Adolescent Pregnancy: Federal Prevention Programs

Updated August 22, 2024

Congressional Research Service

https://crsreports.congress.gov

R45183

Congressional Research Service

SUMMARY

Adolescent Pregnancy: Federal Prevention Programs

Congress has supported adolescent pregnancy prevention efforts for many years. These programs aim to prevent adolescent pregnancy to avert associated public health, social, and economic challenges that can affect adolescents, their children, and society. Since the 1980s, Congress has authorized—and the U.S. Department of Health and Human Services (HHS) has administered— programs with a focus on adolescent pregnancy prevention. This report assists Congress in tracking developments in four currently funded adolescent pregnancy prevention programs.

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 General Departmental (GD) Sexual Risk Avoidance Education program. Despite their similar names and purposes, all of these 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 initially established and funded by the FY2010 omnibus appropriations law (P.L. 111-117). Subsequent appropriations laws have also provided authority for the program and 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 adolescent pregnancy and related risk behaviors. A smaller share of funds is available for research and demonstration grants that implement innovative strategies to prevent adolescent pregnancy. The Further Continuing Appropriations Act, 2024 (P.L. 118-47), provides $101 million for the program for FY2024. Multiple HHS offices also worked together to establish the Teen Pregnancy Prevention Evidence Review process following enactment of P.L. 111-117. The review is 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 adolescent pregnancy prevention programs to use these models. 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 Consolidated Appropriations Act, 2024 (CAA 2024, P.L. 118-42) provides $75 million for FY2024, and extends funding for the program on a prorated basis through December 31, 2024.

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 CAA 2024 provides $75 million for FY2024, and extends funding for the program on a prorated basis through December 31, 2024.

The GD Sexual Risk Avoidance Education program was initially established and funded by the FY2016 omnibus appropriations law (P.L. 114-113). Subsequent appropriations laws have since provided authority for the program and 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. 118-47 provides FY2024 funding of $35 million for the program.

R45183

August 22, 2024

Jessica Tollestrup Specialist in Social Policy

Adolescent Pregnancy: Federal Prevention Programs

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Contents

Introduction ..................................................................................................................................... 1 Federal Approaches to Adolescent Pregnancy Prevention .............................................................. 2

The Use of Evidence-Based Models ......................................................................................... 4

Teen Pregnancy Prevention Evidence Review .................................................................... 4

Additional Evaluations of Teenage Pregnancy Prevention Approaches ............................. 6

Teen Pregnancy Prevention (TPP) Program .................................................................................... 7

Tier 1 Grants.............................................................................................................................. 8 Tier 2 Grants.............................................................................................................................. 9 TPP Evaluation Activities ....................................................................................................... 10

Reproductive Health National Training Center ................................................................ 12

Personal Responsibility Education Program (PREP) .................................................................... 13

State PREP and Competitive PREP ........................................................................................ 14 Tribal PREP............................................................................................................................. 16 Personal Responsibility Education Innovative Strategies (PREIS) ........................................ 16 PREP Evaluation Activities ..................................................................................................... 17

Title V Sexual Risk Avoidance Education Program (Title V SRAE) ............................................ 18

Title V SRAE Evaluation Activities ........................................................................................ 21

General Department Sexual Risk Avoidance Education Program (GD SRAE) ............................ 23

Tables

Table A-1. Federal Teen Pregnancy Prevention Programs: Overview, Eligible Entities,

and Funding ................................................................................................................................ 25

Table B-1. Federal Teen Pregnancy Prevention Programs: Grantees by Jurisdiction ................... 32

Appendixes

Appendix A. Federal Teen Pregnancy Prevention Programs ......................................................... 25

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

by State ....................................................................................................................................... 32

Contacts

Author Information ........................................................................................................................ 35

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Introduction

Despite a substantial decline over the past two decades, the rate of adolescent pregnancy in the United States remains higher than that of comparable high-income countries, with persistent racial, ethnic, and geographic disparities.¹ Adolescent pregnancy has been of interest to Congress for numerous reasons, including concern about a range of associated health, social, and economic challenges that can affect adolescents, their children, and society. For instance, adolescent mothers face heightened risk of maternal complications, and their children are more likely to have poor educational, behavioral, and health outcomes.² In addition, adolescent pregnancy disproportionately affects certain racial and ethnic groups and selected states and insular areas.³

Since the 1980s, Congress and the executive branch have supported programs that focus on delaying sexual activity and preventing pregnancies among adolescents, many of which also focus on the prevention of sexually transmitted infections (STIs).⁴

Four current programs have an exclusive focus on adolescent pregnancy prevention education:⁵

• the Teen Pregnancy Prevention (TPP) program, which is authorized on an annual basis under the Departments of Labor, Health and Human Services, Education, and related agencies (LHHS) appropriations;

• the Personal Responsibility Education Program (PREP), which is authorized under Title V of the Social Security Act, and was most recently reauthorized through FY2023, under Title III, Division CC of the Consolidated Appropriations Act, 2021 (CAA 2021, P.L. 116-260);

• 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 FY2023, under Title III, Division CC of the CAA 2021; and

• the Sexual Risk Avoidance Education program, which is authorized on an annual basis under the LHHS appropriations, and is sometimes referred to as the General Departmental (GD) Sexual Risk Avoidance Education program.

1 Centers for Disease Control and Prevention, About Teen Pregnancy, https://www.cdc.gov/reproductive-health/teen- pregnancy/index.html.

2 Ashley M. Woodall and Anne K. Driscoll, Racial and Ethnic Differences in Mortality Rate of Infants Born to Teen Mothers: United States, 2017–2018, National Center for Health Statistics, Data Brief, No. 371, June 2020, https://www.cdc.gov/nchs/data/databriefs/db371-h.pdf; Emily Holcombe, Kristen Peterson, and Jennifer Manlove, Ten Reasons to Still Keep the Focus on Teen Childbearing, Child Trends, March 2009; Urban Institute, Kids Having Kids: Costs and Social Consequences of Teen Pregnancy; and Stefanie Mollborn, “Teenage Mothers Today: What we Know and How it Matters,” Child Development Perspectives, vol. 11, no. 1 (March 2017), pp. 63-69. See also Anna Aizer, Paul Devereux, and Kjell Salvanes, “Grandparents, Moms, or Dads? Why children of teen mothers do worse in life,” Journal of Human Resources (November 2020), pp. 1019-1052.

3 Michelle J.K. Osterman et al., “Births: Final Data for 2022,” HHS, CDC, National Center for Health Statistics (NCHS), National Vital Statistics Report, vol. 73, no. 2, April 4, 2024. See also, CRS Report R45184, Teen Birth Trends: In Brief.

4 This report uses the terms youth, teenagers, teens, and adolescents interchangeably. All four programs discussed in the report generally may fund grantees that target youth aged 10 to 19, as well as older youth at-risk populations in some cases.

5 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 adolescents, but their focus is not exclusively on adolescents 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).

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This report refers to the latter two programs as the Title V Sexual Risk Avoidance Education program and the GD Sexual Risk Avoidance Education program, respectively, to avoid confusion.⁶ 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 Office of Population Affairs (OPA) in the Office of the Assistant Secretary for Health (OASH) in June 2019.⁷ (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 adolescent pregnancy. It then focuses on the four adolescent pregnancy prevention programs, examining the types of grants they provide as well as related funding, requirements, and research and evaluation activities. Table A-1 summarizes key programmatic information and allows for comparisons across the programs. Table B-1 indicates whether the states and insular areas, 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 Adolescent Pregnancy Prevention

The federal government has long played a role in educating adolescents and the general public about preventing pregnancy and 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 adolescent 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.⁸

Since the early 1980s, the federal government has supported programs that have an exclusive focus on preventing adolescent pregnancy.⁹ Discussion about these programs has often focused on

6 Both of these programs generally require that grantees focus 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 General Departmental (GD) 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. Because it is funded under the General Departmental Management account in appropriations law, HHS often refers to the program as the “General Departmental” Sexual Risk Avoidance Education program.

7 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. See also the Statement of Organization, Functions, and Delegations of Authority filed in the Federal Register on April 12, 2019, explaining the new organizational structure for the OPA that would include the TPP program (84 Federal Register 14951).

8 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.

9 Three programs are no longer funded: the Adolescent Family Life (AFL) program, the Community-Based Abstinence (continued...)

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the type of approaches to pregnancy prevention they should take. Some policymakers and other stakeholders in the adolescent pregnancy prevention field have contended that adolescents should not engage in sex before marriage to avoid unplanned pregnancies and protect against STIs. Further, they support the idea that adolescents need to hear a single, unambiguous message that sex outside of marriage is harmful to their physical and emotional health.¹⁰ 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 adolescents to help them make informed decisions about whether to engage in sex, and about using contraceptives if they do.¹¹ 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 adolescent pregnancy. Of the current programs, the Title V Sexual Risk Avoidance Education and the GD Sexual Risk Avoidance Education programs predominantly focus 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 STIs.”¹² TPP grantees may use either or both approaches.¹³

Surveys measuring public opinion about adolescent sexual activity and contraceptive use show a range of perspectives, possibly due to differences in the design of the survey questions and the population surveyed. 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 contraception, as well as protection from STIs.¹⁴ However, in 2022 Pew Research in its American Trends Panel found that most parents of K-12 students (59%) reported “they would prefer that their children learn [in school] that there are

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.

10 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.

11 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.

12 Section 513(b)(2)(4) of the Social Security Act.

13 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”).

14 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 was 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.

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methods of contraception that are safe and effective ways to prevent unintended pregnancy and STIs; 22% would rather their children learn that abstaining from sex is the only safe and effective method to prevent unintended pregnancy and STIs, and 18% say their children shouldn’t learn about this in school.” The views of respondents differed somewhat based on their political affiliation and the age of their children.¹⁵

The Use of Evidence-Based Models

Two of the current adolescent 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.¹⁶ The two programs use a “tiered evidence” approach, wherein some current grantees employ adolescent pregnancy prevention models that are effective based on rigorous evaluation while other grantees develop and rigorously evaluate new or innovative approaches aimed at reducing teen pregnancy. In addition, although the Title V SRAE and GD SRAE programs do not use this same framework, recent grant announcements have required that grantees use “evidence-based” interventions.¹⁷

Evaluation requirements and projects specific to each of the adolescent pregnancy prevention programs in this report are discussed in their respective report sections. Two broad-based efforts associated with these programs that are intended to inform the field as a whole are summarized below.¹⁸

Teen Pregnancy Prevention Evidence Review

Following enactment of the FY2010 omnibus appropriations law (P.L. 111-117), which authorized the TPP program and required it to use models that are proven effective through rigorous evaluation in reducing teen pregnancy and related outcomes, multiple HHS offices worked together to establish the Teen Pregnancy Prevention Evidence Review (TPPER) process.

