Teen Pregnancy: Federal Prevention Programs

Contents

• Introduction
• Federal Approaches to Teen Pregnancy Prevention
• Shift Toward Evidence-Based Models
• Additional Research
• Teen Pregnancy Prevention (TPP) Program
• Tier 1 Grants
• Tier 2 Grants
• Evaluation Activities
• Personal Responsibility Education Program (PREP)
• State PREP and Competitive PREP
• Tribal PREP
• Personal Responsibility Education Innovative Strategies (PREIS)
• Evaluation Activities
• Title V Sexual Risk Avoidance Education Program
• Evaluation Activities
• Sexual Risk Avoidance Education Program
• Evaluation Activities

Summary

Congress has an interest in preventing pregnancy among teenagers because of the long-term consequences for the families of teen parents and society more generally. Since the 1980s, Congress has authorized—and the U.S. Department of Health and Human Services (HHS) has administered—programs with a focus on teen pregnancy prevention. This report intends to assist Congress with tracking developments in four teen pregnancy prevention programs that are currently funded. The report provides detailed information about each program and includes a table that can illustrate the ways in which the programs are both similar and different.

The four current programs are the Teen Pregnancy Prevention (TPP) program, the Personal Responsibility Education Program (PREP), the Title V Sexual Risk Avoidance Education program, and the Sexual Risk Avoidance Education program. Despite their similar names and purposes, the latter two programs have different authorizing laws and funding mechanisms. Generally, the four programs serve vulnerable young people in schools, afterschool programs, community centers, and other settings. Grantees include states, nonprofits, and other entities.

The TPP program was established and funded by the FY2010 omnibus appropriations law (P.L. 111-117). Subsequent appropriations laws have also provided discretionary funding. As required in appropriations law, the majority of TPP program grants (Tier 1) must use evidence-based education models that have been shown to be effective in reducing teen pregnancy and related risk behaviors. A smaller share of funds is available for research and demonstration grants (Tier 2) that implement innovative strategies to prevent teenage pregnancy. FY2018 funding for the TPP program is $101 million. HHS has taken steps to discontinue the current cohort of grants.

PREP was established under Section 513 of the Social Security Act by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148) in 2010. The program receives mandatory funding and is designed to educate adolescents on both abstinence and contraception for preventing pregnancy and sexually transmitted infections, and on selected adult preparation subjects. The PREP authorizing law requires most grantees to replicate evidence-based programs that are proven to change behavior related to teen pregnancy. FY2018 funding for the program is $75 million.

The Title V Sexual Risk Avoidance Education program is authorized at Section 510 (Title V) of the Social Security Act. It was formerly known as the Title V Abstinence Education Grant program, which was authorized by the 1996 welfare reform law (P.L. 104-193). The Bipartisan Budget Act of 2018 (P.L. 115-123) renamed the program and made other changes. The program focuses on implementing sexual risk avoidance, meaning voluntarily refraining from sex before marriage. Grantees may set aside some of their funding to conduct rigorous and evidence-based research on sexual risk avoidance. FY2018 funding for the program is $75 million.

The Sexual Risk Avoidance Education program (not to be confused with the Title V program of the same name) was established and funded by the FY2016 omnibus appropriations law (P.L. 114-113). Other appropriations laws have since provided discretionary funding. Grantees are to use funding for education on voluntarily refraining from non-marital sexual activity, and they are encouraged to implement evidence-based approaches that teach the benefits associated with resisting risk behaviors. FY2018 funding for the program is $25 million.

Multiple HHS offices worked together to establish the Teen Pregnancy Prevention (TPP) Evidence Review process following enactment of the FY2010 omnibus appropriations law (P.L. 111-117). The review is intended to inform the teen pregnancy prevention field about which prevention models have been shown to be effective based on studies from the past 20 years. TPP Tier 1 grantees must use models identified in the review. HHS encourages grantees for the other teen pregnancy prevention programs to use models identified in the review as well.

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Teen Pregnancy: Federal Prevention Programs

Introduction

The Centers for Disease Control and Prevention (CDC), the federal government's lead public health agency, has identified teen pregnancy as a major public health issue because of its high cost for families of teenage parents and society more broadly.¹ In addition, teen pregnancy disproportionately affects certain minority communities and selected states and territories. The teen birth rate has been in decline; however, given the consequences associated with teen births, Congress has continued to authorize, and the executive branch has administered, programs to delay sexual activity and prevent pregnancies among teenagers.

Four current programs have an exclusive focus on teenage pregnancy prevention education:²

• the Teen Pregnancy Prevention (TPP) program, which is authorized under appropriations law;
• the Personal Responsibility Education Program (PREP), which is authorized under Title V of the Social Security Act;
• the Sexual Risk Avoidance Education program, which is authorized under Title V of the Social Security Act (and formerly known as the Title V Abstinence Education Grant program); and
• the Sexual Risk Avoidance Education program, which is authorized under appropriations law.

This report will refer to the latter two programs as the Title V Sexual Risk Avoidance Education program and the Sexual Risk Avoidance Education program, respectively, to avoid confusion.³ The four programs are administered by the U.S. Department of Health and Human Services (HHS).

This report begins with a brief discussion of recent developments in funding for the four teen pregnancy prevention programs. It then provides background on the role of Congress and the executive branch in preventing teen pregnancy. The remainder of the report focuses on the four programs, examining the types of grants they provide as well as related funding, requirements, and research activities.⁴ Table A-1 in Appendix A summarizes key programmatic information and allows for comparisons across the programs. Table A-2 in Appendix A describes the changes made by the Bipartisan Budget Act of 2018 (BBA of 2018, P.L. 115-123), enacted on February 9, 2018, to Section 510 of the Social Security Act. The BBA of 2018 renamed the Title V Abstinence Education Grant program as the Title V Sexual Risk Avoidance Education program and made other programmatic changes, retroactively effective October 1, 2017. Appendix B includes a table that indicates whether the states and territories, or entities within those jurisdictions, receive funding under each of the four programs.

This report accompanies CRS Report R45184, Teen Birth Trends: In Brief.

Federal Approaches to Teen Pregnancy Prevention

The federal government has long played a role in educating teens and the public generally about preventing pregnancy and sexually transmitted infections (STIs). This has involved public awareness campaigns; providing public health services, including information and access to contraceptives; publishing materials about STIs; and funding organizations to provide sexual education. The federal approach to teen pregnancy prevention has often reflected prevailing public views about sexuality and the role that the federal government should play in the private lives of its citizens.⁶

Since the early 1980s, the federal government has supported programs that have an exclusive focus on preventing teen pregnancy.⁷ Discussion about these programs has often focused on the type of approaches to pregnancy prevention they should take. Some policymakers and other stakeholders in the teen pregnancy prevention field have contended that teens should not engage in sex before marriage to avoid unplanned pregnancies and protect against STIs. Further, they support the idea that teenagers need to hear a single, unambiguous message that sex outside of marriage is harmful to their physical and emotional health.⁸ This approach is sometimes referred to as "abstinence-only," and more recently as "sexual risk avoidance."

