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

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 assists Congress in tracking developments in four teen pregnancy prevention programs that are currently funded.

Multiple HHS offices worked together to establish the Teen Pregnancy Prevention Evidence Review process following enactment of the FY2010 omnibus appropriations. The review, which was discontinued in 2017, was intended to identify prevention models that have been shown to be effective based on studies since approximately the late 1990s. HHS has encouraged or required grantees for some teen pregnancy prevention programs to use these models.

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 initially 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 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 that implement innovative strategies to prevent teenage pregnancy. The Further Consolidated Appropriations Act, 2020 (P.L. 116-94) provides $101 million for the program.

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. The Coronavirus Aid, Relief and Economic Security Act (CARES Act, P.L. 116-136) provides $75 million through FY2020 and additional funding for October 1 through November 30, 2020, equal to the amount appropriated over the same period in FY2020.

The Title V Sexual Risk Avoidance Education program is authorized at Section 510 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 funds to conduct rigorous and evidence-based research on sexual risk avoidance. As with the PREP program, the CARES Act provides $75 million through FY2020 and additional funding for October 1 through November 30, 2020, that is equal to the amount appropriated over the same period in FY2020.

The Sexual Risk Avoidance Education program (sometimes referred to as the General Departmental Management Sexual Risk Avoidance program) was established and funded by the FY2016 omnibus appropriations law (P.L. 114-113). Subsequent appropriations laws have since provided discretionary funding. Grantees are to use funding for education on voluntarily refraining from nonmarital sexual activity, and they are encouraged to implement evidence-based approaches that teach the benefits associated with resisting risk behaviors. P.L. 116-94 provides FY2020 funding of $35 million for the program.

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Introduction

Teen pregnancy is 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 racial and ethnic groups and selected states and territories.² The teen birth rate has been in decline; however, given the consequences associated with teen births, Congress and the executive branch continue to support programs that focus on delaying sexual activity and preventing pregnancies among teenagers.

Four current programs have an exclusive focus on teenage pregnancy prevention education:³

• the Teen Pregnancy Prevention (TPP) program, which is authorized on an annual basis under appropriations law;
• the Personal Responsibility Education Program (PREP), which is authorized under Title V of the Social Security Act, and was most recently reauthorized through November 30, 2020, under Title III, Division A of the Coronavirus Aid, Relief and Economic Security Act (CARES Act, P.L. 116-136);
• the Title V Sexual Risk Avoidance Education program, which is authorized under Title V of the Social Security Act, and was most recently reauthorized through November 30, 2020, under Title III, Division A of the CARES Act;
• the Sexual Risk Avoidance Education program, which is authorized on an annual basis under appropriations law, and is sometimes referred to as the General Department Management Sexual Risk Avoidance Education program.

This report refers 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.⁴ The four programs are administered in the U.S. Department of Health and Human Services (HHS). The TPP program was administered by the Office of Adolescent Health (OAH) until it was subsumed under the newly created Office of Population Affairs (OPA) in the Office of the Assistant Secretary for Health (OASH) in June 2019.⁵ (The footnotes of the report continue to reference publications that were authored by OAH.) The three other programs are administered by the Family and Youth Services Bureau (FYSB) in HHS's Administration for Children and Families (ACF).

This report provides background on the role of Congress and the executive branch in preventing teen pregnancy. It then focuses on the four programs, examining the types of grants they provide as well as related funding, requirements, and research activities.⁶ The table in Appendix A summarizes key programmatic information and allows for comparisons across the programs. 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. The report accompanies CRS Report R45184, Teen Birth Trends: In Brief; and CRS In Focus IF10877, Federal Teen Pregnancy Prevention Programs.

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.⁷

Since the early 1980s, the federal government has supported programs that have an exclusive focus on preventing teen pregnancy.⁸ 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.⁹ 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.¹⁰ 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."¹¹ TPP grantees may use either or both approaches.¹²

Understanding of the public's opinion about teen abstinence and contraception is incomplete, largely due to contradictory results obtained from survey questionnaires fielded by different organizations. The design of the survey questions may have contributed to this variation. Based on one nationally representative survey in 2017 by Power to Decide, an organization focused on preventing unplanned pregnancy, most adults believe that teens should receive more information about abstinence and birth control, as well as protection from sexually transmitted infections. Another nationally representative telephone survey conducted in 2019 by The Barna Group, a research organization that focuses on providing information to spiritual influencers, affirmed some of these findings; however, the study also indicated that respondents differed based on their political affiliation with regard to questions on whether certain sexual education topics should be taught.¹³

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 effective social interventions and eliminate those that are ineffective.¹⁴ The two programs use a "tiered evidence" approach: some current 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.