15 The Pew American Trends Panel is a nationally representative panel of randomly selected U.S. adults who serve as a survey panel and agree to take multiple surveys. In this survey, panel members who are parents of K-12 students were asked whether they would prefer their children learn in school that “there are methods of contraception that are safe and effective ways to prevent unintended pregnancy and STIs” [59% supported this view], “abstinence is the only safe and effective way to prevent unintended pregnancy and sexually transmitted infections” [22%], and “children should not learn about this in school” [18%]. See Pew Research Center, “Parents Differ Sharply by Part Over What Their K-12 Children Should Learn in School,” October 26, 2022, https://www.pewresearch.org/social-trends/2022/10/26/parents- differ-sharply-by-party-over-what-their-k-12-children-should-learn-in-school/.

16 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.

17 “Evidence-based” is defined as “interventions, strategies, approaches, and/or program models that have been evaluated using rigorous evaluation design such as randomized controlled or high-quality, quasi-experimental trials, and that have demonstrated positive impacts for youth, families, and communities.” See HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education (SRAE), Funding Opportunity Announcement and Instruction, HHS- 2024-ACF-ACYF-TS-0040, 2024; and HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD-SRAE), Funding Opportunity Announcement and Instructions. HHS-2024-ACF-ACYF-SR-0041, 2024.

18 This section does not address other surveillance or research activities, such as the CDC Youth Risk Behavior Surveillance System or the National Vital Statistics System.

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Broadly, the TPPER systematically reviews research on teen pregnancy prevention to identify programs that have an impact on reducing (1) teen pregnancy and STIs and (2) sexual risk behaviors.¹⁹ The TPPER is 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). Despite the connection to the TPP program, the review is intended to more broadly inform the adolescent pregnancy prevention field.

The TPPER was initially active from 2010 to 2019, and identified teen pregnancy prevention models that were shown to be effective based on studies from the prior 30 years.²⁰ After a pause in activity during the Trump Administration, funding to restart the review was set aside as part of FY2022 appropriations, and HHS issued a call for new studies to be submitted for review.²¹ The latest findings were released in 2023.²²

The TPPER uses a systematic process to identify studies with statistically significant impacts on at least one of five outcomes: (1) sexual activity, (2) number of sexual partners, (3) contraceptive use, (4) STIs or HIV, and (5) pregnancies. The review specifically examines studies on U.S. youth who are ages 19 and younger; however, the review examines studies from programs that are delivered in various settings (e.g., one-on-one educational sessions, or classroom-based curricula) and from programs that may use a range of methods or approaches (e.g., skill-building sessions, psycho-social interventions).

Additionally, the studies must evaluate impacts of programs or program components using randomized controlled trials (RCTs) or quasi-experimental impact study designs.²³ For the studies that meet these initial criteria, reviewers assign each one a rating of high, moderate, or low quality based on the study design, the degree of attrition, whether the study controls for differences between the treatment and comparison groups, and whether it meets certain other criteria that minimize the risk of study bias.²⁴

The TPPER has been updated multiple times since its initial establishment in 2010. The first review covered research released from 1989 through January 2010 and identified 28 effective

19 Office of the Assistant Secretary for Health: Office of Population Affairs, Updated Findings from the HHS Teen Pregnancy Prevention Evidence Review (TPPER): What is the TPPER?, https://opa.hhs.gov/research-evaluation/teen- pregnancy-prevention-program-evaluations/tpp-evidence-review.

20 When it was initially established, 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.

21 See page H2684 of the joint explanatory statement accompanying FY2022 LHHS appropriations (Congressional Record, vol. 168, no. 42, book IV [March 9, 2022]); in reestablishing the TPPER, HHS contracted with Mathematica Policy Research to lead the review of the submitted studies (HHS, HHS Teen Pregnancy Prevention (TPP) Evidence Review Call for Studies, https://youth.gov/sites/default/files/2022-03/2022_TPPER_Call_for_Papers.pdf).

22 HHS, OPA, OASH, “Updated Findings from the HHS Teen Pregnancy Prevention Evidence Review (TPPER),” July 5, 2023, https://opa.hhs.gov/research-evaluation/teen-pregnancy-prevention-program-evaluations/tpp-evidence-review.

23 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.

24 See Mathematica Policy Research, Identifying Programs That Impact Teen Pregnancy, Sexually Transmitted Infections, and Associated Sexual Risk Behaviors, Review Protocol, version 7.0, for HHS, ASPE, October 2023.

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program models. Subsequent reviews were conducted on an annual or biannual basis through 2018, and again through May 2023, to incorporate recent research, including newly available evidence for programs that were previously reviewed. Cumulatively through 2023, TPPER reviews have identified 52 evidence-based program models.²⁵

The most recent TPPER includes program models that approach adolescent pregnancy from different frameworks. HHS categorizes the evidence-based models based on certain key features. For example, three of the identified models use a sexual risk avoidance approach; other models focus, for example, on health relationships, positive youth development, or sexual health education. The models also differ based on their outcomes, settings (e.g., schools, clinics, homes, communities), session length and duration over time, and target population (e.g., intended race/ethnicity, age or grade level, gender, sexually active youth).²⁶

Additional Evaluations of Teenage Pregnancy Prevention Approaches

HHS has developed additional research on adolescent pregnancy prevention interventions through annual transfers under Section 241 of the Public Health Service Act (PHSA) of approximately $4.5 million to $6.8 million from FY2011-FY2024.²⁷ These Section 241 transfers are directed in annual LHHS appropriations acts under a provision in the General Departmental Management account, the same account that funds the TPP program. The purpose of these funds is “to carry out evaluations (including longitudinal evaluations) of teenage pregnancy prevention approaches.” For FY2025, these evaluation supports include

• two research-to-practice centers to develop and disseminate research-informed practice resources for professionals who work with youth involved in the child welfare and/or justice systems, youth experiencing homelessness, and disconnected youth (also referred to as opportunity youth), and to develop resources for providing trauma-informed and inclusive care;

• research grants that examine the settings and youth characteristics to determine under what conditions TPP programs are most and least effective, and the determining factors that prevent and reduce disparities in sexual health outcomes;

• rigorous evaluation training and technical assistance to TPP program grantees conducting research and evaluation;

• collection and analysis of program performance measures for monitoring, program improvement, and reporting;

• multiple research projects with the goals of identifying, measuring, and evaluating the effectiveness of core components of TPP programs; and

• in partnership with the Office of the Assistant Secretary for Planning and Evaluation and the Administration for Children and Families, the HHS TPP Evidence Review to build a collective understanding of the program models that

25 HHS, OPA, OASH, “Updated Findings from the HHS Teen Pregnancy Prevention Evidence Review (TPPER,” July 5, 2023, https://opa.hhs.gov/research-evaluation/teen-pregnancy-prevention-program-evaluations/tpp-evidence-review.

26 HHS, OASH, OPA, “Find and Compare Programs,” https://youth.gov/evidence-innovation/tpper/compare-programs.

27 Section 241 of the PHSA provides authority for HHS to transfer funds between PHSA accounts to conduct evaluations of the implementation and effectiveness of public health programs. LHHS appropriations acts commonly establish requirements in addition to those in statute. These include directing specific amounts of funding transferred pursuant to Section 241 to selected HHS programs.

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have been rigorously evaluated and shown to reduce teen pregnancy, sexually transmitted infections, or associated sexual risk behaviors.²⁸

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 (TPP).²⁹ The OAH administered the program until it was subsumed under the OPA in June 2019.³⁰

The TPP program has been funded via the appropriations process through FY2024. Funding has ranged from approximately $98 million to $110 million annually. As discussed above, the TPP program primarily provides funds for evidence-based programs and/or programs that show promise toward reducing adolescent and young adult pregnancy, including those that focus on sexual risk avoidance and/or use of contraceptives (see the “The Use of Evidence-Based Models” section).

Generally, the appropriations laws have stated that funding should be competitively awarded. They have further specified that no more than 10% of TPP funding may be used 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 also 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. In 2023, “age appropriateness” was defined by HHS in the funding announcement for the most recent Tier 1 cohort as, “Ensures that topics, messages, and teaching methods are suitable to particular ages or age groups of children and adolescents, based on developing cognitive, emotional, and behavioral capacity typical for the age or age group.” “Medical accuracy” was defined as “verified or supported by the weight of research conducted in compliance with accepted scientific methods; and published in peer-reviewed journals, where

28 HHS, Fiscal Year 2025 Justification of Estimates for Appropriations Committees for General Departmental Management, pp. 132-133, https://www.hhs.gov/sites/default/files/fy-2025-gdm-cj.pdf. 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.”

29 The program had been proposed as part of President Obama’s FY2010 budget 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.

30 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.

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applicable or comprising information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete.”³¹

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 multiple cohorts of Tier 1 grantees since FY2010. The first cohort was funded for FY2010-FY2014.³² The second cohort had multiple rounds of funding due to the early termination of the first round of funding in 2017 (initially awarded for FY2015-FY2020);³³ an additional round of funding was later awarded for FY2019-FY2021.³⁴ A third cohort of Tier 1 funding was funded for FY2020-FY2023³⁵ and FY2021-FY2023.³⁶ The fourth (and most recent) cohort of Tier 1 awards covers the period of FY2023-FY2028, contingent on the future availability of funds.³⁷

This fourth cohort of Tier 1 grantees—Advancing Equity in Adolescent Health through Evidence- Based Teen Pregnancy Prevention Program and Services—supports 53 grantees in 25 states and Puerto Rico.³⁸ These grants seek to scale up effective programs that have been proven through

31 HHS, OASH, OPA, Advancing Equity in Adolescent Health through Evidence-Based Teen Pregnancy Prevention Programs and Services, AH-TP1-23-001, 2023. Other definitions have been used by HHS over the years. For example, in the funding opportunity announcement for 2020, “age appropriate” was defined as content “appropriate for the general developmental and social maturity of the targeted age group. The ability to cognitively understand a concept is not evidence that the concept is age appropriate.” For content to be “medically accurate,” that “information [would] be referenced to peer reviewed publications by educational, scientific, governmental, or health organizations.” HHS, OASH, OPA, Optimally Changing the Map for Teen Pregnancy Prevention (Tier 1), Funding Opportunity Announcement and Application Instructions, AH-TP1-20-001, 2020.