Other stakeholders have prioritized an approach that provides broad information to teenagers to help them make informed decisions about whether to engage in sex, and about using contraceptives if they do.⁹ They contend that such an approach allows young people to make choices regarding abstinence, gives them the information they need to set relationship limits and resist peer pressure, and provides them with information on the use of contraceptives and the prevention of STIs.

Congress has authorized and provided funding for programs that take one or both of these approaches to preventing teen pregnancy. Of the current programs, the Title V Sexual Risk Avoidance Education and the Sexual Risk Avoidance Education programs focus exclusively on abstaining from premarital sex. The PREP program requires most grantees to place "substantial emphasis on both abstinence and contraception for the prevention of pregnancy among youth and sexually transmitted infections."¹⁰ The TPP program does not necessarily focus on any one approach, and some grantees use multiple program models to meet the various needs of youth. For example, a TPP program grantee in South Carolina uses an evidence-based model that provides abstinence-only education and other evidence-based models that have broader approaches.¹¹

The general public appears to support educating teenagers about both abstinence and contraception. A nationally representative telephone survey conducted in 2017 for Power to Decide, an organization focused on preventing unplanned pregnancy, found that about 8 out of 10 adults believe teens should receive more information about abstinence and birth control and protection from sexually transmitted infections.¹²

Shift Toward Evidence-Based Models

Two of the current teen pregnancy programs, TPP and PREP, reflect government-wide efforts beginning in the George W. Bush Administration and extending into the Obama Administration to expand social programs that work and eliminate those that do not.¹³ The two programs use a "tiered evidence" approach: some grantees employ teen pregnancy prevention models that are effective based on rigorous evaluation while other grantees develop and rigorously evaluate new or innovative approaches to reducing teen pregnancy.

HHS has identified which teen pregnancy prevention program models meet selected criteria for being considered "evidence-based." Multiple HHS offices worked together to establish the Teen Pregnancy Prevention (TPP) Evidence Review process following enactment of the FY2010 omnibus appropriations law (P.L. 111-117). P.L. 111-117 also authorized the TPP program and required it to use models that are proven effective through rigorous evaluation in reducing teen pregnancy and related outcomes. Despite the connection to the TPP program, the review is intended to more broadly inform the teen pregnancy prevention field.

The TPP Evidence Review seeks to identify which teen pregnancy prevention models have been shown to be effective based on studies from the past 20 years.¹⁴ The review team prioritizes studies of programs based on whether they include youth ages 19 and younger and are intended to address teen pregnancy outcomes through some combination of educational, skill-building, or psycho-social interventions. The first review covered research released from 1989 through January 2010. Subsequent reviews have since been conducted on an annual or biannual basis to incorporate new research, including newly available evidence for programs that were previously reviewed.

These studies must have one statistically significant impact on at least one of five areas: (1) sexual activity, (2) number of sexual partners, (3) contraceptive use, (4) STIs or HIV, and (5) pregnancies. In addition, the studies must examine impacts of programs using randomized controlled trials (RCTs) and quasi-experimental impact study designs.¹⁵ For the studies that meet these initial criteria, reviewers assign each one a rating of high, moderate, or low quality based on whether it uses RCTs and quasi-experimental design, has relatively low attrition, controls for differences between the treatment and comparison groups, and meets certain other criteria.¹⁶

After its latest round of studies, the TPP Evidence Review includes 41 evidence-based program models. Evidence-based teen pregnancy prevention programs are varied and approach the problem from different frameworks. HHS categorizes the evidence-based models based on certain key features. For example, three of the models use an abstinence-only approach and some of the models incorporate information about abstinence. Other models focus on sexual health education, youth development, clinic-based services, and/or youth with certain histories (e.g., youth who are incarcerated). Programs differ based on their outcomes, settings (e.g., schools, clinics, homes, afterschool programs), session length and duration over time, and target population (e.g., males, females, African American youth, Hispanic youth, low-income youth, rural youth).¹⁷

Additional Research

HHS has taken additional steps to develop research on teen pregnancy prevention interventions. These efforts have been funded through annual appropriations of approximately $4.5 million to $6.8 million in each of FY2011 through FY2018 for Section 241 of the Public Health Services Act (PHSA). Section 241 provides authority for HHS to conduct evaluations of the implementation and effectiveness of public health programs. The funding has been used to support federal evaluations on teen pregnancy, including evaluation of TPP grantees; technical assistance about using rigorous program evaluation for TPP program grantees and unrelated grantees funded through the CDC; the TPP Evidence Review; and measuring performance data for the TPP program and Pregnancy Assistance Fund (PAF) grantees.¹⁸ The PAF provides competitive funding to state and tribal agencies to support pregnant and parenting teens and adults in school-based and community-based settings.

Teen Pregnancy Prevention (TPP) Program

The Consolidated Appropriations Act, FY2010 (P.L. 111-117) established and provided annual funding for the Teen Pregnancy Prevention (TPP) program.¹⁹ The TPP program has been funded via the appropriations process in subsequent years, including through FY2018. Funding has ranged from approximately $98 million to $110 million annually. The program primarily provides funds to public and private entities for evidence-based or promising programs that reduce teen pregnancy, including those that focus on sexual risk avoidance and/or use of contraceptives. However, HHS is in the process of discontinuing funding for the current cohort of TPP program grantees. See "Recent Developments" at the beginning of this report for further detail about the status of current funding.

Generally, the appropriations laws have specified that no more than 10% of TPP funding is for training and technical assistance, outreach, and other program support. Of the remaining amount, the appropriations laws have further stated the following:

• 75% is for grants to replicate programs that have been proven through rigorous evaluation to be effective in reducing teenage pregnancy, behavioral factors underlying teen pregnancy, or other related risk factors. HHS refers to these as "Tier 1" grants.
• 25% is for research and demonstration grants to develop, replicate, and refine additional models and innovative strategies for reducing teenage pregnancy. HHS refers to these as "Tier 2" grants.

Appropriation laws generally have not included additional guidance on how the program is to be administered. HHS has established eligibility and other requirements via funding announcements and other publications. Funding recipients must ensure they provide "age appropriate" and "medically accurate" information to their teen clients, as these terms have been defined in program funding announcements.²⁰ The HHS Office of Adolescent Health (OAH), which administers the program, must approve the materials used by grantees for this purpose.²¹

A range of public and private entities have been eligible to apply for TPP funding. Such entities include nonprofit and for-profit organizations, universities and colleges, faith- and community-based organizations, hospitals, and research institutions, among other entities.