Following enactment of the FY2010 omnibus appropriations law (P.L. 111-117), multiple HHS offices worked together to establish the Teen Pregnancy Prevention Evidence Review process. This review was active from 2010 to 2017, and identified teen pregnancy prevention models that were shown to be effective based on studies from the prior 30 years.¹⁵ The review team prioritized studies of programs based on whether they—included youth ages 19 and younger and were 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 were conducted on an annual or biannual basis to incorporate recent research, including newly available evidence for programs that were previously reviewed.

The evidence review identified studies with statistically significant impacts 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 had to evaluate impacts of programs using randomized controlled trials (RCTs) and quasi-experimental impact study designs.¹⁶ For the studies that met these initial criteria, reviewers assigned each one a rating of high, moderate, or low quality based on whether it used RCTs and quasi-experimental design, had relatively low attrition, controlled for differences between the treatment and comparison groups, and met certain other criteria.¹⁷

The last review of studies, which covered the period through October 2016, included 48 evidence-based program models. The identified programs are varied and approach the problem from different frameworks. HHS categorized the evidence-based models based on certain key features. For example, four of the identified models used an abstinence-only approach, other models focused on both abstinence and contraception, and others addressed healthy relationships and youth development. Programs differed based on their outcomes, settings (e.g., schools, clinics, homes, after school programs), session length and duration over time, and target population (e.g., males, females, selected racial and ethnic groups, sexually active youth, etc.).¹⁸

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 was intended to more broadly inform the teen pregnancy prevention field.

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 FY2020 for Section 241 of the Public Health Service 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 Centers for Disease Control and Prevention (CDC); the Teen Pregnancy Prevention Evidence Review; and measuring performance data for the TPP program and Pregnancy Assistance Fund (PAF) grantees.¹⁹ 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 discretionary funding for the Teen Pregnancy Prevention program.²⁰ The TPP program has been funded via the appropriations process through FY2020. 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.

Generally, the appropriations laws have stated that funding should be competitively awarded. It has further 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 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 has referred 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 have specified that funds must be used for "age appropriate" and "medically accurate" programs that reduce teen pregnancy. HHS has expanded on these terms and has established eligibility and other requirements via funding announcements and other publications.²¹ The Office of Adolescent Health had administered the program until it was subsumed under the Office of Population Affairs in June 2019.²²

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 three cohorts of Tier 1 grantees. This first cohort was funded for FY2010-FY2014,.²³ a second round of funding was provided for FY2015-FY2019, and a third round of funding is provided for FY2019-FY2020.²⁴

This third cohort of Tier 1 grantees—referred to as Tier 1 Phase 1 Replication—supports 29 grantees in 15 states.²⁵ The grant seeks to scale up effective programs that have been proven through rigorous evaluation to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors. Rigorous evaluation refers to scientific methods that include a randomized control trial, quasi-experimental design, or other rigorous alternative design. ²⁶

In general, Tier 1 grantees must implement their models consistent with the original evidence-based model and have minimal adaptations (e.g., changing names). In addition, HHS requires Tier 1 grantees to use evidence-based approaches to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or associated risks.²⁷ HHS emphasized the importance of Tier 1 grantees in the second cohort replicating programs that have the strongest evidence and that have been evaluated as effective in multiple sites, in different settings, and with different populations.²⁸

Tier 2 Grants

As with Tier 1 grantees, HHS funded a cohort of Tier 2 grants with funds for FY2010-2014 and a second cohort of grantees for FY2015-FY2019: ²⁹ Tier 2A (supporting and enabling early innovation to advance adolescent health and prevent teen pregnancy), Tier 2B (rigorous evaluation of new or innovative approaches to prevent teen pregnancy), and Tier 2C (effectiveness of teen pregnancy prevention programs designed specifically for young males).

HHS has also provided FY2019 and FY2020 funding for Phase I Tier 2 (New and Innovative Strategies) funding to 14 grantees in 14 states. ³⁰ In early 2020, HHS issued funding announcements to support additional grantees with FY2020 funds.³¹

Phase I Tier 2 grantees are evaluating and testing innovative strategies to reduce teen pregnancy, improve adolescent health, and address youth sexual risk holistically by focusing on protective factors for youth (e.g., positive connections to supportive adults) and/or key elements of effective practices that are recognized to affect adolescent risk behavior. Innovative strategies can include new or promising approaches, curricula, or services informed by scientific theory or empirical evidence that may lead to, or have the potential to result in, substantial reductions in teen pregnancy rates.