32 HHS, OASH, OAH, The Teen Pregnancy Prevention (TPP) Program: Performance in the First Five Years, April 2016.

33 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. In response, eight lawsuits were filed in February and March 2018 on behalf of all the grantees except for the Tier 2C grantees (discussed later in this report). 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. In 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 Tier 2C 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.

34 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.

35 HHS, OASH, OPA, “OPA Awards $56.3 Million in Grants to Replicate Effective Teenage Pregnancy Prevention Programs,” June 30, 2020, https://opa.hhs.gov/about/news/grant-award-announcements/opa-awards-563-million- grants-replicate-effective-teenage.

36 HHS, OASH, OPA, “OPA Awards $12.6 Million in Grants to Replicate Effective Teenage Pregnancy Prevention Programs,” June 28, 2021, https://opa.hhs.gov/about/news/grant-award-announcements/opa-awards-12-million-grants- replicate-effective-teenage#:~:text= The%20Office%20of%20Population%20Affairs,a%20two%2Dyear%20project%20period.

37 HHS, OASH, OPA, “HHS Announces $68 Million for Teen Pregnancy Prevention Opportunities,” June 23, 2023, https://www.hhs.gov/about/news/2023/06/23/hhs-announces-69-million-for-teen-pregnancy-prevention- opportunities.html.

38 HHS, OASH, OPA, About the Teen Pregnancy Prevention Program, https://opa.hhs.gov/grant-programs/teen- (continued...)

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rigorous evaluation to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors. Rigorous evaluation refers to results that come from robust evaluation designs, particularly experiments or quasi-experiments.³⁹

In general, Tier 1 grantees must implement their models consistent with the original evidence- based model listed in the TPP Evidence Review and have minimal adaptations (e.g., changing names). In the application materials for the most recent Tier 1 grantee cohort, HHS defined “evidence-based approaches” as those “that have been proven effective through rigorous evaluation to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors.”⁴⁰ HHS further emphasized the importance of grantees using materials accompanying the evidence-based programs that are “age appropriate, medically accurate, culturally and linguistically appropriate, trauma-informed, and inclusive of all youth.”⁴¹

Grantee Profile: Partners in Social Research, LLC (PSR)

PSR aims to reduce teen pregnancy by partnering with schools, community stakeholders, afterschool programs, a teen clinic in the city of New Britain, CT, and statewide programs for youth with child welfare involvement to select and implement evidence-based teen pregnancy prevention programs. This project will establish a Teen Pregnancy Prevention Advisory, which will work in coordination with the New Britain Prevention Council to create and sustain a robust network of partners: community stakeholders, educators, health providers, families and caregivers, LGBTQ+ advocates, and youth leaders as equal decisionmakers in this effort. The programs will be implemented in middle schools (grades 6-8), high schools, alternative schools, community and afterschool programs, clinics, and in child welfare settings. All materials disseminated to youth will be reviewed at least annually to ensure that they are medically accurate, age-appropriate, culturally and linguistically appropriate, trauma-informed, and inclusive of all youth. The project will not only give young people the tools to prevent teen pregnancy and sexually transmitted infections (STIs), but it will also mobilize the community to build a network of youth-friendly services to meet young people’s social, physical, psychological, and financial needs. Source: HHS, OASH, OPA, Current Teen Pregnancy Prevention Grant Recipients: Advancing Equity in Adolescent Health through Evidence-Based Teen Pregnancy Prevention Program and Services (TPP23 Tier 1) – 2023-2028. Note: This report includes examples of grantees recently funded under the four teen pregnancy prevention programs. The grantees were selected by CRS based on information available on the HHS website or provided via correspondence with HHS. Collectively, the grantees described in the report are intended to represent all regions of the country and are included for illustrative purposes only.

Tier 2 Grants

As with Tier 1 grantees, HHS has funded multiple cohorts of Tier 2 grants over the years, with the different announcements within a cohort sometimes referred to as “phases.” The first cohort of grantees was funded for FY2010-2014. The second cohort of grantees was funded for FY2015-

pregnancy-prevention-program/about-tpp-program; and HHS, OASH, OPA, Current Teen Pregnancy Prevention Grant Recipients, https://opa.hhs.gov/grant-programs/teen-pregnancy-prevention-program/tpp-grant-recipients/current-tpp- grant-recipients.

39 HHS, OAH, Teenage Pregnancy Prevention: Replication of Evidence-based Programs Funding Opportunity Announcement and Application Instructions, 2010.

40 HHS, OASH, OPA, Advancing Equity in Adolescent Health through Evidence-Based Teen Pregnancy Prevention Programs and Services, Funding Opportunity Announcement and Application Instructions, AH-TP1-23-001, 2023.

41 Ibid.

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FY2020⁴² with some additional grants later awarded and funded for FY2018-FY2020.⁴³ The third cohort of Tier 2 grants was funded for FY2020-FY2023 and separated into two phases: TPP Innovation and Impact Networks (Tier 2; TPP20 Innovation Networks),⁴⁴ and Phase 2 Rigorous Evaluation of Promising TPP Interventions (Tier 2 Phase 2; TPP Rigorous Evaluation).⁴⁵ The fourth (and most recent) cohort of Tier 2 grants was awarded for FY2023-FY2028, contingent on the future availability of funds; as with the third cohort, these grants are distinguished by the phase of evidence-building that they are intended to support. The Adolescent Sexual Health Innovation Hubs and Rigorous Evaluation Cooperative Agreements support six grantees in four states as they carry out programs that will “develop, refine, and test additional models and innovative strategies.”⁴⁶ In addition, TPP Rigorous Evaluation Cooperative Agreements were awarded to 12 grantees across nine states and the District of Columbia to continue the work of previous Phase 2 grants.⁴⁷

TPP Evaluation Activities

Since the early years of the TPP program, HHS has supported numerous program evaluations to determine which models and approaches are effective. These evaluations have shown a range of results, with many identifying programs with positive impacts on teen pregnancy-related outcomes. For example, for the first cohort of grantees HHS supported a federal effort to conduct 41 evaluations.⁴⁸ Of these, 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.⁴⁹ In the intervening years since the inception of the program, HHS has continued to fund evaluations of TPP program effectiveness; some of these are summarized below.

42 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.

43 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 was to build on the results achieved in Phase I and is limited to successful Phase I grantees.

44 HHS, OASH, OPA, “OPA Awards $19.2 Million in Grants to Develop Innovation and Impact Networks to Prevent Teen Pregnancy and Achieve Optimal Health,” July 14, 2020, https://opa.hhs.gov/about/news/grant-award- announcements/opa-awards-192-million-grants-develop-innovation-and-impact.

45 HHS, OASH, OPA, “OPA Awards $3.7 Million in Grants to Conduct Evaluation of Promising Interventions to Prevent Teen Pregnancy and Achieve Optimal Health,” July 14, 2020, https://opa.hhs.gov/about/news/grant-award- announcements/opa-awards-37-million-grants-conduct-evaluation-promising.

46 HHS, OASH, “HHS Awards $23 Million to Support Evidence-Based Teen Pregnancy Prevention Programs,” August 25, 2023, https://www.hhs.gov/about/news/2023/08/25/hhs-awards-23-million-support-evidence-based-teen- pregnancy-prevention.html.

47 Ibid.

48 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.

49 Amy Feldman Farb and Amy L. Margolis, “The Teen Pregnancy Prevention Program (2010-2015): Synthesis of Impact Findings.”

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In general, the Tier 1 TPP grants across all cohorts have required some type of evaluation for at least some grantees, although these requirements have varied. For the first cohort (FY2010- FY2014), all Tier 1 grantees that received a specified level of funding were required to be evaluated, and all grantees regardless of funding level were required to monitor and report on program implementation and outcomes according to performance measures.⁵⁰ The second (FY2015-FY2021) and third (FY2020-FY2023) cohorts did not distinguish between grantees by level of funding, and instead expected that all grantees evaluate the implementation of their programs.⁵¹ The fourth cohort (FY2023-FY2028) grantees are to monitor and report on their program impacts, but were directed not to use funds for a rigorous impact evaluation.⁵²

With regard to the Tier 2 TPP grantees, as the general purpose of these grants is to establish an evidence base for new approaches, they have all generally required some type of evaluation. However, most cohorts have split these grantees into phases, with the first phase supporting interventions that are in the early stage of development, and the second phase supporting interventions that are ready for rigorous evaluation.⁵³ In such cases, the type of evaluation expected in each phase has differed. For example, Phase 1 of the third cohort (FY2020-FY2023) required that the grantee test and evaluate interventions at different stages of development. In the funding opportunity announcement, HHS stated, “It is expected that some interventions will move between testing and development, evolving throughout the course of the project, and it is expected that interventions will be refined based on learnings. Grantees should use testing and evaluation methods appropriate for the stage of intervention development, collecting and analyzing data to make changes and assess impacts.”⁵⁴ In contrast, Phase 2 funding was provided specifically to support more developed programs where rigorous evaluation was appropriate.⁵⁵ Similarly, the fourth cohort (FY2023-FY2028) of Tier 2 grants were awarded in two separate funding streams: grants for “innovation hubs” to support early evaluation efforts for developing programs, and grants for interventions that are ready to be rigorously evaluated.⁵⁶

The MITRE Corporation, which currently operates the Health Federally Funded Research and Development Center (FFRDC) under contract with the Centers for Medicare and Medicaid Services (CMS), was awarded funding for FY2017 and FY2018 to test and replicate meaningful ways to improve programs related to teen pregnancy prevention under the Teen Pregnancy

50 HHS, OAH, “Teenage Pregnancy Prevention: Replication of Evidence-based Programs (Tier 1),” Funding Opportunity Announcement, OPHS/OAHTPP Tier1-2010, 2010.