Tier 1 Grants

The TPP grants have supported two cohorts of Tier 1 grantees. This first cohort, from FY2010-FY2014, included 75 grantees in 37 states and the District of Columbia. ²² The current round of Tier 1 funding began with FY2015, and is in the process of being discontinued. The second cohort includes 58 grantees in 28 states, the District of Columbia, and the Marshall Islands.²³

The second round of funds has been used to support two types of grants. ²⁴ Tier 1A grantees are intermediary organizations that are providing capacity-building assistance (CBA) to youth-serving organizations to replicate evidence-based teen pregnancy prevention programs in areas with higher-than-average teen birth rates. CBA refers to the "transmission of knowledge and building of skills to enhance the ability of organizations to implement, evaluate, and sustain evidence-based TPP programs." Tier 1B grantees are entities that are replicating evidence-based programs to scale in communities with populations in the greatest need. Grantees are expected to develop and implement a plan to prevent teen pregnancy, engage in planning and piloting the programs, and then implement the programs.

In general, HHS requires Tier 1 grantees to use evidence-based approaches that the department has determined to be effective as part of its TPP Evidence Review. Grantees must implement their models consistent with the original evidence-based model and have minimal adaptations (e.g., changing names or details in a role play). In addition, HHS has emphasized the importance of Tier 1 grantees in the second cohort replicating programs that have the strongest evidence and that evaluations have shown to be effective in multiple sites, in different settings, and with different populations.²⁵

Tier 2 Grants

As with Tier 1 grantees, HHS has funded two cohorts of Tier 2 grants from FY2010-FY2014 and FY2015-FY2019. The first cohort included 18 grantees in 10 states and the District of Columbia, and the second cohort includes 26 grantees in 11 states, the District of Columbia, and the Marshall Islands.²⁶ HHS is currently (FY2015-FY2019) funding three types of Tier 2 grants in the second cohort, though as noted, these grants are in the process of being discontinued. The grants include the following:²⁷

Supporting and enabling early innovation to advance adolescent health and prevent teen pregnancy (Tier 2A grants): these grants are intended to establish independent intermediaries that select, fund, and support a portfolio of innovators across the country to design, test, and refine interventions for advancing adolescent health and preventing teen pregnancy.

Rigorous evaluation of new or innovative approaches to prevent teen pregnancy (Tier 2B grants): these grants are intended to increase the number of evidence-based teen pregnancy prevention interventions by rigorously evaluating new or innovative approaches for preventing teen pregnancy and related risk behaviors.

Effectiveness of teen pregnancy prevention programs designed specifically for young males (Tier 2C grants): these grants are intended to rigorously evaluate innovative interventions designed for young men ages 15 to 24 to reduce their risk of fathering a teen pregnancy. These interventions are to be feasibly implemented in target settings such as clinics and schools. This grant is administered by the CDC, in partnership with the OAH.

Evaluation Activities

HHS supported 41 program evaluations of the first cohort of TPP grants (FY2010-FY2015). This included 19 Tier 1 evaluations of 10 evidence-based models identified as part of the TPP Evidence Review. The evaluations also included 22 studies of Tier 2 grantees, which were expected to implement new or innovative models to improve teen pregnancy-related outcomes.

HHS provided detailed findings from these evaluations in a special supplement of the American Journal of Public Health in September 2016. Of the 41 evaluations, 12 showed a positive impact in at least one teen pregnancy-related outcome. Another 16 had no impacts (one of these also had a negative impact), and 13 had inconclusive results. Some of the evaluations were inconclusive because of high attrition, of weak contrasts between the treatment and control groups, or they did not meet HHS's research standards, or for other reasons.²⁸

Personal Responsibility Education Program (PREP)

PREP is a broad approach to teen pregnancy prevention that seeks to educate adolescents ages 10 through 19 and pregnant and parenting youth under age 21 on both abstinence and contraceptives to prevent pregnancy and STIs. The Patient Protection and Affordable Care Act (ACA, P.L. 111-148) established PREP, appropriating $75 million annually in mandatory spending for FY2010 through FY2014. ²⁹ PREP authorization has been extended three times (P.L. 113-93, P.L. 114-10, and P.L. 115-123) with mandatory funding of $75 million for each of FY2015 through FY2019.

PREP funds states and other entities to carry out sexual education programs that places "substantial emphasis on both abstinence and contraception." Recipients of PREP funds must fulfill requirements outlined in the law, including that they must implement programs that

• provide youth with information on at least three of six specified adulthood preparation subjects (healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills);
• are "medically-accurate and complete";
• include activities to educate youth who are sexually active regarding responsible sexual behavior with respect to both abstinence and the use of contraception; and
• provide age-appropriate information and activities, while ensuring these are delivered in the most appropriate cultural context for the individuals served in the program.³⁰

As with the TPP program, PREP uses a tier-evidence approach. Some grantees replicate evidence-based effective programs that have been proven to delay sexual activity, increase condom or contraceptive use for sexually active youth, or reduce pregnancy among youth. Other grantees substantially incorporate elements of effective programs that have been proven to change behavior.

PREP includes four types of grants: (1) State PREP grants, (2) Competitive PREP grants, (3) Tribal PREP, and (4) Personal Responsibility Education Innovative Strategies (PREIS). Most of the PREP appropriation is allocated to states and territories via the State PREP grant. Funding for states and territories that did not apply for this grant is available to local entities under Competitive PREP grants. The law specifies certain levels of funding for the other components, including $10 million for the PREIS grants. After this set-aside, HHS must reserve 5% for grants to Indian tribes and tribal organizations (Tribal PREP) and 10% for training, technical assistance, and evaluation. Total FY2017 funding for the four grants was $63.7 million (the most recent information available). Of this amount, $40.5 million was for State PREP, $10.3 million was for Competitive PREP, $3.3 million was for Tribal PREP, and $9.6 million was for PREIS.³¹

State PREP and Competitive PREP

The 50 states, District of Columbia, and territories are eligible for State PREP funding. Funds are allocated by a formula that is based on the proportion of youth ages 10 through 19 in each jurisdiction relative to other jurisdictions. State PREP funds do not require a match. A total of 50 jurisdictions applied for and received FY2017 PREP funding. This included 44 states, the District of Columbia, Guam, Puerto Rico, the Republic of Palau, the Virgin Islands, and the Federated States of Micronesia.³² States and territories can administer the project directly or through sub-awards to public or private entities.

