence Review produced a list of 28 evidence-based program models for youth. The evidence review includes programs that use a number of approaches—abstinence-based, sexual health education, youth development, and programs for delivery in clinical settings and for special populations—all of which show positive results in a least one rigorous program evaluation. A searchable database of the model programs and a description of the evidence review methods are located on the OAH Web site.

The original list of 28 evidence-based program models was published in the FOA, establishing the evidence-based list of program models that could be proposed for replication (and evaluation) by applicants. The release of the Tier 1 FOA was essentially a public announcement of both the requirements for this new grant program, but also the standards that defined what constituted an evidence-based teen pregnancy prevention program. Previously, various nongovernment organizations had identified lists of “what works” in teen pregnancy prevention, but this was the first time the Federal government had released such a list and clearly described the evidence standards.

Congress provided funding to establish OAH due to its concern about the historic lack of funding and focus on the significant unmet and often interrelated health needs of adolescents, recognizing that health problems that emerge during the second decade of life have important consequences for adult morbidity and mortality. As such, the OAH is dedicated to improving the health and well-being of adolescents to enable them to become healthy, productive adults. OAH coordinates adolescent health promotion and disease prevention programs and initiatives across the U.S. Department of Health and Human Services (HHS) and works in partnership with other HHS agencies to support evidence-based approaches to improve the health of adolescents.

A mixture of evaluation strategies is utilized in both TPP Tiers to address the question of whether the replicated evidence-based teen pregnancy prevention programs and the new, innovative strategies for preventing teen pregnancy are effective. The evaluation strategies include: (1) Federal evaluation; and (2) grantee-level evaluation with Federal training, technical assistance, and oversight. The multipronged evaluation approach ensures that programs can be replicated effectively and expands the evidence base of what works and what does not. Figure 2 depicts the locations of OAH-funded evaluation activities.

The TPP program has features unique among Federally funded grant programs, namely collaboration across HHS offices. At about the time OAH was developing the initial FOA for the Tier 2 demonstration projects, the Patient Protection and Affordable Care Act was signed into law. Among other things it included funding for a new program, the Personal Responsibility Education Program (PREP), a program of formula grants to states to educate young people on both abstinence and contraception, and provide adult preparation education. In addition, the Affordable Care Act also authorized $10 million in competitive, discretionary grant funds for a new program to support projects to explore innovative approaches to teen pregnancy prevention with vulnerable populations including homeless youth, youth in foster care, youth living in rural areas or areas with high teen birth rates, youth from minority groups, and mothers under the age of 21 years. This program came to be known as Personal Responsibility Education Innovation Strategies (PREIS). Given the similar nature of the TPP Tier 2 and the PREIS approaches, HHS made a decision to braid the two programs in one funding announcement that set forth a common set of requirements and established a partnership between OAH and ACF. PREIS is administered by ACF's Family Youth Services Bureau in collaboration with the OAH's Teen Pregnancy Prevention Tier 2 Research and Demonstration Program. OAH awarded grants to 19 organizations and ACF supports 13 PREIS projects, which are demonstration projects to implement and test innovative approaches to teen pregnancy prevention. The TPP FOAs also served to inform the frameworks for the subsequent funding announcement released by ACF for states to submit applications for the PREP grants.

At the same time, OAH established a partnership with the CDC's Division of Reproductive Health to build on their previous work and expertise in community-based approaches to teen pregnancy prevention. In a slightly different partnership arrangement, OAH helps CDC support eight community-wide project sites and CDC provides funding for five national training organizations.

Another distinctive feature of the TPP grant program is the collaborative approach to evaluation. The Office of the Assistant Secretary for Planning and Evaluation (ASPE), OAH, and the other Federal agencies collaborate on performance measures for grantees, grantee-led program evaluation, and additional Federal TPP evaluations. Figure 3 presents the current TPP efforts taking place at HHS.

The Office of Adolescent Health works to elevate the importance of the second decade of life. Adolescent health experts recognize adolescence as a critical period of development where health-promoting behaviors (such as establishing physical activity habits or learning to positively cope with stress) or risky behaviors (such as smoking, drug use, or unprotected sex) emerge. Behaviors learned in the second decade of life have a substantial influence on health status into adulthood. OAH is working to build awareness of the importance of the teen years on healthy development and lifelong health. OAH's attention to adolescent health is timely and will serve to advance the Healthy People 2020 objectives, which now include a new topic area focused on adolescents.

Our goal in regard to teen pregnancy prevention specifically is to reduce teen pregnancy, as well as sexually transmitted diseases and associated sexual risk behaviors while also building the evidence base about these outcomes. We strive to build capacity within communities to select and implement, and eventually sustain, effective programs that best meet their needs. To this end, OAH supports the annual HHS Pregnancy Prevention Research Evidence Review, invests heavily in implementation and evaluation support for grantees, and conducts Federal evaluations.

A great deal of attention is given to the health of young children, who are generally well-understood to be in a critical developmental period by both health practitioners and the general public. What is often overlooked is the importance of adolescent development. The Teen Pregnancy Prevention program is just one of the Office of Adolescent Health's efforts to address Congress' call for new attention to the adolescent years as a critically important decade. The tools, resources, lessons learned in undertaking such a program, and ultimately the results of the numerous rigorous outcome evaluations within OAH, and in collaboration with our partner offices within HHS, will be shared with those working toward improving the health of adolescents. Together, great progress is being made toward improving the lives of our country's adolescents and putting them on a path to healthy adult years.