Phase I Tier 2 grantees may take a risk avoidance approach (i.e., abstinence) or a broader approach when carrying out their projects. Grantees are required to develop strategies drawn from one of two research tools, SMARTool or TAC.³²

Evaluation Activities

HHS supported 41 program evaluations of the first cohort of TPP grants (funded for FY2010-FY2015). This included 19 Tier 1 evaluations of 10 evidence-based models identified as part of the Teen Pregnancy Prevention 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, weak contrasts between the treatment and control groups, a failure to meet HHS's research standards, or other reasons.³³

Separately, HHS conducted an evaluation to test whether three evidence-based models—¡Cuídate!, Reducing the Risk, and Safer Sex Intervention (SSI)—that were shown to be effective in a single study continued to have positive outcomes when replicated across nine TPP grantees in the first cohort. The evaluation examined behavioral outcomes related to teen pregnancy prevention. Cuídate! and SSI increased knowledge about sexual risk behavior in the short-term but did not have lasting impacts on this measure or other sexual risk behaviors or sexual activity. In the short term, SSI demonstrated a statistically significant impact on women's use of birth control when they engaged in sexual intercourse. Over the longer term, SSI had a promising impact on program participants who avoided pregnancy over 18 months after the start of the program. SSI did not have an effect on other sexual behaviors or outcomes.³⁴

HHS also awarded FY2017 and FY2018 funding to MITRE Corporation to test and replicate meaningful ways to improve programs concerning teen pregnancy prevention under what is known as the Teen Pregnancy Prevention Study.³⁵ MITRE currently operates the Health Federally Funded Research and Development Center (FFRDC) under contract with the Centers for Medicare and Medicaid (CMS). The TPP program funds are supporting a contract with MITRE as part of the Health FFRDC. MITRE has subcontracted with multiple entities to carry out activities under the contract. The project has several activities underway, including revising SMARTool (discussed previously), evaluating organizations that implement sexual risk avoidance education curricula that align with SMARTool, and developing and testing surveys of youth with key topics from SMARTool.³⁶

Some TPP grantees in the first cohort were also involved in other evaluation work, including an experimental study of innovative strategies for preventing teen pregnancy prevention, known as the Adolescent Pregnancy Prevention Approaches (PPA) study, a cost study of grantees implementing 10 evidence-based programs, and a study of financial sustainability after TPP funding ended.³⁷ Similarly, some TPP grantees in the second cohort are involved in research studies, including the Tier 1B grantees and grantees that implemented the Making Proud Choices! Model.³⁸ In addition to these efforts, each grantee in both the first and second cohorts were required to conduct their own evaluation to examine the goals of their respective grant tiers (e.g., Tier 1, Tier 2A, and Tier 2B).³⁹

Personal Responsibility Education Program (PREP)

The Personal Responsibility Education Program 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 FY2014.⁴⁰ PREP authorization and funding has been extended multiple times, most recently by the CARES Act for $75 million through FY2020 and additional funding for October 1 through November 30, 2020, equal to the amount appropriated over the same period in FY2020.

PREP funds states and other entities to carry out sexual education programs that place "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.⁴¹

As with the TPP program, PREP uses a tiered-evidence approach. Nearly all PREP participants are in 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.⁴² Other grantees substantially incorporate elements of effective programs that have been proven to change behavior. As specified in the law, grantees must serve youth who are ages 10 through 19 and are the most high-risk or vulnerable for pregnancies or otherwise have special circumstances, including youth who are in foster care, are homeless, live with HIV/AIDS, or reside in areas with high birth rates for youth. The program can also serve pregnant youth or mothers under age 21.

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 FY2019 funding for the four grants was $66.3 million. Of this amount, $43.6 million was for State PREP, $10.2 million was for Competitive PREP, $3.3 million was for Tribal PREP, and $9.1 million was for PREIS.⁴³

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 51 jurisdictions applied for and received FY2019 PREP funding. This included 44 states, the District of Columbia, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, the Virgin Islands, and the Federated States of Micronesia.⁴⁴ 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 selected years, it is ineligible to apply for funding in certain subsequent years.⁴⁵ 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.⁴⁶ 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 in Florida, Indiana, North Dakota, Texas, Virginia, American Samoa, Guam, and the Northern Mariana Islands.⁴⁷ Entities in Kansas did not apply for Competitive PREP funds. The Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123), extended the funding period for the grantees through FY2019.⁴⁸ Funding has since been extended, most recently by the CARES Act through November 30, 2020.