If a state or territory did not submit an application for formula funding in FY2010 or later years, it is ineligible to apply for funding for each of FY2010 through FY2019.³³ Organizations in such a state or territory are eligible to apply competitively for funding, which is to be awarded as a three-year grant. In practice, Competitive PREP applicants can include county or city governments, public institutions of higher education, and for-profit and nonprofit organizations, among other entities.³⁴

Ten states and territories did not apply for State PREP funding: Florida, Indiana, Kansas, North Dakota, Texas, Virginia, American Samoa, Northern Mariana Islands, Marshall Islands, and Palau.³⁵ HHS awarded Competitive PREP funding for FY2012 through FY2014 to organizations in states that did not apply for funding in FY2010 or FY2011, and awarded Competitive PREP funding for FY2015 through FY2017 to organizations in states that did not apply for funding in FY2016 and FY2017. For each of FY2015 through FY2017, Competitive PREP funded 21 grantees. These grantees are in the states that did not receive PREP funds, except Kansas. Entities in Kansas did not apply for Competitive PREP funds. The Bipartisan Budget Act (P.L. 115-123), the law that most recently reauthorized the PREP program, specified that the Competitive grants that were awarded for any of FY2015 through FY2017 are to be extended for an additional two years, through FY2019.

Each State PREP and Competitive PREP applicant must include a description of its plan for using the allotment to achieve its goals related to reducing pregnancy rates and birth rates for youth populations. Applicants are required to specify the populations they will serve, and such populations must be the most high-risk or vulnerable for pregnancies or otherwise have special circumstances. As specified in the law, this includes youth who are ages 10 to 20 and in foster care, are homeless, live with HIV/AIDS, or reside in areas with high birth rates for youth, among other populations; pregnant youth who are under age 21; and mothers who are under age 21.³⁶

States, territories, and entities that apply for State PREP or Competitive PREP funds must replicate evidence-based teen pregnancy prevention programs or substantially incorporate elements of effective programs. Grantees are referred to the TPP Evidence Review, though they are not required to adopt the models identified in the review. A 2014 review of PREP grantees in 44 states and the District of Columbia, found that more than 90% of them expected to implement such evidence-based models.³⁷

Tribal PREP

Tribal PREP grants are intended to support projects that educate American Indian and Alaska Native youth ages 10 to 20 and pregnant and parenting youth under age 21 on abstinence and contraception for the prevention of pregnancy, STIs, and HIV/AIDS. Specifically, grantees must support the design, implementation, and sustainability of culturally and linguistically appropriate teen pregnancy programs. Such programs must replicate evidence-based models, sustainably incorporate elements of effective models, or include promising practices within tribal communities.³⁸ Although Tribal PREP grantees are referred to HHS's TPP Evidence Review, the review has not identified teen pregnancy prevention programs specifically for tribal youth. Indian tribes and tribal organizations, as these terms are defined in the Indian Health Care Improvement Act, are eligible to apply for Tribal PREP funding. The first cohort of 15 grantees received funding from FY2011 through FY2015. ³⁹ The project period for the second cohort of eight grantees is from FY2016 through FY2020.⁴⁰

Personal Responsibility Education Innovative Strategies (PREIS)

PREIS grants are intended to build evidence for promising teen pregnancy prevention programs serving high-risk youth populations. The grants are awarded on a competitive basis to public and private entities to implement and evaluate innovative youth pregnancy prevention strategies that have not been rigorously evaluated and/or to participate in a federal evaluation of their program strategies if selected. According to the most recent program funding announcement, innovative strategies could include those that are technology-based and/or computer-based, use social media, or are implemented in non-traditional classroom settings. Such strategies must be targeted to high-risk, vulnerable, and culturally under-represented youth populations. The law specifies that this includes youth ages 10 to 20 in or aging out of foster care; homeless youth; youth with HIV/AIDS; pregnant and parenting women who are under age 21 and their partners; young people residing in areas with high birth rates for youth; and victims of human trafficking. HHS also lists selected other youth populations in the program funding announcement: youth who have been trafficked, runaway and homeless youth, and rural youth.⁴¹ PREIS funds are awarded as five-year cooperative agreements. The first cohort of PREIS grantees (FY2011 through FY2015) included 11 organizations.⁴² The second cohort of grantees (FY2016 through FY2020) includes 13 organizations in 10 states and the District of Columbia.⁴³

Evaluation Activities

The PREP authorizing law directs HHS to evaluate PREP programs and activities.⁴⁴ In fulfilling this requirement, HHS is conducting an evaluation of four State PREP grantees—California, Maine, Pennsylvania, and South Carolina—to learn how PREP-funded programs are implemented and to assess their effectiveness in reducing teen pregnancies, STIs, and sexual risk behaviors. According to an early report on implementation of the program, the four states have developed similar approaches to supporting evidence-based strategies. The impact evaluation is underway, and is expected to be completed in 2018.⁴⁵

Separate from these evaluation efforts, PREIS and Tribal PREP direct grantees to carry out evaluation activities. PREIS grantees must contract with independent third-party evaluators to conduct RCT or quasi-experimental research to determine whether grantees' interventions led to reduced pregnancies, births, and STIs. Tribal PREP grantees must partner with a university or other organization not associated with the grantee to conduct an evaluation (known as a "local evaluation") that is either descriptive (without treatment and comparison groups) or examines impacts using treatment and comparison groups. State PREP and Competitive PREP grantees may choose to conduct such evaluations.

Title V Sexual Risk Avoidance Education Program

The 1996 welfare reform law (P.L. 104-193) established the "Separate Program for Abstinence Education" under Section 510 in Title V of the Social Security Act.⁴⁶ The program had long been known as the Title V Abstinence Education Grant program. The BBA of 2018 (P.L. 115-123) replaced Section 510, thereby changing the name of the program to the Sexual Risk Avoidance Education program; revising the program purpose areas; and adding new requirements on financial allotments, educational elements, research and data, and evaluation. Table A-2in Appendix A includes a side-by-side comparison of the statutory changes made by the BBA, which went into effect on October 1, 2017. The overall purpose of the program remains essentially the same, which is to provide youth ages 10 through 19 with education that focuses on refraining from sexual activity before marriage.

The Title V Sexual Risk Avoidance Education program is funded through mandatory spending. P.L. 104-193 provided $50 million per year for five years (FY1998-FY2002). The program was subsequently funded through June 30, 2009, by various legislative extensions. The ACA reauthorized the program, providing $50 million for each of FY2010 through FY2014. Three subsequent laws extended the program: The Protecting Access to Medicare Act of 2014 (P.L. 113-93), which provided $50 million in FY2015; the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10), which provided $75 million per year for FY2016 and FY2017; and the BBA of 2018, which provides $75 million for each of FY2018 and FY2019.