51 HHS, OAH, “Capacity Building to Support Replication of Evidence-Based TPP Programs (Tier 1B), AH-TP1-15- 001, 2015; HHS, OAH, “Phase I Replicating Programs (Tier 1) Effective in the Promotion of Healthy Adolescence and the Reduction of Teenage Pregnancy and Associated Risk Behaviors,” AH-TP1-18-001, 2018; and HHS, OAH, OPA, “Optimally Change the Map of Teen Pregnancy through Replication of Programs Proven Effective (Optimally Changing the Map for Teen Pregnancy Prevention – Tier 1),” AH-TP1-20-001, 2020.

52 HHS, OAH, OPA, “Advancing Equity in Adolescent Health through Evidence-Based Teen Pregnancy Prevention Programs and Services” AH-TP1-23-001, 2023.

53 See, for example, HHS, OAH, “Supporting and Enabling Early Innovation to Advance Adolescent Health and Prevent Teen Pregnancy (Tier 2A), AH-TP2-15-001, 2015; HHS, OAH, “Rigorous Evaluation of New or Innovative Approaches to Prevent Teen Pregnancy (Tier 2B),” AH-TP2-15-002, 2015.

54 HHS, OAH, OPA, “Tier 2 Innovation and Impact Network Grants: Achieving Optimal Health and Preventing Teen Pregnancy in Key Priority Areas” AH-TP2-20-002, 2020.

55 HHS, OAH, OPA, “Teen Pregnancy Prevention (TPP) Tier 2, Phase II Rigorous Evaluation of Promising Interventions” AH-TP2-20-001, 2020.

56 HHS, OAH, OPA, “Teen Pregnancy Prevention Tier 2 Adolescent Sexual Health Innovation Hubs” AH-TP2-23-002, 2023; and HHS, OAH, OPA, “Teen Pregnancy Prevention Tier 2 Rigorous Evaluation Cooperative Agreements” AH- TP2-23-001, 2023.

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Prevention Study.⁵⁷ MITRE subcontracted with multiple entities to carry out activities under the contract. The project included several activities, including revising SMARTool,⁵⁸ 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.⁵⁹

For the third cohort of TPP grantees, in addition to the required individual grantee evaluations, OPA contracted with Abt Associates and its partners, Decision Information Resources and Data Soapbox, to evaluate how the Tier 1 (Optimally Changing the Map for Teen Pregnancy Prevention) and Tier 2 (Innovation Networks) grantees for FY2020 and FY2021 implemented each grant strategy and develop recommendations for additional TPP evaluation options. The contract period for this evaluation was September 2021 through April 2024.⁶⁰

HHS-led TPP research and evaluation projects that are currently underway include the following:⁶¹

• Teenage Pregnancy Prevention Evaluation and Research Grants (Performance Period: September 30, 2022-September 29, 2024). Four grantees will “explore new questions in teen pregnancy prevention, adolescent sexual and reproductive health, and family planning more broadly that improve the efficiency, effectiveness, and quality of these programs for adolescents or young adults, and/or reduce existing disparities.”⁶²

• Research to Practice Center Grants (Performance Period: September 30, 2022- September 29, 2026). Two grantees will “synthesize and translate existing research into practice for health promotion activities that will lead to adoption of healthy behaviors, improve adolescent health more broadly, and ultimately help to reduce teen pregnancy.”⁶³

Reproductive Health National Training Center

In 2020, HHS OPA and Office on Women’s Health (OWH) awarded a set of three cooperative agreements to JSI Research & Training Institute, Inc. (JSI) to establish and operate a National

57 HHS, ACF, “HHS Announces New Efforts to Improve Teen Pregnancy Prevention & Sexual Risk Avoidance Programs,” press release, November 3, 2017, https://www.acf.hhs.gov/archive/media/press/2017/hhs-announces-new- efforts-improve-teen-pregnancy-prevention-sexual-risk. MITRE’s work using these TPP program funds was to occur under the Health FFRDC.

58 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.

59 These activities are described further at USASpending.gov, “Contract Summary, HHS, The MITRE Corporation,” https://www.usaspending.gov/#/award/23605015.

60 HHS, OASH, OPA, Teen Pregnancy Prevention Tier 1 and 2 Evaluation Overview, https://opa.hhs.gov/sites/default/ files/2022-04/tpp-fy2020-fy2021-evaluation-overview_0.pdf.

61 For further detail on the work to be conducted by each grantee, as well as other ongoing program evaluations, see OASH, OPA, “Current TPP Research & Evaluation Grantees,” https://opa.hhs.gov/research-evaluation/teen-pregnancy- prevention-program-evaluations/current-tpp-research-evaluation-grantees.

62 These grantees are AMTC & Associates; State University of New Jersey, Rutgers; University of Maryland, Baltimore; and University of South Florida.

63 These grantees are Child Trends, Inc.; and Healthy Teen Network.

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Training Center for Family Planning and Teen Pregnancy Prevention.⁶⁴ Named the Reproductive Health National Training Center (RHNTC), its purpose is to “ensure that personnel working in OPA-funded Title X⁶⁵ and TPP projects have the knowledge, skills, and attitudes necessary to deliver high-quality services and programs.”⁶⁶ The RHNTC allows users to filter through resources by specific program (i.e., TPP or Title X) and includes resources on topics ranging from youth-friendly care and the promotion of healthy relationships to strategies for improved clinic efficiency and quality.⁶⁷

Personal Responsibility Education Program (PREP)

The Personal Responsibility Education Program (PREP) 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.⁶⁸ The Patient Protection and Affordable Care Act (ACA, P.L. 111-148) established PREP by amending Title V of the Social Security Act (SSA) and appropriating $75 million annually in mandatory spending for FY2010 through FY2014.⁶⁹ PREP authorization and funding has been extended multiple times, most recently through December 31, 2024, under Division G of the Consolidated Appropriations Act, 2024 (CAA 2024, P.L. 118-42).

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.⁷⁰

64 According to the FOA, a maximum of $7.4 million would be available for the first 12-month budget period of a project not to exceed five years between the three cooperative agreements funded by Title X, TPP, and OWH. (See HHS, OASH, OPA, and Office of Women’s Health (OWH) FOA, “National Training Center for Family Planning and Teen Pregnancy Prevention, PA-FPT-20-001 / AH-TPS-20-001 / WH-AST-20-002, p. 4.)

65 For further information about Title X, see CRS In Focus IF10051, Title X Family Planning Program.

66 See https://rhntc.org/about.

67 Ibid.

68 The Personal Responsibility Education Program acronym “PREP” is similar to “PrEP,” which refers to pre-exposure prophylaxis medication, which is used to reduce the risk of HIV infection. This report uses PREP to exclusively refer to the adolescent pregnancy prevention programs, although some programs may focus on STI prevention. This report does not cover other federal programs focused on HIV prevention or treatment.

69 Section 513 of the Social Security Act (42 U.S.C. §513).

70 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 (continued...)

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As with the TPP program, PREP uses a tiered-evidence approach. Nearly all participants in programs implemented by PREP grantees are evidence-based and been proven to delay sexual activity, increase condom or contraceptive use for sexually active youth, or reduce pregnancy among youth.⁷¹ 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 insular areas (Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau) via the State PREP grant. Funding for states and insular areas 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 FY2024 funding for the four grants was $75.0 million. Of this amount, $42.8 million was allocated for State PREP, $12.4 million was for Competitive PREP, $3.3 million was for Tribal PREP, and $10.7 million was for PREIS.⁷²

State PREP and Competitive PREP

The 50 states, District of Columbia, and insular areas 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 FY2022 PREP funding for the period of October 1, 2021, through September 30, 2024. This included 44 states, plus the District of Columbia, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, the Virgin Islands, and the Federated States of Micronesia.⁷³ States and insular areas can administer the project directly or through sub-awards to public or private entities.

If a state or insular area did not submit an application for formula funding for FY2010 or FY2011, it is ineligible to apply for that formula funding through December 31, 2024.⁷⁴

suitable to particular ages of children and adolescents, based on their developing cognitive, emotional, and behavioral capacity.

71 HHS, ACF, FY2025 Justification of Estimates for Appropriations Committee, p. 266. 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.

72 Ibid.

73 See Table B-1 for a list of states receiving the formula grant (from HHS, ACF, FYSB, State Personal Responsibility Education Program (PREP) Grantees FY2022, December 31, 2022, https://www.acf.hhs.gov/fysb/grant-funding/state- personal-responsibility-education-program-prep-grantees.) 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.)

74 The law originally stated that jurisdictions that did not submit an application in FY2010 or FY2011 were ineligible to (continued...)

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Organizations in such a state or insular area 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.⁷⁵ HHS awarded Competitive PREP funding for FY2012- FY2014 to organizations located in states that did not apply for funding in FY2010 or FY2011, and awarded a second cohort Competitive PREP funding for FY2015-FY2020.⁷⁶ In FY2021, HHS awarded a third cohort of Competitive PREP funds for FY2021 to 27 grantees in Florida, Indiana, Kansas, North Dakota, Texas, and Virginia.⁷⁷ HHS noncompetitively continued PREP funding for FY2022 and FY2023, and issued a notice of funding opportunity for FY2024 funds, due June 24, 2024.⁷⁸

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.⁷⁹ 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, insular areas, and entities that apply for State PREP or Competitive PREP funds must replicate evidence-based adolescent pregnancy prevention programs or substantially incorporate elements of effective programs.⁸⁰

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), November 30, 2020 (P.L. 116-136), FY2023 (P.L. 116-260), and through December 31, 2024 (P.L. 118-42).

75 HHS, ACF, FYSB, FY 2024 Competitive Personal Responsibility Education Program (PREP), HHS-2024-ACF- ACYF-AK-0032, 2024.