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.⁴⁹ 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. 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 have been referred to the (now discontinued) Teen Pregnancy Prevention Evidence Review, though they are not required to adopt the models identified in the review.

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.⁵⁰ 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 FY2015.⁵¹ The project period for the second cohort of eight grantees is from FY2016 through FY2020.⁵²

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 nontraditional classroom settings. Such strategies must be targeted to high-risk, vulnerable, and culturally under-represented youth populations.⁵³ 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 other selected youth populations in the program funding announcement: youth who have been trafficked, runaway and homeless youth, and rural youth.⁵⁴ PREIS funds are awarded as five-year cooperative agreements. The first cohort of PREIS grantees, funded for FY2011 through FY2015, included 11 organizations.⁵⁵ The second cohort of grantees, funded for FY2016 through FY2019, includes 13 organizations in 10 states and the District of Columbia that are funded for a project period that will expire with the end of FY2021.⁵⁶

Evaluation Activities

As amended by the Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-23), PREP authorizing law directs HHS to evaluate PREP programs and activities.⁵⁷ In fulfilling this requirement, HHS is conducting an evaluation that has multiple components, including (1) describing how states have designed and implemented PREP programs, (2) collecting and analyzing performance measurement data, and (3) conducting a random assignment evaluation of grantees that receive State PREP or Competitive PREP funding.

The study of the grantees overall found that 472 providers operated 543 PREP programs across the country.⁵⁸ The largest share of youth served by programs have been ages 13 through 16, and over one-quarter of programs served the most highly vulnerable youth (e.g., those who were in foster care, identified as LGBTQ, were in residential treatment for mental health issues).⁵⁹ Further, youth tended to be served primarily through schools, during school hours. About three quarters of the youth reported that participating in PREP made them more prepared for adulthood.

The random assignment evaluation involved grantees implementing four evidence-based programs in rural Kentucky; Davenport, IA; New York City; and San Angelo, TX. Generally, the studies found mixed results, with some positive impacts such as an improvement in knowledge of contraception and STIs (Davenport, IA, grantee) and the reduced incidence of unprotected sex among youth who had previously had sex (San Angelo, TX, grantee).

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. 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.

Multiple subsequent laws extended the program: (1) The Protecting Access to Medicare Act of 2014 (P.L. 113-93), which provided $50 million in FY2015; (2) the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10), which provided $75 million per year for FY2016 and FY2017; (3) BBA 2018, which provided $75 million for each of FY2018 and FY2019; (4) the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019 (P.L. 116-59), which provided $10.7 million through November 21, 2019; (5) the Further Continuing Appropriations Act, 2020, and Further Health Extenders Act of 2019 (P.L. 116-69), which provided $16.6 million through December 20, 2019; (6) the Further Consolidated Appropriations Act, 2020 (P.L. 116-94), which provides $48.3 million through May 22, 2020; and (7) the CARES Act (P.L. 116-136), which provides $75 million through FY2020 and additional funding for October 1 through November 30, 2020, equal to the amount appropriated over the same period in FY2020.

States are eligible to request mandatory Title V Sexual Risk Avoidance Education funds if they submit an application for Maternal and Child Health (MCH) Block Grant funds. 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.⁶⁰ 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.⁶¹ The law does not require states to provide a match.⁶²

HHS was authorized to 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 law does not define the entities that would be eligible.) The HHS Secretary is required to publish a notice to solicit grant applications for any remaining competitive funds. The solicitation must be published within 30 days after the deadline for states to apply for MCH Services Block Grant funds.⁶³ 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 entity or entities would receive the amount that would have been otherwise allotted to that state.

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) were eligible to apply for FY2018 and FY2019 funding. In total, 37 states and two of the territories (Puerto Rico and the Federated States of Micronesia) applied for and received FY2019 funding. Another seven grantees in four states (Alaska, California, Hawaii, and Washington) and one territory (Guam) received new Competitive SRAE funding, in addition to grantees already funded, for FY2019.⁶⁴

The law directs states/territories or other entities 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.⁶⁵ As described in the previous text box, sexual risk avoidance education must address six topics. According to the grant announcements for the program, 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.

Under the authorizing statute, 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. Recent grant announcements for the program specify that jurisdictions must assess the success of their sexual risk avoidance education programs through at least two outcome measures, one of which must be abstinence as a means for preventing teen pregnancy, births, and/or STIs, among other outcomes.