States are eligible to request mandatory Title V Sexual Risk Avoidance Education funds for FY2018 and FY2019 if they submit an application for Maternal and Child Health (MCH) Block Grant funds for those same fiscal years. The MCH Block Grant, authorized under Title V of the Social Security Act, is a flexible source of funds that states use to support maternal and child health programs.⁴⁷ Title V Sexual Risk Avoidance Education funds are allocated to each jurisdiction based on two factors: (1) the amount provided to the program minus any reservations (up to 20%) made by HHS for administering it, and (2) states' relative proportion of low-income children nationally.⁴⁸ The law does not require states to provide a match.⁴⁹

HHS may competitively award FY2018 and FY2019 funds to one or more entities within a state/territory that had not previously applied for its share of funding. The entity or entities would receive the amount that would have been otherwise allotted to that state. (The law does not define the entities that would be eligible.) The HHS Secretary is required to publish a notice to solicit grant applications for the remaining competitive funds. The solicitation must to be published within 30 days after the deadline for states to apply for MCH Services Block Grant funds. Eligible states are required to apply for the Title V Sexual Risk Avoidance Education funds no later than 120 days after the deadline closed for states to apply for MCH Services Block Grant funds.

The 50 states, the District of Columbia, and the territories (Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, the Republic of the Marshall Islands, and Republic of Palau) are eligible to apply. In FY2017, 37 states and two territories (Puerto Rico and the Federated States of Micronesia) applied for and received funding (under the Title V Abstinence Education Grant program).⁵⁰

States/territories or other entities are required to implement sexual risk avoidance education that is medically accurate and complete, age-appropriate, and based on adolescent learning and developmental theories for the age group receiving the education.⁵¹ The education must also be culturally appropriate, recognizing the experiences of youth from diverse communities, backgrounds, and situations. As described in the previous text box, sexual risk avoidance education must address six topics. If sexual risk avoidance education includes any information about contraception, such information must be medically accurate and ensure that students understand that contraception reduces physical risk but does not eliminate risk. In addition, sexual risk avoidance education may not include demonstration, simulations, or distribution of such contraceptive devices.

A state or other entity that receives Title V Sexual Risk Avoidance Education funding must, as specified by the HHS Secretary, collect information on the programs and activities funded through their allotments and submit reports to HHS on the data collected from such programs and activities.

Under the Title V Abstinence Education Grant program, HHS has required all jurisdictions to measure the success of their abstinence programs through at least two outcome measures, one of which must be abstinence as a means for preventing teen pregnancy, births, and/or STIs.⁵²Additionally, HHS has encouraged jurisdictions to identify programs that have demonstrated effectiveness in delaying the initiation of sexual activity or promoting abstinence from sexual activity. HHS has directed grantees to the TPP Evidence Review, though has not require grantees to use the models identified in the review.

Evaluation Activities

A state or other entity receiving funding under the Title V Sexual Risk Avoidance Education program may use up to 20% of its allotment to build the evidence base for sexual risk avoidance education by conducting or supporting research. Any such research must be rigorous, evidence-based, and designed and conducted by independent researchers who have experience in conducting and publishing research in peer-reviewed outlets.⁵³

Separately, HHS is required to conduct one or more rigorous evaluations of the education (and associated data) funded through the Title V Sexual Risk Avoidance Education program. This evaluation is to be conducted in consultation with "appropriate State and local agencies." HHS is to consult with relevant stakeholders and evaluation experts about the evaluation(s). HHS must submit a report to Congress on the results of the evaluation(s). The report must also include a summary of the information collected and reported by states and other entities on their Sexual Risk Avoidance Education programs and activities.

The Balanced Budget Act of 1997 (P.L. 105-133) directed HHS to conduct evaluation activities of the prior Title V Abstinence Education Grant program.⁵⁴ In response, HHS undertook a multi-year evaluation that included a study of how grantees in four states implemented abstinence education programs and a separate study that rigorously evaluated whether grantees' programs had impacts on teen sexual abstinence and related outcomes. The programs targeted youth in elementary and middle school and engaged them as part of the school setting, including in afterschool programming. Each youth participated for more than 50 hours. The study tracked outcomes for youth four and six years after they were enrolled in it. The impact evaluation found that youth who received abstinence education under the program did not have different outcomes than youth in the control group. They were no more likely than their peers in the study to have abstained from sex.⁵⁵

Sexual Risk Avoidance Education Program

As noted, federal funding has supported abstinence-only education through the Community-Based Abstinence Education program (FY2001 through FY2009) and the Competitive Abstinence-Only program (FY2012 through FY2015). In each of FY2016 through FY2018, annual omnibus appropriations laws provided funding to support abstinence-only education through the Sexual Risk Avoidance Education program. Funding was $5 million in FY2016, $15 million in FY2017, and $25 million in FY2018. The appropriations laws have specified that Sexual Risk Avoidance Education grants are to

• be awarded by HHS on a competitive basis;
• use medically accurate information;
• "implement an evidence-based approach integrating research findings with practical implementation that aligns with the needs and desired outcomes for the intended audience;" and
• "teach the benefits associated with self-regulation, success sequencing for poverty prevention, healthy relationships, goal setting, and resisting sexual coercion, dating violence, and other youth risk behaviors such as underage drinking or illicit drug use without normalizing teen sexual activity."⁵⁶

The appropriations law provided that up to 10% of the funding for sexual risk avoidance can be made available for technical assistance and administrative costs.

Through the grant application process for the Sexual Risk Avoidance Education program, HHS has identified multiple types of entities that are eligible for funding, including states, territories, and localities (county, city, township, special districts); school districts; public and state-controlled institutions of higher education; federally recognized tribal governments; Native American tribal organizations; public and Indian housing authorities; nonprofit organizations other than institutions of higher education; private institutions of higher education; small business; and for-profit organizations other than small businesses.⁵⁷ ACF awarded 10 grants in FY2015, 21 grants in FY2016, and 27 grants in FY2017.⁵⁸

As specified in the funding announcement, grantees must incorporate an evidence-based program and/or effective strategies that have demonstrated impacts on delaying the initiation of sexual activity. HHS advises Sexual Risk Avoidance Education grantees to review evidence-based program models that are included as part of the TPP Evidence Review. In addition, grantees must link program participants to services with community agencies that support the health, safety, and well-being of participants.