76 The length of this grant period was related, in part, to a series of short-term funding extensions for PREP that were enacted during this period. The Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123) extended the funding period for the grantees through FY2019. As a result, HHS did not publish funding announcements for FY2018 or FY2019 for Competitive PREP or any other component of PREP. (Based on CRS correspondence with HHS, December 2019.) Funding was subsequently extended, most recently through FY2023 (CAA 2021, P.L. 116-260). The FY2022 budget request noted that the project period for 20 of the 21 Competitive PREP grantees was FY2015 through FY2020, with the remaining grantee being extended through January 2022. HHS, ACF, FY 2022 Justification of Estimates for Appropriations Committee, p. 286.

77 HHS, ACF, FYSB, “Competitive Personal Responsibility Education Program (PREP) Grantees FY2021,” October 7, 2021, https://www.acf.hhs.gov/fysb/grant-funding/fysb/competitive-personal-responsibility-education-program-prep- grantees-fy2021.

78 See Table B-1 for a list of the states with competitive grantees (from HHS, ACF, FYSB, “Competitive Personal Responsibility Education Program (PREP) Grantees FY2023,” February 5, 2024, https://www.acf.hhs.gov/fysb/grant- funding/fysb/competitive-personal-responsibility-education-program-prep-grantees.) See also HHS, ACF, FYSB, FY 2024 Competitive Personal Responsibility Education Program (PREP), HHS-2024-ACF-ACYF-AK-0032, 2024. Note that although New Hampshire applied for State PREP funding in FY2021 and FY2022, it opted to discontinue receiving State PREP funds for FY2023. As a consequence, entities within New Hampshire were eligible to apply for competitive funds for FY2023; such funds were awarded to two New Hampshire organizations. Eligible FY2024 competitive PREP applicants are limited to local organizations and entities or consortia in the following states and insular areas: Florida, Idaho, Indiana, Kansas, New Hampshire, North Dakota, Texas, Virginia, American Samoa, and the Marshall Islands.

79 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; and HHS, ACF, FYSB, FY 2024 Competitive Personal Responsibility Education Program (PREP), HHS-2024-ACF-ACYF-AK-0032, 2024.

80 Grantees are referred to the Teen Pregnancy Prevention Evidence Review, though they are not required to adopt the models identified in the review.

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Grantee Profile: Massachusetts

The PREP program in Massachusetts serves youth ages 10 through 19 and pregnant or parenting youth up to age 21. Providers focus on populations with the greatest disparities in reproductive health outcomes in the state, including Hispanic and Latino youth, African-American youth, gender and sexual minority youth, youth in or aging out of foster care, youth with physical and intellectual disabilities, and pregnant or parenting youth. The program implements the following evidence-based curricula in school and community-based settings: It Pays: Partners for Youth Success, Making Proud Choices!, Teen Outreach Program, Be Proud! Be Responsible!, and Get Real. The program also educates its youth in three of the adulthood preparation subjects: adolescent development, financial literacy, and healthy relationships. Source: HHS, Administration for Children and Families (ACF), Family and Youth Services Bureau (FYSB), State Personal Responsibility Education Program (PREP) Grantee Profiles, August 24, 2017. Note: This report includes examples of grantees recently funded under the four teen pregnancy prevention programs. The grantees were selected by CRS based on information available on the HHS website or provided via correspondence with HHS. Collectively, the grantees described in the report are intended to represent all regions of the country and are included for illustrative purposes only.

Tribal PREP

Tribal PREP competitive 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 adolescent pregnancy programs. Such programs must replicate evidence-based models, sustainably incorporate elements of effective models, or include promising practices within tribal communities.⁸¹ Indian tribes and tribal organizations, as these terms are defined in the Indian Health Care Improvement Act (P.L. 94-437; 25 U.S.C. §1601) , are eligible to apply for Tribal PREP funding. The first cohort of 15 grantees received funding from FY2011 through FY2015.⁸² The second cohort of eight grantees received funding from FY2016 through FY2020.⁸³ The project period for the third cohort of eight grantees (in seven states) that was awarded in FY2021 is five years.⁸⁴

Personal Responsibility Education Innovative Strategies (PREIS)

PREIS competitive grants are intended to build evidence for promising adolescent 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.

81 HHS, ACF, FYSB, Tribal Personal Responsibility Education Program for Teen Pregnancy Prevention, HHS-2021- ACF-ACYF-AT-1922, 2021.

82 HHS, ACF, FYSB, 2015 Tribal Personal Responsibility Education Grant Awards, https://www.acf.hhs.gov/fysb/ resource/2015-tribal-prep.

83 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.

84 HHS, ACF, FYSB, Tribal Personal Responsibility Education Program (PREP) Grantees FY2021, December 30, 2022, https://www.acf.hhs.gov/fysb/grant-funding/tribal-personal-responsibility-education-program-prep-grantees. One grantee, Tewa Women United, was not continued after FY2021.

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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.⁸⁵ 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.⁸⁶ PREIS funds are awarded as five-year cooperative agreements. The first cohort of PREIS grantees, funded for FY2011 through FY2015, included 11 organizations.⁸⁷ The second cohort of grantees, funded for FY2016 through FY2020, included 13 organizations in 10 states plus the District of Columbia.⁸⁸ The third cohort of grantees, funded in FY2021 with a five-year project period, included 12 organizations in nine states plus the District of Columbia.⁸⁹

PREP Evaluation Activities

PREP authorizing law directs HHS to evaluate PREP programs and activities.⁹⁰ The PREP Multi- Component Evaluation (2011-2021) supported the first cohort of PREP grantees. The activities of this evaluation included (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.⁹¹ The study of the grantees overall found that the largest share of youth served by PREP 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).⁹² 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.⁹³

The PREP Studies of Performance Measures and Adulthood Preparation Subjects (2016-2024) supported the second cohort of PREP grantees. This evaluation was comprised of two key

85 HHS, ACF, FYSB, Personal Responsibility Education Program Innovative Strategies (PREIS), HHS-2021-ACF- ACYF-AP-1928, 2021.

86 Ibid.

87 HHS, ACF, FYSB, 2015 Personal Responsibility Education Innovative Strategies (PREIS) Grant Awards, https://www.acf.hhs.gov/fysb/resource/2015-preis.

88 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 2022 Justification of Estimates for Appropriations Committee, p. 286.

89 HHS, ACF, FYSB, Personal Responsibility Education Innovative Strategies (PREIS) Program Grantees FY2021, October 6, 2021, https://www.acf.hhs.gov/fysb/grant-funding/fysb/personal-responsibility-education-innovative- strategies-preis-program.

90 Section 513(c)(2(B)(iii) of the Social Security Act.

91 HHS, ACF, OPRE, Personal Responsibility Education Program (PREP) Multi-Component Evaluation, https://www.acf.hhs.gov/opre/project/personal-responsibility-education-program-prep-multi-component-evaluation- 2011-2021.

92 HHS, ACF, Office of Policy Research and Evaluation (OPRE), Personal Responsibility Education Program (PREP) Evaluation: Nationwide Implementation of PREP Programs, OPRE Report Number 2018-23, April 2018; HHS, ACF, OPRE, Inputs and Outcomes: PREP Programs Serving Highly Vulnerable Youth, OPRE Report #2018-45, April 2018.

93 HHS, ACF, OPRE, PREP Studies of Performance Measures and Adult Preparation Subjects, Fact Sheet, 2020-2021 Performance Measures, OPRE Report #2023-029, February 2023.

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components related to performance measures for PREP and adulthood preparation subjects (APS). The multiple purposes of this project included revising measures used for PREP grantee reporting of performance data, creating a performance dashboard tool, and developing APS conceptual models.⁹⁴ In addition, grantee training technical support for the second cohort was provided via the Promising Youth Programs Project.⁹⁵

Grantee Profile: Kentucky Department of Health

The Reducing the Risk teen pregnancy prevention curriculum is designed to help teens prevent pregnancy and the transmission of STIs by developing skills such as risk assessment, communication, decisionmaking, planning, and refusal strategies. The Kentucky Department of Health tested the efficacy of providing the curriculum over a shorter duration (8 hours instead of 12 hours) for students in a rural area of the state. The treatment group enrolled in Reducing the Risk (which still covered the same topics, just in a shorter period) and the control group received the school’s standard health curriculum. The adapted version reduced the likelihood of having sex without a condom among students who were already sexually active, but it did not change the likelihood of having sex or having sex without a condom for the overall sample. Source: HHS, ACF, OPRE, Personal Responsibility Education Program (PREP) Evaluation: Evaluating a Teen Pregnancy Prevention Program in Rural Kentucky, OPRE Report Number 2018-105, October 2018. Note: This report includes examples of grantees recently funded under the four teen pregnancy prevention programs. The grantees were selected by CRS based on information available on the HHS website or provided via correspondence with HHS. Collectively, the grantees described in the report are intended to represent all regions of the country and are included for illustrative purposes only.

Currently, the PREP Local Evaluation Support and Dissemination (PLESD) project provides support for grantees to conduct rigorous program evaluations and to build research and evaluation capacity. This support for grantees is expected to extend through 2026.⁹⁶

Separate from these evaluation efforts, PREIS and Tribal PREP grantees are directed 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 outcomes such as 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 local evaluations.

Title V Sexual Risk Avoidance Education Program (Title V SRAE)

A Separate Program for Abstinence Education was established under Section 510 in Title V of the Social Security Act by The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, P.L. 104-193). Now named the Title V Sexual Risk Avoidance Education program (Title V SRAE), it is funded through mandatory appropriations in the Social Security Act. When the program was initially established, PRWORA provided $50 million per year for

94 ACF, ACF, OPRE, Personal Responsibility Education Program (PREP) Studies of Performance Measures and Adulthood Preparation Subjects, https://www.acf.hhs.gov/opre/project/prep-studies-performance-measures-and- adulthood-preparation-subjects-2016-2022.

95 ACF, ACF, OPRE, Promising Youth Programs Project, https://www.acf.hhs.gov/fysb/programs/adolescent- pregnancy-prevention/evaluation/promising-youth-programs-project.

96 ABT Associates, Personal Responsibility Education Program (PREP) Local Evaluation Support and Dissemination (PLESD), https://www.abtassociates.com/projects/providing-local-evaluation-support-to-acfs-prep-grantees.