Additionally, the grant announcements have specified that grantees must implement a project with a "best practice and/or evidence-based approach." The grant announcements direct applicants to research documents, such as SMARTool and the CDC's HECAT (Health Education Curriculum Assessment Tool), that identify "critical elements to success in implementing programs to positively change youth behavior."⁶⁶ As noted in the discussion of the TPP New and Innovative Strategies (Tier 2) grant, SMARTool was developed by the Center for Relationship Education, a nonprofit organization, in partnership with the CDC. The HECAT is an assessment tool to help schools and other entities identify a curriculum for health education courses and analyze the acceptability and appropriateness of the curriculum, among other objectives. This tool addresses multiple health topics, including sexual health.⁶⁷

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.⁶⁸

Separately, the law, as amended by the BBA 2018, requires HHS 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.

HHS has contracted with Mathematica Policy Research, in partnership with Public Strategies, to conduct evaluation activities under what is known as the Sexual Risk Avoidance National Evaluation (SRANE). The evaluation includes both Title V SRAE grantees and SRAE program grantees funded under the General Departmental Management account, and has three components:

• National Descriptive Study: This will describe SRAE grantees' program plans (Early Implementation Study) and examine grantees' implementation and youth outcomes (Nationwide Study).
• Program Components Impacts Study: This will provide an analysis of promising program approaches and the effectiveness of SRAE program components (e.g., parent engagement and/or staff training strategies). It will not evaluate the effectiveness of the full program.
• Data Capacity Building and Local Evaluation Support: This component focuses on supporting grantees in collecting and using local data to improve their programs and support grantee-funded evaluations.⁶⁹

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.⁷⁰ 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. Further, it found that youth were no more likely than their peers in the study to have abstained from sex.⁷¹

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 FY2020, 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, $25 million in FY2018, and $35 million in FY2019 and FY2020. 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."⁷²

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.⁷³ HHS awarded 10 grants for FY2015, 21 grants for FY2016, 27 grants for FY2017, 57 grants for FY2018, and 22 grants for FY2019.⁷⁴

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 that grantees provide data that demonstrate how the selected curriculum and their proposals apply key program elements that have been found to be effective in promoting positive youth behavior changes, especially delaying sexual activity, returning to a lifestyle without sex, and refraining from nonmarital sex. The grant announcement points out that such elements have been identified in research summary documents such as SMARTool and HECAT, both of which are described in the Title V Sexual Risk Avoidance Education funding announcements (and discussed previously in this report).⁷⁵

Appendix A. Federal Teen Pregnancy Prevention Programs

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

Author Contact Information

Acknowledgments

Isaac Nicchitta, Research Assistant, Domestic Social Policy Division, provided invaluable research support and editorial comments on this report.