Evaluation Activities

Appropriations law and program funding announcements do not direct HHS or grantees to carry out evaluation activities. HHS tracks Sexual Risk Avoidance Education grantee performance—related to youth served, fidelity to curriculum, implementation, outcome measures, and community data—for monitoring purposes, not to measure the impacts of the program.⁵⁹

Appendix A. Federal Teen Pregnancy Prevention Programs

Appendix B. Grantees Funded Under the Federal Teen Pregnancy Prevention Programs, by State

Author Contact Information

Footnotes

1.	The U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), Winnable Battles Final Report, no date.
2.	There are several other federally funded programs that have a pregnancy prevention component and thereby may use their funds to provide pregnancy prevention information and/or contraception services to teenagers, but their focus is not exclusively on teenagers. These programs include Medicaid Family Planning (Title XIX of the Social Security Act), Title X Family Planning, the Maternal and Child Health block grant (Title V of the Social Security Act), the Temporary Assistance for Needy Families (TANF) block grant (Title IV-A of the Social Security Act), the Title XX Social Services block grant, and several other HHS programs.
3.	Both of these programs require that grantees focus exclusively on teaching abstinence before marriage. The programs can be distinguished in a few ways. The Title V Sexual Risk Avoidance Education program is authorized at Section 510 (Title V) of the Social Security Act. It was formerly known as the Title V Abstinence Education Grant program, which was authorized by the 1996 welfare reform law (P.L. 104-193). The Bipartisan Budget Act of 2018 (BBA of 2018, P.L. 115-123) renamed the program and specified new program requirements on financial allotments, educational elements, research and data, and evaluations. The Sexual Risk Avoidance Education program was established and first funded by the FY2016 omnibus appropriations laws and has since been funded by the FY2017 and FY2018 omnibus appropriations laws (P.L. 115-31 and P.L. 115-141, respectively). The appropriations laws have provided some detail about how the Sexual Risk Avoidance Education program is to be carried out.
4.	This report uses the terms "youth," "teenagers," "teens," and "adolescents" interchangeably.
5.	HHS, Office of the Assistant Secretary for Health (OASH), Office of Adolescent Health (OAH), "Fact Sheet: FY 2018 Funding Opportunity Announcements for Teen Pregnancy Prevention Program," press release, April 20, 2018. The Phase I project period is expected to extend from September 1, 2018, through August 31, 2020. According to HHS, Phase II projects will build on results achieved with the Phase I projects, and will extend from September 1, 2020, through August 31, 2021.
6.	Alexandra M. Lord, Condom Nation: the U.S. Government's Sex Education Campaign From World War I to the Internet (Baltimore: Johns Hopkins University Press, 2010), pp. 1-24, 115-137, 162-186.
7.	Three programs are no longer funded: the Adolescent Family Life (AFL) program, the Community-Based Abstinence Education (CBAE) program, and the Competitive Abstinence-Only program. The AFL program was established in 1981 and funded through FY2001, with appropriations ranging from $1.4 million to $30.4 million annually. The program focused on issues of adolescent sexuality, pregnancy, and parenting, and in 1998 it began incorporating abstinence-only education. The CBAE program was supported from FY2001 through FY2009, with funding ranging from $20 million to $108.9 million annually. The program provided competitive grants to public and private entities to develop and implement abstinence-only education programs for adolescents ages 12 through 18 in communities nationwide. Following CBAE, the Competitive Abstinence-Only program supported similar types of grants with an exclusive focus on abstinence education. It was funded from FY2012 through FY2015, with appropriations of $4.7 million to $10 million annually.
8.	See, for example, U.S. House of Representatives, Committee on Energy and Commerce, The Policy Paper Series: Transforming Ideas Into Solutions, vol. 1, issue 2, "A Better Approach to Teenage Pregnancy Prevention-Sexual Risk Avoidance," July 2012.
9.	HHS, CDC, Dear Colleague Letter by Thomas R. Frieden, Director, January 14, 2011. Dr. Frieden served under the Obama Administration from May 2009 to January 2017.
10.	Section 513(b)(2)(4) of the Social Security Act.
11.	HHS, OASH, OAH, Mary Black Foundation: Connect.
12.	SSRS, an independent research organization, conducted the poll for Power to Decide (formerly, the National Campaign to Prevent Teen and Unplanned Pregnancy). The poll involved a nationally representative telephone survey of approximately 1,000 adults in the United States that asked, "Do you believe that teens should receive more information about abstinence or postponing sex [8% supported this view], birth control and STI protection [10% supported this view], or both [79% supported this view]?" See Power to Decide, "Survey Says: Support for Birth Control," January 2017. The Barna Group, a research organization that focuses on providing information to spiritual influencers, conducted a poll about sex education for Ascend, an organization that supports sexual risk avoidance. The poll involved a national representative online survey of nearly 1,300 adults that asked whether the primary message in sex education classes should be "one that says teen sex is OK, so long as they use contraception" (29% supported this view) or "one that uses practical skills to reinforce waiting for sex" (71% supported this view). See Barna Group, "Should Sex Ed Teach Abstinence? Most Americans Say Yes," September 5, 2017.
13.	Evelyn M. Kappeler and Amy Fedlman Farb, "Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program," Journal of Adolescent Health, vol. 54, no. 3 (March 2014) (Hereinafter, Evelyn M. Kappeler and Amy Fedlman Farb, "Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program.") See also, Ron Haskins and Greg Margolis, Show Me the Evidence: Obama's Fight for Rigor and Results in Social Policy, Brookings Institution Press, Washington, DC, 2014; and Heather Fish et al., What Works for Adolescent Sexual and Reproductive Health: Lessons From Experimental Evaluations of Programs and Interventions, Child Trends, publication no. 2014-64, December 2014.
14.	The TPP Evidence Review is maintained by three HHS Offices: the Assistant Secretary for Planning and Evaluation (ASPE), FYSB within the Administration for Children and Families, and OAH within OASH. HHS has contracted with Mathematica Policy Research, Inc., a social policy research organization, to review studies of teen pregnancy prevention programs. Such research is identified through a call for studies and review of journals, conference proceedings, and websites for research and policy organizations. See Juliet Lugo-Gil et al., Updated Findings from the HHS Teen Pregnancy Prevention Evidence Review: July 2014 through August 2015, Mathematic Policy Research, for HHS, ASPE, June 2016.