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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 and increased its funding. The Protecting Access to Medicare Act of 2014 (P.L. 113-93) provided $50 million in FY2015. Next, the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10) increased funding to $75 million per year for FY2016 and FY2017. Two additional fiscal years (FY2018 and FY2019) of funding were enacted by the Bipartisan Budget Act of 2018 (P.L. 115-123, BBA 2018). Following several temporary extensions, funding has been most recently provided through December 31, 2024, under Division G of the CAA 2024 (P.L. 118-42).

States are eligible to request mandatory Title V SRAE funds if they submit an application for Title V State Maternal and Child Health (MCH) Block Grant funds. The State MCH Block Grant program, authorized under Title V of the Social Security Act, is a flexible source of funds administered through a federal-state partnership which supports a range of maternal and child health programs.⁹⁷ Title V SRAE funds are allocated to each jurisdiction based on two factors: (1) the total amount of annual funding provided to the Title V SRAE program in Section 510 minus any reservations (up to 20%) made by HHS for administering it, and (2) states’ relative proportion of low-income children nationally.⁹⁸ The law does not require states to provide a match.⁹⁹

97 For further information, see CRS Report R48088, Maternal and Child Health Services Block Grant: Overview and Issues for Congress. All states, the District of Columbia, and five insular areas (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands), and three freely associated states (Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau) receive MCH Block Grant funds. (See HHS, HRSA, Explore the Title V Federal-State Partnership, https://mchb.tvisdata.hrsa.gov/.)

98 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, Standing Notice of Funding Opportunity for Title V State Sexual Risk Avoidance Education, HHS-2024-ACF-ACYF-SRAE-0044, 2024.

99 Previously, such a matching requirement was specified at Section 510(c) of the Social Security Act, which referenced 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 (continued...)

Title V Sexual Risk Avoidance

Education T opics

Sexual risk avoidance education, also sometimes referred to as abstinence-only education, must ensure that the “unambiguous and primary emphasis and context” for each of six sexual risk avoidance topics is “a message to youth that normalizes the optimal health behavior of avoiding nonmarital sexual activity.” The sexual risk avoidance topics include the following:

• The holistic individual and societal benefits associated with personal responsibility, self- regulation, goal setting, healthy decisionmaking, and a focus on the future.

• The advantage of refraining from nonmarital sexual activity in order to improve the future prospects and physical and emotional health of youth.

• The increased likelihood of avoiding poverty when youth attain self-sufficiency and emotional maturity before engaging in sexual activity.

• The foundational components of healthy relationships and their impact on the formation of healthy marriages and safe and stable families.

• How other youth risk behaviors, such as drug and alcohol usage, increase the risk for teen sex.

• How to resist, avoid, and receive help regarding sexual coercion and dating violence, recognizing that, even with consent, teen sex remains a youth risk behavior.

Source: Section 510(b)(3) of the Social Security Act.

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HHS is authorized to competitively award FY2018 through FY2025 funds to one or more entities within a state/insular area 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 State MCH Block Grant funds. Eligible states are required to apply for the Title V SRAE funds no later than 120 days after the deadline closed for states to apply for State MCH 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 insular areas (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 for funding. In total, 36 states plus Puerto Rico and the Federated States of Micronesia applied for and received funding for FY2022-FY2024.¹⁰⁰ Another 34 grantees in 12 states plus Guam and the U.S. Virgin Islands received new Competitive SRAE funding for FY2023-FY2024.¹⁰¹

The law directs states/insular areas 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.¹⁰² 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, simulation, or distribution of contraception.

Additionally, the grant announcements have previously specified that grantees must implement a project with a “best practice and/or evidence-based approach.” The grant announcements have directed 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.”¹⁰³ (For further information, see the “TPP Evaluation Activities” section.) These announcements also have pointed to the TPPER

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).

100 See Table B-1 for a list of states receiving the formula grant (from HHS, ACF, FYSB, Title V State Sexual Risk Avoidance Education (SRAE) Grantees FY2022, https://www.acf.hhs.gov/fysb/grant-funding/fysb/title-v-state-sexual- risk-avoidance-education-srae-grantees).

101 See Table B-1 for a list of the states with competitive grantees (from HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education (SRAE) Grantees, FY2023, https://www.acf.hhs.gov/fysb/grant-funding/title-v-competitive- sexual-risk-avoidance-education-srae-grantees).

102 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.

103 See, for example, Standing Announcement for Title V State Sexual Risk Avoidance Education, HHS-2020-ACF- ACYF-SRAE-1848, 2020.

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website for a list of evidence-based programs, although applications are not required to implement these approaches.¹⁰⁴

Title V SRAE Evaluation Activities

Under the authorizing statute, a state or other entity that receives Title V SRAE 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 have specified that jurisdictions must assess the success of their sexual risk avoidance education programs through at least two outcome measures.¹⁰⁵ Furthermore, a state or other entity receiving funding under the Title V SRAE 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.¹⁰⁶

Grantee Profile: Arizona

The Title V Abstinence Education program in Arizona is implementing the following education models: Choosing the Best, Love Notes SRA Edition, Making a Difference, Promoting Health Among Teens (PHAT)! Abstinence Only, and the Teen Outreach Program (TOP). The target population is youth ages 11 through 19 who are in areas across the state with high teen pregnancy rates; Hispanic, black, or American Indian youth; and youth in foster care. The program’s services are provided by one county health department and with community-based organizations in schools and community-based settings. Generally, the program focuses on the benefits of protective factors to support adolescents’ decisions in refraining from nonmarital sex, including healthy relationships, setting goals, self- regulation, and academic success. In addition to the curriculum above, the program may deliver an optional parental education component to parents of youth aged 11 through 19. Sources: HHS, ACF, FYSB, Title V State Sexual Risk Avoidance Education (SRAE) Grantee Profiles, April 2, 2021; and Arizona Department of Health Services, Title V State Sexual Risk Avoidance Education Program State Plan, 2018. Note: In the absence of information about Title V Sexual Risk Avoidance Education grantees on the HHS website, this grantee was selected by CRS based on an internet search. Collectively, the grantees described in the report are intended to represent all regions of the country and are included for illustrative purposes only.

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 SRAE program. This evaluation is to be conducted in consultation with “appropriate State and local agencies.” HHS is to also 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 Title V SRAE 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 is a five-year study that includes both Title V SRAE

104 See, for example, HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education (SRAE), HHS-2024- ACF-ACYF-SRAE-0040, 2024.

105 See, for example, HHS, ACF, FYSB, Standing Notice of Funding Opportunity for Title V State Sexual Risk Avoidance Education, HHS-2024-ACF-ACYF-SRAE-0044, 2024.

106 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.

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grantees and SRAE program grantees funded under the General Departmental Management account (see the “General Department Sexual Risk Avoidance Education Program (GD SRAE)” section for further information), and has three components:

1. National Descriptive Study: This will describe SRAE grantees’ program plans

(Early Implementation Study) and examine grantees’ implementation and youth outcomes (Nationwide Study).

2. 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.

3. 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.¹⁰⁷

In addition, the Sexual Risk Avoidance Education Performance Analysis Study (2019-2027) is intended to collect performance measures data from Title V SRAE program participants and providers to allow both the program office and grantees to monitor and report on progress in implementing SRAE initiatives. Primary activities include support to grantees to collect and submit performance measures, the development of a portal for performance measures submission, and development of a dashboard for use by grantees and the program office for continuous quality improvement. The contract for this evaluation was awarded to Public Strategies (with Mathematica as a subcontractor) for FY2019-FY2023, and to Mathematica (with Public Strategies as a subcontractor) for FY2022-FY2027.¹⁰⁸

With regard to the prior Title V Abstinence Education Grant program, the Balanced Budget Act of 1997 (P.L. 105-133) directed HHS to conduct evaluation activities.¹⁰⁹ 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 adolescent sexual abstinence and related outcomes. The programs enrolled youth in elementary and middle school and engaged them as part of the school setting, including in afterschool programming. Each individual participated for more than 50 hours. The study tracked longitudinal outcomes among participants for four and six years after they were enrolled in the program. The impact evaluation found that youth who received abstinence education under the program did not have different outcomes than youth in the control in terms of likelihood to abstain from sex, number of sexual partners, and mean age of initiation.¹¹⁰

107 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. Several SRANE studies have been published at https://www.acf.hhs.gov/opre/project/sexual- risk-avoidance-education-national-evaluation-2018-2023.

108 HHS, ACF, OPRE, Sexual Risk Avoidance Education Performance Analysis Study, https://www.acf.hhs.gov/opre/ project/sexual-risk-avoidance-education-performance-analysis-study-2019-2022.

109 P.L. 105-133 did not amend Title V of the Social Security Act.

110 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.

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General Department Sexual Risk Avoidance Education Program (GD SRAE)

In the past, federal funding 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 FY2024, annual appropriations laws provided funding to support abstinence-only education through the General Department Sexual Risk Avoidance Education (GD SRAE) program. Funding was $5 million in FY2016, $15 million in FY2017, $25 million in FY2018, and $35 million in FY2019 through FY2024. The appropriations laws have specified that GD SRAE 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.”¹¹¹

The appropriations laws have 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 GD SRAE 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.¹¹² GD SRAE grants are awarded for two-year project periods, typically with some new and some noncompetitive continuations each year. Most recently, HHS awarded 31 new grants for FY2021 (totaling $12.8 million, FY2021-FY2022 project period) and noncompetitively continued 51 grants (totaling $21.5 million, FY2021-FY2022 project period); grants were noncompetitively continued for FY2022 and FY2023.¹¹³ HHS has also issued a notice of funding opportunity for FY2024 funds, due June 24, 2024.¹¹⁴

As specified in the funding announcements, 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

111 This text has been included in each of the appropriation laws for FY2016 through FY2024.

112 HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD-SRAE), HHS-2024-ACF-ACYF- SR-0041, 2024.

113 HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD SRAE) Grantees (FY2021, FY2022, FY2023), https://www.acf.hhs.gov/fysb/grant-funding/fysb/general-departmental-sexual-risk-avoidance- education-gd-srae-grantees. See Table B-1 for a list of states with GD SRAE grantees for FY2023.