Footnotes

1.	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. CDC highlights that the teen pregnancy rate has decreased steadily, dropping below CDC's target goal of 30.3 per 1,000 females aged 15 to 17 by 2015; however, CDC also raises the concern that the United States has one of the highest rates of teen births of all industrialized countries. See U.S. Department of Health and Human Services (HHS), CDC, Winnable Battles Final Report 2010-2015, https://www.cdc.gov/winnablebattles/index.html.
2.	Joyce A. Martin et al., "Births: Final Data for 2018," HHS, CDC, National Center for Health Statistics (NCHS), National Vital Statistics Report, vol. 68, no. 13, November 7, 2019. See also, CRS Report R45184, Teen Birth Trends: In Brief.
3.	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 or on educational efforts. 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), and selected other programs administered by the U.S. Department of Health and Human Services (HHS).
4.	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 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 subsequent appropriations laws. The appropriations laws have provided some detail about how the Sexual Risk Avoidance Education program is to be carried out. Further, because it is funded under the General Departmental Management (GDM) account in appropriations law, HHS sometimes refers to the program as the GDM Sexual Risk Avoidance Education program.
5.	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 (OAH) responsible for implementing and administering the Teen Pregnancy Prevention (TPP) program. The report also directed OAH to coordinate its efforts with ACF, CDC, and other appropriate offices and operating divisions in HHS.
6.	This report uses the terms youth, teenagers, teens, and adolescents interchangeably.
7.	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.
8.	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 aged 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.
9.	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.
10.	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.
11.	Section 513(b)(2)(4) of the Social Security Act.
12.	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) (hereinafter, Amy Feldman Farb and Amy L. Margolis, "The Teen Pregnancy Prevention Program (2010-2015): Synthesis of Impact Findings").
13.	SSRS, an independent research organization, conducted the poll for Power to Decide, which generally supports providing youth with information so they can make informed decisions about whether, when, and under what circumstances to get pregnant and have a child (Power to Decide is formerly known as 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. See also Leslie Kantor, Nicole Levitz, and Amelia Holstrom, "Support for Sex Education and Teenage Pregnancy Prevention Programmes in the USA: Results from a National Survey of Likely Voters," Sex Education, September 2, 2019. 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.
14.	Evelyn M. Kappeler and Amy Feldman 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 Feldman Farb, "Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program.") In June 2019, the Office of Adolescent Health was subsumed under the Office of Population Affairs (OPA). 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.
15.	The Teen Pregnancy Prevention Evidence Review was managed by the Assistant Secretary for Planning and Evaluation (ASPE) in collaboration with FYSB within the Administration for Children and Families (ACF), and the former Office of Adolescent Health (OAH) within the Office of the Assistant Secretary for Health (OASH). HHS contracted with Mathematica Policy Research, Inc., a social policy research organization, to review studies of teen pregnancy prevention programs. Such research was 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: August 2015 through October 2016, Mathematica Policy Research for HHS, ASPE, April 2018. The website for the evidence review notes that additional updates are not planned for the future. See Youth.gov, "HHS Teen Pregnancy Prevention Evidence Review, Review Process," https://tppevidencereview.youth.gov/ReviewProtocol.aspx.
16.	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.
17.	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.
18.	HHS, OASH, OPA, "Evidence-Based Teen Pregnancy Prevention Programs at a Glance," https://www.hhs.gov/ash/oah/sites/default/files/ebp-chart1.pdf.
19.	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; HHS, Fiscal Year 2019 Justification of Estimates for Appropriations Committees for General Departmental Management, p. 136; HHS, Fiscal Year 2020 Justification of Estimates for Appropriations Committees for General Departmental Management, p. 137; and HHS, Fiscal Year 2021 Justification of Estimates for Appropriations Committee for General Departmental Management, p. 126. See also Evelyn M. Kappeler and Amy Feldman Farb, "Historical Context for the Creation of the Office of Adolescent Health and the Teen Pregnancy Prevention Program."
20.	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.
21.	"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-TP1-15-001, 2015 (hereinafter, HHS, ASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions).
22.	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.
23.	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).