15.	RCTs involve assigning individuals to two groups—an intervention group and a control group—using a random process (e.g., a lottery) to compare outcomes across these groups. Under ideal conditions, this can help to explain whether an intervention, like abstinence education, is effective because youth in both the program and control groups were similar in all respects except for their access to the program. Quasi-experimental designs refer to studies that attempt to estimate a treatment's impact on a group of subjects, but, in contrast to RCTs, do not have random assignment to treatment and control groups. Some quasi-experiments are controlled studies (i.e., with a control group), but others lack a control group.
16.	See Mathematica Policy Research, Identifying Programs That Impact Teen Pregnancy, Sexually Transmitted Infections, and Associated Sexual Risk Behaviors, Review Protocol, version 5, for HHS, ASPE, April 2016.
17.	HHS, OASH, OAH, Evidence-Based Teen Pregnancy Prevention Programs at a Glance, https://www.hhs.gov/ash/oah/sites/default/files/ebp-chart1.pdf. Three additional models are listed but are either not available to be implemented or evidence of favorable impacts is more than 20 years old.
18.	For an overview of how funds have been used for this purpose, see HHS, Fiscal Year 2018 Justification of Estimates for Appropriations Committees for General Departmental Management, pp. 134-135. See also, Evelyn M. Kappeler and Amy Fedlman Farb, "Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program."
19.	The program had been proposed as part of President Obama's FY2010 budget proposal to replace the abstinence education program known as the Community-Based Abstinence Education (CBAE) program. See HHS, Fiscal Year 2010 Justification of Estimates for Appropriations Committees for Administration for Children and Families, pp. 55-56 and 74. The CBAE program was funded from FY2001 through FY2009.
20.	"Age appropriate" means the topics and teaching methods are suitable to particular ages or groups of children and youth based on their cognitive, emotional, and behavioral capacity. "Medically accurate" means information that is verified by or supported by research conducted in compliance with accepted scientific methods and published in peer-reviewed journals, where applicable, or comprised of information that stakeholders in the field recognize as accurate, objective, and complete. HHS, OASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions, AH-TPI-15-001, 2015. (Hereinafter, HHS, ASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions.)
21.	The conference report (H.Rept. 111-366) accompanying the FY2010 appropriations law (P.L. 111-117) directed the HHS Secretary to establish an Office of Adolescent Health responsible for implementing and administering the TPP program. The report also directed OAH to coordinate its efforts with ACF, CDC, and other appropriate offices and operating divisions in HHS.
22.	HHS, OASH, OAH, The Teen Pregnancy Prevention (TPP) Program: Performance in the First Five Years, April 2016. (Hereinafter, HHS, OASH, OAH, The Teen Pregnancy Prevention (TPP) Program: Performance in the First Five Years.)
23.	HHS, OASH, OAH, Current Teen Pregnancy Prevention Program (TPP) Grantees, https://www.hhs.gov/ash/oah/grant-programs/teen-pregnancy-prevention-program-tpp/current-grantees/index.html.
24.	See, HHS, OASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions; and HHS, OASH, OAH, Replicating Evidence-Based Teen Pregnancy Prevention Programs to Scale in Communities with the Greatest Need (Tier 1B), Funding Opportunity Announcement and Application Instructions, AH-TPI-15-002, 2015.
25.	HHS, OASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions.
26.	HHS, OASH, OAH, The Teen Pregnancy Prevention (TPP) Program: Performance in the First Five Years; HHS, OASH, OAH, Current Teen Pregnancy Prevention Program (TPP) Grantees.
27.	HHS, OASH, OAH, Supporting and Enabling Early Innovation to Advance Adolescent Health and Prevent Teen Pregnancy (Tier 2A), Funding Opportunity Announcement and Application Instructions, AH-TP2-15-001, 2015; HHS, OASH, OAH, Rigorous Evaluation of New or Innovative Approaches to Prevent Teen Pregnancy Tier 2B), Funding Opportunity Announcement and Application Instructions, AH-TP2-15-002, 2015; and HHS, CDC, Effectiveness of Teen Pregnancy Prevention Programs Designed Specifically for Young Males [Tier 2C], Funding Opportunity Announcement, RFA-DP-15-007, 2015.
28.	Amy Feldman Farb and Amy L. Margolis, "The Teen Pregnancy Prevention Program (2010-2015): Synthesis of Impact Findings," American Journal of Public Health, vol. 106, no. 51 (September 2016).
29.	Section 513 of the Social Security Act (42 U.S.C. §513).
30.	The law defines "medically-accurate and complete" as verified or supported by research that is conducted in compliance with accepted scientific methods and published in peer-reviewed journals, where applicable, or comprising information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete. This definition is generally consistent with the definition of "medically accurate" used in the other three programs. The law defines "age-appropriate" as topics, messages, and teaching methods that are suitable to particular ages of children and adolescents, based their on developing cognitive, emotional, and behavioral capacity.
31.	CRS correspondence with HHS, ACF, FYSB, July 2017.
32.	HHS, ACF, FYSB, 2017 State Personal Responsibility Education Program (PREP) Awards, January 19, 2017, https://www.acf.hhs.gov/fysb/resource/2017-state-prep-awards#.
33.	The law originally stated that jurisdictions that did not submit an application in FY2010 or FY2011 were ineligible to apply for funding in FY2010 through FY2014. Amendments to the law extended the period from FY2014 to FY2015 (P.L. 113-93) and then to FY2017 (P.L. 114-10) and FY2019 (P.L. 115-123).
34.	Competitive PREP funding is available to entities in states and territories that declined funding in FY2016 and FY2017. HHS, ACF, FYSB, Personal Responsibility Education Program (PREP) Competitive Grants under the Affordable Care Act (for FY2015-FY2017), HHS-2015-ACF-ACYF-AK-0984, 2015. (Hereinafter HHS, ACF, FYSB, Personal Responsibility Education Program (PREP) Competitive Grants under the Affordable Care Act.) According to this funding announcement, a separate funding opportunity announcement will be published regarding the Competitive PREP grants in FY2018.
35.	HHS, ACF, FYSB, Competitive Personal Responsibility Education (PREP) Awards FY2017, https://www.acf.hhs.gov/fysb/competitive-prep-awards-fy2017.