114 HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD-SRAE), HHS-2024-ACF-ACYF- SR-0041, 2024.

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in promoting positive youth behavior changes, especially delaying sexual activity, returning to a lifestyle without sex, and refraining from nonmarital sex. The grant announcements point out that such elements have been identified in research summary documents such as HECAT (discussed in the “TPP Evaluation Activities” section), and the TPPER, but applicants are not required to implement these approaches.¹¹⁵

Grantee Profile: Healthy Visions in Ohio

HHS awarded FY2023-FY2024 Sexual Risk Avoidance Education funding to Healthy Visions, a social services organization located in Cincinnati, OH. The organization implements four curricula: Real Essentials, Choosing the Best, Love Notes, and TYRO Rites of Passage. The program serves youth in grades 4-12 in school-based settings. The curricula focus on topics such as risk avoidance (such as delaying sex), setting goals, healthy relationships, communication skills, conflict resolution, stress management, and self-respect. Source: HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (SRAE) Program Grantee Profiles, February 11, 2022; and Healthy Visions, “Quick Look,” https://healthyvisions.org/quick-look/. Note: This report includes examples of grantees recently funded under the four teen pregnancy prevention programs. The grantees were selected by CRS based on information available on the HHS website or provided via correspondence with HHS. Collectively, the grantees described in the report are intended to represent all regions of the country and are included for illustrative purposes only.

115 HHS, ACF, ACYF, Sexual Risk Avoidance Education Program, HHS-2021-ACF-ACYF-SR-1927, 2021. HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD-SRAE), HHS-2024-ACF-ACYF-SR-0041, 2024.

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Appendix A. Federal Teen Pregnancy Prevention Programs

Table A-1. Federal T een Pregnancy Prevention Programs: Overview, Eligible Entities, and Funding

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

Authorizing law (and statutory citation, where applicable)

Initial authorizing law was the Consolidated Appropriations Act, 2010 (P.L. 111-117) and authority has continued under subsequent appropriation laws. The most recent appropriations law is Division D of the Further Consolidated Appropriations Act, 2024 (P.L. 118- 47).

Patient Protection and Affordable Care Act (ACA, P.L. 111-148), most recently reauthorized through December 31, 2024 under Division G of the Consolidated Appropriations Act, 2024 (CAA 2024, P.L. 118-42).

Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), most recently reauthorized through December 31, 2024 under Division G of the CAA 2024 (P.L. 118-42).

Initial authorizing law was the Consolidated Appropriations Act, 2016 (P.L. 114-113) and authority has continued under subsequent appropriation laws. The most recent appropriations law is Division D of the Further Consolidated Appropriations Act, 2024 (P.L. 118-47). HHS additionally cites its general authority to administer the program (42 U.S.C. §1310) in its program funding announcements.^b

Description The program funds grantees to replicate programs that have been proven effective in reducing teen pregnancy and behavioral risk factors underlying teenage pregnancy (Tier 1 grants); and to develop, test, and refine additional programs and strategies for preventing teenage pregnancy (Tier 2 grants).

The program funds states, insular areas, and other entities, under four components: State PREP, Competitive PREP, Tribal PREP, and Personal Responsibility Education Innovative Strategies (PREIS). “Personal responsibility education program” refers to a program that is (1) designed to educate adolescents on both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections (STIs), including HIV/AIDS; and (2) incorporate at least three of six adult preparatory subjects (healthy relationships, adolescent development, financial literacy, education and career success, parent-child communication, and healthy life skills).

The program funds states and insular areas (or other entities in a jurisdiction that did not apply for funds) to implement education exclusively on sexual risk avoidance, meaning voluntarily refraining from sexual activity. Sexual risk avoidance education must ensure that the “unambiguous and primary emphasis and context” for each of six sexual risk avoidance topics specified in the law is “a message to youth that normalizes the optimal health behavior of avoiding nonmarital sexual activity.” If any information is provided about contraception, it must be medically accurate and ensure that students understand that contraception reduces physical risk,

The program funds grantees to implement sexual risk avoidance education that teaches participants how to voluntarily refrain from nonmarital sexual activity and prevent other youth risk behaviors.

CRS-26

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

but does not eliminate risk. In addition, it may not include demonstration, simulation, or distribution of contraception.

Administering agency within the U.S. Department of Health and Human Services (HHS)

Office of Population Affairs (OPA) within the Office of the Assistant Secretary for Health (OASH).

Family and Youth Services Bureau (FYSB) within the Administration for Children and Families (ACF).

FYSB/ACF FYSB/ACF

Entities eligible to apply, and how funds are awarded

Eligible entities are specified in the program funding announcements. Eligible entities vary depending on the grant, but generally include nonprofit and for-profit organizations; small, minority, and women-owned businesses; state and local governments; universities and colleges; community- and faith-based organizations; hospitals; federally recognized or state-recognized American Indian and Alaska Native tribal governments; and other tribal entities (e.g., Alaska Native health corporations). Funds are awarded on a competitive basis.

As specified in the authorizing law, funds are awarded on a formula basis to states and insular areas under the State PREP program. Funds are allocated based on the proportion of children in each state between the ages of 10 and 19, relative to the total number of youth nationally. State PREP funds that would have been allocated to states that did not apply for them are competitively awarded under the Competitive PREP program. As listed in the program funding announcements, entities eligible to apply for the Competitive PREP program and PREIS generally have included state, territorial, or county governments; city or township governments; special district governments; independent, regional, and local school districts; public and state controlled institutions of higher education; federally recognized Native American tribal governments; public housing authorities/Indian housing authorities; Native American tribal organizations; nonprofit organizations; private institutions of higher education; for-profit organizations other than small

As specified in the authorizing law, all states and insular areas that receive State Maternal and Child Health (MCH) block grant funds in FY2018 through FY2025 are eligible to apply. HHS may competitively award FY2018 through FY2025 funds to one or more entities (not defined) within a state/insular area 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/insular area. Allotments are 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.

Eligible grantees are specified in the program funding announcements. They have included state, territorial, or county governments; city or township governments; special district governments; independent, regional, and local school districts; public and state controlled institutions of higher education; federally recognized Native American tribal governments; public housing authorities/Indian housing authorities; Native American tribal organizations; nonprofit organizations; private institutions of higher education; for-profit organizations other than small businesses; and small businesses. Funds are awarded on a competitive basis.

CRS-27

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

businesses; local affiliates of national organizations; and small businesses. Also as listed in the program funding announcement, 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.

Type of funding, year(s) of funding, and funding set-asides (where applicable)

Discretionary spending; funded through appropriations law. Funding is provided for FY2024 as of the cover date of this report. Up to 10% of appropriated funds can be used for training and technical assistance, outreach, and other program support. Of the remaining amount, 75% is to be used to replicate programs (Tier 1 grants) and 25% is to be used for developing, testing, and refining additional models (Tier 2 grants).

Mandatory spending; funded through authorizing law. Funding is authorized through December 31, 2024, as of the cover date of this report. The law provides $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. Most of the remaining PREP appropriation is allocated to states and insular areas via State PREP (with a minimum of $250,000 for each state allotment). Funding for states and insular areas that declined the State PREP grant is available to eligible entities under Competitive PREP.

Mandatory spending; funded through authorizing law. Funding is authorized through December 31, 2024, as of the cover date of this report.

Discretionary spending; funded through appropriations law. Funding is authorized for FY2024 as of the cover date of this report.

Cost sharing Not applicable. Not applicable. Not applicable. Not applicable.

Enacted federal funding from FY2010-FY2024^c

FY2010: $110.0 million FY2011: $104.8 million FY2012: $104.8 million FY2013: $98.3 million FY2014: $100.8 million FY2015: $101.0 million FY2016: $101.0 million FY2017: $100.8 million FY2018: $101.0 million

FY2010: $75.0 million FY2011: $75.0 million FY2012: $75.0 million FY2013: $71.2 million FY2014: $69.6 million FY2015: $75.0 million FY2016: $75.0 million FY2017: $69.8 million FY2018: $75.0 million

FY2010: $50.0 million FY2011: $50.0 million FY2012: $50.0 million FY2013: $47.5 million FY2014: $46.4 million FY2015: $50.0 million FY2016: $75.0 million FY2017: $69.8 million FY2018: $75.0 million

FY2010: Not funded FY2011: Not funded FY2012: $5.0 million FY2013: $4.7 million FY2014: $5.0 million FY2015: $5.0 million FY2016: $10.0 million FY2017: $15.0 million FY2018: $25.0 million

CRS-28

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

FY2019: $101.0 million FY2020: $101.0 million FY2021: $101.0 million FY2022: $101.0 million FY2023: $101.0 million FY2024: $101.0 million

FY2019: $75.0 million FY2020: $75.0 million FY2021: $75.0 million FY2022: $70.7 million FY2023: $70.7 million FY2024: $75.0 million

FY2019: $75.0 million FY2020: $75.0 million FY2021: $75.0 million FY2022: $70.7 million FY2023: $70.7 million FY2024: $75.0 million

FY2019: $35.0 million FY2020: $35.0 million FY2021: $35.0 million FY2022: $35.0 million FY2023: $35.0 million FY2024: $35.0 million

Use of evidence-based interventions

Per the FY2024 appropriations law (P.L. 118-47), “75 percent [of funds] shall be for replicating programs that have been proven effective through rigorous evaluation to reduce teenage pregnancy, behavioral risk factors underlying teenage pregnancy, or other associated risk factors, and 25 percent shall be available for research and demonstration grants to develop, replicate, refine, and test additional models and innovative strategies for preventing teenage pregnancy.” Previously, Tier 1 applicants have been referred in the program funding announcement to the Teen Pregnancy Prevention Evidence Review (TPPER) for information on evidence-based models.