24.	In spring 2017, HHS sent notices to all 84 TPP grantees funded in the second round informing them that their expected five-year projects would end in June or September 2018 instead of June or September 2020. In addition, five organizations that provided technical assistance to the grantees were informed that their expected five-year grant period ended in June 2017 instead of June 2022. This included all of the TPP grant types, which are referred to as Tier 1A, Tier 1B, Tier 2A, Tier 2B, and Tier 2C. In response, eight lawsuits were filed in February and March 2018 on behalf of all the grantees except for the Tier 2C grantees. From April to June 2018, five of the lawsuits were decided in favor of the grantees, including a class action lawsuit that applied to the three remaining lawsuits. As of September 2018, HHS discontinued funding for two of the three Tier 2C grantees, which were not included in the original litigation. That same month, one of the grantees, Promundo, filed a separate lawsuit. The court dismissed this grantee's claim for FY2018 funding because the funding was no longer available for obligation.
25.	HHS, OASH, Office of Population Affairs (OPA), "OPA Awards $13.5 Million in Grants to Replicate Teenage Pregnancy Programs," July 11, 2019, https://www.hhs.gov/ash/oah/news/news-releases/2019-tpp-tier1-award-grantees/index.html.
26.	HHS, OASH, OAH, Announcement of Availability of Funds for Replication of Programs Proven Effective through Rigorous Evaluation to Reduce Teenage Pregnancy, Behavioral Risk Factors Underlying Teenage Pregnancy, or Other Associated Risk Factors (Tier 1) – Phase I, AH-TP1-19-001, 2019.
27.	Ibid.
28.	HHS, OASH, OAH, Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1A), Funding Opportunity Announcement and Application Instructions.
29.	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.
30.	HHS, OASH, OPA, Phase I New and Innovative Strategies (Tier 2) to Prevent Teenage Pregnancy and Promote Health Adolescence, Funding Opportunity Announcement, AH-TP2-18-001, 2018. According to the funding announcement, the objective for Phase II is to build on the results achieved in Phase I and is limited to successful Phase I grantees.
31.	HHS, OASH, OPA, "Grant Opportunities," https://www.hhs.gov/opa/grants-and-funding/grant-opportunities/index.html.
32.	SMARTool was developed by the Center for Relationship Education, a nonprofit organization, with support from the CDC. SMARTool is a program guide for use by schools and other entities that provide sexual risk avoidance education, and it identifies nine protective factors that help prevent sexual risk behaviors in youth. TAC is a resource for use by schools and other entities that describes 17 elements of effective sexual risk reduction programs, which can include sexual risk avoidance approaches or broader approaches such as the use of contraceptives. The tool was developed by ETR Associates and the Healthy Teen Network, nonprofit organizations, with support from the CDC. David Kirby, Lori A. Rolleri, and Mary Martha Wilson, Tool to Assess the Characteristics of Effective Sex and STD/HIV Education Programs, ETR and Health Teen Network, 2007.
33.	Amy Feldman Farb and Amy L. Margolis, "The Teen Pregnancy Prevention Program (2010-2015): Synthesis of Impact Findings."
34.	HHS, OASH, OFA, "Teen Pregnancy Prevention Replication Study," https://www.hhs.gov/ash/oah/evaluation-and-research/teen-pregnancy-prevention-program-evaluations/teen-pregnancy-prevention-program-replication-study/index.html. A lawsuit has been filed for injunctive relief
35.	HHS, ACF, "HHS Announces New Efforts to Improve Teen Pregnancy Prevention & Sexual Risk Avoidance Programs," press release, November 3, 2017. The MITRE website for these efforts is https://teenhealthpartners.com.
36.	These activities are described further at USASpending,gov, "Contract Summary, HHS, The MITRE Corporation," https://www.usaspending.gov/#/award/23605015.
37.	HHS, OASH, OFA, "Teen Pregnancy Prevention Program Evaluations," https://www.hhs.gov/ash/oah/evaluation-and-research/teen-pregnancy-prevention-program-evaluations/index.html.
38.	Ibid.
39.	HHS, OASH, OAH, "Grantee Evaluations FY2010-2014," https://www.hhs.gov/ash/oah/evaluation-and-research/teen-pregnancy-prevention-program-evaluations/2010-2014-grantees/index.html; and HHS, ASH, OAH, "FY2015-2019 OAH Teen Pregnancy Prevention Grant Program," https://www.hhs.gov/ash/oah/evaluation-and-research/teen-pregnancy-prevention-program-evaluations/fy-2015-2019/index.html.
40.	Section 513 of the Social Security Act (42 U.S.C. §513).
41.	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.
42.	HHS, ACF, FY 2021 Justification of Estimates for Appropriations Committee, p. 280. A review of PREP grantees and participants in 2013 and 2014 found that more than 95% of youth were in programs with evidence-based models. See HHS, OPRE and FYSB, Personal Responsibility Education Program: A Snapshot of the PREP Performance Measures Report to Congress, July 2015.
43.	CRS correspondence with HHS, ACF, FYSB, December 2019. The sum of the grants totals $66.2 due to rounding.
44.	HHS, ACF, FYSB, FY2019 State Personal Responsibility Education Program Awards, February 13, 2019, https://www.acf.hhs.gov/fysb/resource/fy2019-state-prep-awards. Guam did not apply for State PREP funding for FY2010 through FY2015, and funding instead was awarded under Competitive PREP. Guam first received State PREP funds for FY2016. Similarly, the Northern Mariana Islands did not apply for State PREP funding for FY2010 through FY2016, and funding was provided under Competitive PREP. The Northern Mariana Islands first received State PREP funds for FY2017. (Based on CRS correspondence with HHS, December 2019.)