36.	HHS, OASH, OAH, and HHS, ACF, FYSB, Teenage Pregnancy Prevention (TPP): Research and Demonstration Programs and Personal Responsibility Education Program (PREP), Funding Opportunity Announcement and Application Instructions; and HHS, ACF, FYSB, State Personal Responsibility Education Program (PREP), Funding Opportunity Announcement and Instructions (for FY2016 and FY2017), HHS-2016-ACF-ACYF-PREP-1138, 2016, (Hereinafter, HHS, ACF, FYSB, State Personal Responsibility Education Program (PREP), Funding Opportunity Announcement and Instructions (for FY2016 and FY2017).
37.	HHS, OPRE and FYSB, How States are Implementing Evidence-Based Teen Pregnancy Prevention Programs Through the Personal Responsibility Education Program, OPRE Report #2014-27 and FYSB Report #2014-1, April 2014.
38.	HHS, ACF, FYSB, Affordable Care Act Tribal Personal Responsibility Education Program for Teen Pregnancy Prevention, Funding Opportunity Announcement and Instruction, HHS-2016-ACF-ACYF-AT-1130, 2016.
39.	HHS, ACF, FYSB, "2015 Tribal Personal Responsibility Education Grant Awards," https://www.acf.hhs.gov/fysb/resource/2015-tribal-prep.
40.	HHS, ACF, FYSB, Tribal Personal Responsibility Program (PREP) Awards FY2017, https://www.acf.hhs.gov/fysb/tribal-prep-awards-fy2017.
41.	HHS, ACF, FYSB, Personal Responsibility Education Program (PREP) Innovative Strategies, Funding Opportunity Announcement and Instruction, HHS-2016-ACF-ACYF-AP-1153, 2016. (Hereinafter HHS, ACF, FYSB, PREP Innovative Strategies, Funding Opportunity Announcement and Instruction.)
42.	HHS, ACF, FYSB, 2015 Personal Responsibility Education Innovative Strategies (PREIS) Grant Awards, https://www.acf.hhs.gov/fysb/resource/2015-preis.
43.	HHS, ACF, FYSB, Personal Responsibility Education Innovative Strategies (PREIS) Program Awards FY2017, https://www.acf.hhs.gov/fysb/preis-awards-fy2017.
44.	Section 513(c)(2(B)(iii) of the Social Security Act.
45.	Patricia Del Grosso et al., Supporting Statewide Implementation of Evidence-Based Teen Pregnancy Prevention Programs: Findings from Four PREP Grantees, Mathematica Policy Research, Inc., for HHS, OPRE, and HHS, ACF, FYSB, OPRE Report Number 2016-87, November 2016. HHS, OPRE, and HHS, ACF, FYSB, PREP Multi-Component Evaluation, 2011-2018," https://www.acf.hhs.gov/opre/research/project/personal-responsibility-education-program-prep-multi-component.
46.	Section 510 of the Social Security Act (42 U.S.C. §710).
47.	For further information, see CRS Report R44929, Maternal and Child Health Services Block Grant: Background and Funding. All states, the District of Columbia, and six territories (American Samoa, Federated States of Micronesia, Guam, Northern Mariana Islands, Republic of the Marshall Islands, and Republic of Palau) receive MCH Block Grant funds.
48.	Census data are not available for the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau. Thus, the allocations for these three entities, when applicable, are based on the amounts allocated to them by HHS in prior fiscal years. HHS, ACF, FYSB, Title V State Abstinence Education Grant Program Combined FY 2016 and FY 2017 Announcement, HHS-2016-ACF-ACYF-AEGP-1131, 2016. (Hereinafter, HHS, ACF, FYSB, Title V State Abstinence Education Grant Program Combined FY 2016 and FY 2017 Announcement.)
49.	As enacted, P.L. 115-123, the most recent law to reauthorize the program, maintained a match requirement. This requirement was specified at Section 510(c) of the Social Security Act, which references the Maternal and Child Health Block Grant at Section 503. Section 503(a) states that HHS is to fund four-sevenths ( approximately 57%) of the program activities under the MCH Services Block Grant. To receive federal funding, a state must match every $4 in federal funds with $3 in state funds—via state dollars, local government dollars, private dollars, or in-kind support—that will be used solely for activities specified in the law. This match applied to the Title V Abstinence Education program. This requirement, as it temporarily applied to the Title V Sexual Risk Avoidance Education program, was struck by the Consolidated Appropriations Act, 2018 (P.L. 115-141).
50.	The states are AL, AR, AK, CO, FL, GA, HI, IL, IN, IA, KS, KY, LA, MD, MI, MN, MS, MO, NE, NV, NJ, NM, NY, NC, ND, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WV, and WI. For further information, see HHS, ACF, FYSB, 2017 Title V State Abstinence Education Program Grant Awards, January 19, 2017, https://www.acf.hhs.gov/fysb/resource/2017-aegp-awards.
51.	The law defines "medically accurate and complete" as information verified or supported by research that is conducted in compliance with accepted scientific methods and published in peer-reviewed journals, where applicable, or information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete. This definition is generally consistent with the definition of "medically accurate" used in the other three programs. The law defines "age appropriate" as topics, messages, and teaching methods that are suitable to particular ages of children and adolescents, based their on developing cognitive, emotional, and behavioral capacity.
52.	HHS, ACF, FYSB, Title V State Abstinence Education Grant Program Combined FY 2016 and FY 2017 Announcement.
53.	The law defines "rigorous," with respect to research and evaluation, to mean using (1) established scientific methods for ensuring the impact of an intervention or program model in changing behavior (specifically sexual activity or other risk behaviors), or reducing pregnancy among youth; or (2) other evidence-based methodologies established by the HHS Secretary for purposes of the Title V Sexual Risk Avoidance Education program.
54.	P.L. 105-133 did not amend Title V of the Social Security Act.
55.	Barbara Devaney, The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report, Mathematica Policy Research, Inc., for HHS, OPRE, April 2002; and Christopher Trenholm et al., Impacts of Four Title V, Section 510 Abstinence Education Programs: Final Report, Mathematica Policy Research, Inc., for HHS, ACF, ASPE, April 2007.
56.	This text has been included in each of the omnibus appropriation laws for FY2016, FY2017, and FY2018.
57.	HHS, ACF, ACYF, Sexual Risk Avoidance Education Program, Funding Opportunity Announcement and Instruction, HHS-2016-ACF-ACYF-SR-1197, 2016. (Hereinafter, HHS, ACF, ACYF, Sexual Risk Avoidance Education Program Funding Opportunity Announcement.)
58.	HHS, FY 2019 Justification of Estimates for Appropriations Committees for the Administration for Children and Families, p. 275; and HHS, ACF, FYSB, Sexual Risk Avoidance Education (SRAE) Grantees FY2017, https://www.acf.hhs.gov/fysb/sexual-risk-avoidance-grantees-fy2017. The 21 entities that received funding in FY2017 are in 14 states: AZ (1 grantee), CO (1 grantee), FL (3 grantees), GA (1 grantee), IN (2 grantee), IL (1 grantee), KS (1 grantee), KY (1 grantee), MI (4 grantees), MO (2 grantees), OH (2 grantees), NJ (1 grantee), TX (2 grantees), and WV (1 grantee). For further information, see HHS, ACF, FYSB, Competitive Abstinence Education Grantee Profiles, August 7, 2017, https://www.acf.hhs.gov/fysb/resource/aegp-profiles.
59.	HHS, ACF, ACYF, Sexual Risk Avoidance Education Program Funding Opportunity Announcement.