45.	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 shifted the latter years to FY2015 (P.L. 113-93), FY2017 (P.L. 114-10), FY2019 (P.L. 115-123), November 21, 2019 (P.L. 116-59), December 20, 2019 (P.L. 116-69), May 22, 2020 (P.L. 116-94), and November 30, 2020 (P.L. 116-136).
46.	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).
47.	HHS, ACF, FYSB, Competitive Personal Responsibility Education (PREP) Awards FY2017, https://www.acf.hhs.gov/fysb/competitive-prep-awards-fy2017.
48.	As a result, HHS has not published funding announcements for FY2018 or FY2019 for Competitive PREP or any other component of PREP. (Based on CRS correspondence with HHS, December 2019.) The budget request notes that the project period was extended for 20 of the 21 Competitive PREP grantees. HHS, ACF, FY 2021 Justification of Estimates for Appropriations Committee, p. 281.
49.	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).
50.	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.
51.	HHS, ACF, FYSB, "2015 Tribal Personal Responsibility Education Grant Awards," https://www.acf.hhs.gov/fysb/resource/2015-tribal-prep.
52.	HHS, ACF, FYSB, Tribal Personal Responsibility Program (PREP) Awards FY2017, https://www.acf.hhs.gov/fysb/tribal-prep-awards-fy2017. See also HHS, ACF, FY 2021 Justification of Estimates for Appropriations Committee, p. 281.
53.	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.)
54.	Ibid.
55.	HHS, ACF, FYSB, 2015 Personal Responsibility Education Innovative Strategies (PREIS) Grant Awards, https://www.acf.hhs.gov/fysb/resource/2015-preis.
56.	HHS, ACF, FYSB, Personal Responsibility Education Innovative Strategies (PREIS) Program Awards FY2017, https://www.acf.hhs.gov/fysb/preis-awards-fy2017; and HHS, ACF, FY 2021 Justification of Estimates for Appropriations Committee, p. 282. The project end date was provided in CRS correspondence with HHS, December 2019.
57.	Section 513(c)(2(B)(iii) of the Social Security Act.
58.	HHS, OPRE, Personal Responsibility Education Program (PREP) Evaluation: Nationwide Implementation of PREP Programs, OPRE Report Number 2018-23, April 2018.
59.	Ibid.
60.	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.
61.	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 Sexual Risk Avoidance Education Program Funding Announcement, HHS- HHS-2018-ACF-ACYF-SR-1359, 2018 (hereinafter, HHS, ACF, FYSB, Title V State Sexual Risk Avoidance Education Program Funding Announcement, 2018).
62.	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).
63.	HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education Funding Announcement, HHS-2018-ACF-ACYF-TS-1384, 2018 (hereinafter, Title V Competitive Sexual Risk Avoidance Education Funding Announcement, 2018).
64.	The states that received FY2019 State SRAE funding are AL, AZ, AR, CO, FL, GA, ID, IL, IN, IA, KY, LA, MD, MA, MI, MN, MS, MO, MT, NE, NV, NJ, NM, NY, NC, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WV, and WI. For further information, see HHS, ACF, FYSB, FY2019 State Sexual Risk Avoidance Education Program Awards, February 13, 2019, https://www.acf.hhs.gov/fysb/resource/fy2019-state-srae-program-awards. The list of states that received Competitive FY2019 SRAE Funding is available at HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education (SRAE) Grantees FY2019), https://www.acf.hhs.gov/fysb/resource/fysb-fy2019-title-v-competitive-srae-grantees. For a list of FY2018 Competitive SRAE grantees, see HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education Fact Sheet, February 2019.
65.	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.
66.	HHS, ACF, FYSB, Title V State Sexual Risk Avoidance Education Program Funding Announcement; and HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education Funding Announcement, 2018.
67.	CDC. "Health Education Curriculum Analysis Tool (HECAT)," https://www.cdc.gov/healthyyouth/HECAT/index.htm.
68.	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.
69.	HHS, ACF, OPRE, Sexual Risk Avoidance Education National Evaluation, 2018 – 2023, https://www.acf.hhs.gov/opre/research/project/sexual-risk-avoidance-education-national-evaluation; and HHS, ACF, FYSB and OPRE, Looking Back, Moving Forward: SRAE National Evaluation Frequently Asked questions, https://sraene.com/sites/default/files/pdfs/SRAENE_FAQ.pdf. See also Katie Adamek et al., Conceptual Models to Depict the Factors that Influence the Avoidance and Cessation of Sexual Risk Behaviors Among Youth, Mathematica Policy Research, Inc., for HHS, OPA and OPRE, OPRE Research Brief Number 2020-02, February 2020.
70.	P.L. 105-133 did not amend Title V of the Social Security Act.
71.	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.
72.	This text has been included in each of the omnibus appropriation laws for FY2016 through FY2020.
73.	HHS, ACF, ACYF, Sexual Risk Avoidance Education Program, Funding Opportunity Announcement, HHS-2018-ACF-ACYF-SR-1358, 2018 (hereinafter, HHS, ACF, ACYF, Sexual Risk Avoidance Education Program Funding Opportunity Announcement).
74.	HHS, FY 2021 Justification of Estimates for Appropriations Committees for the Administration for Children and Families, p. 282; and HHS, ACF, FYSB, FYSB FY2019 Adolescent Pregnancy Prevention (APP) Sexual Risk Avoidance Education Program (General Departmental-Funded) Grantees, October 4, 2019. The 22 grantees that received Sexual Risk Avoidance Education program funding are in 14 states: AL (1 grantee), AR (2 grantees), FL (4 grantees), GA (1 grantee), KS (1 grantee), LA (1 grantee), MI (2 grantees), MN (1 grantee), MS (1 grantee), MO (2 grantees), OH (3 grantees), NJ (1 grantee), SC (1 grantee), and WV (1 grantee).
75.	HHS, ACF, ACYF, Sexual Risk Avoidance Education Program Funding Opportunity Announcement.