State PREP jurisdictions and Competitive PREP grantees must replicate evidence-based, effective programs or substantially incorporate elements of effective programs that have been proven on the basis of rigorous scientific research to change behavior. The grant announcements have referred applicants to the TPPER for information on such programs, though other models can be implemented that meet the requirement of being rigorously evaluated. The grant announcements have specified that Tribal PREP grantees are to replicate evidence-based effective programs; substantially incorporate elements of effective programs to the extent possible; or include promising practices within the American Indian/Alaska Native (AI/AN) communities. There are no pregnancy prevention programs specifically for AI/AN communities in the TPP Evidence Review. The grant announcements have specified that PREIS grantees are to use innovative strategies, with promising evidence of effectiveness or impact, but which must not have been rigorously evaluated. Therefore, the evidence-

A state/insular area or other entity receiving funding under the Sexual Risk Avoidance Education program may use up to 20% of such allotment to build the evidence base for sexual risk avoidance 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. As specified in the most recent funding announcements, 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

Per the FY2024 appropriations law (P.L. 118-47), grantees must “implement an evidence-based approach integrating research findings with practical implementation that aligns with the needs and desired outcomes for the intended audience.” As specified in the funding announcements, 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 demonstrates 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 HECAT.^d

CRS-29

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

based programs identified in the TPPER are not eligible interventions for this specific program.

research summary documents such as HECAT.^d

Target population The TPP grants generally do not specify a certain target population (either in the authorizing statute or program funding announcement), with the exception of the Tier 2 Innovation Network grants. The Innovation Network grants are to target one of several key priority areas: juvenile justice, foster care/child welfare, caregivers, expectant and parenting youth, youth with disabilities, youth access to and experience with sexual health care, and youth engagement. The other grants focus on youth in geographic areas with the greatest need (Tier 1) and addressing disparities in teen pregnancy rates using innovative approaches (Tier 2 Rigorous Evaluation).

The authorizing statute specifies that jurisdictions and grantees are generally to provide services to youth ages 10 through 19, with a focus on high-risk or vulnerable youth. This includes youth in or aging out of foster care, homeless youth, youth with HIV/AIDS, pregnant and parenting women under 21 years of age and their partners, and young people residing in areas with high birth rates for youth. Tribal PREP grantees must serve American Indian/Alaska Native (AI/AN) youth age 10 through 19 or pregnant and parenting women age 21 and under. Per the program funding announcement, Tribal PREP grantees may serve AI/AN youth who have the additional risk factors previously discussed (and other risk factors such as having experienced sex trafficking).

Youth ages 10 through 19. Per the program funding announcement, grantees are to target youth (defined as ages 10- 19) populations that are at risk for nonmarital sexual activity and other risk behaviors. These at-risk populations are not specifically defined.

Number of youth participants (most recent fiscal year data available)

Grantees served 140,935 youth in FY2023.

Grantees served 87,035 youth in FY2022.

Grantees served 240,055 youth in FY2023.

HHS estimates that approximately 54,000 youth participated in FY2019.

CRS-30

Program Feature

Teen Pregnancy Prevention

(TPP) Program

Personal Responsibility Education

Program

Title V Sexual Risk Avoidance

Education Program^a

GD Sexual Risk Avoidance

Education Program

Setting for services (selected examples)

Schools Out-of-school programs Clinics Juvenile justice centers Faith-based organizations Out-of-home care (foster care) Runaway/homeless youth centers

Schools (in school or after school) Community-based organizations Foster care settings Juvenile detention centers Clinics Outpatient and residential treatment facilities for youth with social, emotional, or substance abuse disorders Other settings

(Under the prior Title V Abstinence Education Grant program, school was the primary setting) Schools (in school or after school) Mentoring programs School rallies and assemblies

Schools Community-based organizations Foster care organizations Juvenile detention centers Homeless shelters

Sources: Authorizing and appropriation laws (referenced in table); Congressional Research Service (CRS) correspondence with the U.S. Department of Health and Human Services (HHS), Administration for Children and Families (ACF), Office of the Assistant Secretary for Health (OASH), Office of Population Affairs (OPA, formerly Office of Adolescent Health, OAH) December 2019; HHS, Fiscal Year 2025 Justification of Estimates for Appropriations Committees for General Departmental Management, p. 91; and HHS, Fiscal Year 2025 Justification of Estimates for Appropriations Committee for Administration for Children and Families, pp. 272-273; and as referenced below.

Teen Pregnancy Prevention (TPP) Program: (1) HHS, OASH, OPA, Advancing Equity in Adolescent Health through Evidence-Based Teen Pregnancy Prevention Programs and Services, AH-TP1-23-001, 2023; (2) HHS, OAH, OPA, “Teen Pregnancy Prevention Tier 2 Adolescent Sexual Health Innovation Hubs” AH-TP2-23-002, 2023; and (3) HHS, OAH, OPA, “Teen Pregnancy Prevention Tier 2 Rigorous Evaluation Cooperative Agreements,” AH-TP2-23-001, 2023.

Personal Responsibility Education Program (PREP): (1) HHS, ACF, FYSB, State Personal Responsibility Education Program (PREP), HHS-2016-ACF-ACYF-PREP-1138, 2016; (2) HHS, ACF, FYSB, FY 2024 Competitive Personal Responsibility Education Program (PREP), HHS-2024-ACF-ACYF-AK-0032, 2024; (3) HHS, ACF, FYSB, Tribal Personal Responsibility Education Program for Teen Pregnancy Prevention, Funding Opportunity Announcement and Instruction, HHS-2021-ACF-ACYF-AT-1922, 2021; and (4) HHS, ACF, FYSB, Personal Responsibility Education Program Innovative Strategies (PREIS), Funding Opportunity Announcement and Instruction, HHS-2021-ACF-ACYF-AP- 1928, 2021.

Title V Sexual Risk Avoidance Education Program: (1) HHS, ACF, FYSB, Standing Notice of Funding Opportunity for Title V State Sexual Risk Avoidance Education, HHS-2024-ACF-ACYF-SRAE-0044, 2024; and (2) HHS, ACF, FYSB, Title V Competitive Sexual Risk Avoidance Education (SRAE), HHS-2024-ACF-ACYF-SRAE-0040, 2024.

Sexual Risk Avoidance Education Program: (1) HHS, ACF, ACYF, Sexual Risk Avoidance Education Program, Funding Opportunity Announcement, HHS-2021- ACF-ACYF-SR-1927, 2021; and (2) HHS, ACF, FYSB, General Departmental Sexual Risk Avoidance Education (GD-SRAE), HHS-2024-ACF-ACYF-SR-0041, 2024. a. The Title Sexual Risk Avoidance Education Program was known as the Title V Abstinence Education Grant program through FY2017.

b. This law provides authority to HHS to make grants to states and other public organizations for paying part of the cost of research and demonstration projects, such as those relating to the prevention and reduction of dependency, among other related topics.

c. See HHS, Fiscal Years 2013-2025 Justifications of Estimates for Appropriations Committee for Administration for Children and Families (PREP, Title V Sexual Risk Avoidance Education program, and Sexual Risk Avoidance Education program) and HHS, Fiscal Years 2013-2025 Justifications of Estimates for Appropriations Committee for General Departmental Management (Sexual Risk Avoidance Education program and TPP). These appropriations include sequestration for all four TPP programs in FY2013, and sequestration for PREP and Title V SRAE (or its predecessor program, the Title V Abstinence Education Grant program) only in

CRS-31

FY2014, FY2017, FY2022, and FY2023. The Title V Abstinence Education Grant program is the only program to have received funding prior to FY2010. In each of FY1998 through FY2009, the program received $50 million annually.

d. The HECAT is an assessment tool to help schools and other entities identify curricula for health education courses and analyze the acceptability and appropriateness of these curricula, among other objectives. This tool addresses multiple health topics, including sexual health. Another tool cited in prior grant announcements, SMARTool, was developed by the Center for Relationship Education, a nonprofit organization, in partnership with the CDC. SMARTool is a program guide for use by schools and other entities interested in sexual risk avoidance education, and it identifies nine protective factors that help prevent sexual risk behaviors in youth.

Adolescent Pregnancy: Federal Prevention Programs

Congressional Research Service 32

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

Table B-1. Federal T een Pregnancy Prevention Programs: Grantees by Jurisdiction

(The table may omit grantees that are supported with program funding from prior years with project

periods that include the fiscal year referenced in the column.

Some TPP grantees and PREP grantees serve youth in multiple states.)

State or

Insular Area

Teen Pregnancy

Prevention (TPP)

Grantees

in Jurisdiction

(FY2023)

Type(s) of Personal

Responsibility

Education Program

(PREP)

Grants in

Jurisdiction

(FY2022)

Title V Sexual Risk

Avoidance

Education (SRAE)

Grant Funding

(FY2023)

GD Sexual Risk

Avoidance

Education

Grantees in

Jurisdiction

(FY2023)

Alabama No State PREP State Title V SRAE No

Alaska No State PREP

Tribal PREP No No

Arizona Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Arkansas No State PREP State Title V SRAE Yes

California Tier 1 (FY2023-FY2028) Tier 2 (FY2023-FY2028)

State PREP

PREIS

Competitive Title V

SRAE Yes

Colorado No State PREP State Title V SRAE Yes

Connecticut Tier 1 (FY2023-FY2028) State PREP Competitive Title V

SRAE No

Delaware No State PREP Competitive Title V

SRAE No

District of Columbia Tier 2 (FY2023-FY2028) State PREP

PREIS

Competitive Title V

SRAE No

Florida Tier 1 (FY2023-FY2028) Competitive PREP

PREIS

State Title V SRAE

Yes

Georgia Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Hawaii No State PREP Competitive Title V

SRAE Yes

Idaho No State PREP State Title V SRAE No

Illinois No State PREP Competitive Title V

SRAE Yes

Indiana No Competitive PREP

PREIS State Title V SRAE Yes

Iowa Tier 1 (FY2023-FY2028) State PREP State Title V SRAE No

Kansas No Competitive PREP Competitive Title V

SRAE No

Kentucky Tier 1 (FY2021-FY2023) State PREP State Title V SRAE Yes

Adolescent Pregnancy: Federal Prevention Programs

Congressional Research Service 33

State or

Insular Area

Teen Pregnancy

Prevention (TPP)

Grantees

in Jurisdiction

(FY2023)

Type(s) of Personal

Responsibility

Education Program

(PREP)

Grants in

Jurisdiction

(FY2022)

Title V Sexual Risk

Avoidance

Education (SRAE)

Grant Funding

(FY2023)

GD Sexual Risk

Avoidance

Education

Grantees in

Jurisdiction

(FY2023)

Louisiana Tier 2 (FY2023-FY2028) State PREP

PREIS State Title V SRAE Yes

Maine No State PREP Competitive Title V

SRAE No

Maryland Tier 1 (FY2023-FY2028) Tier 2 (FY2023-FY2028)

State PREP

PREIS State Title V SRAE No

Massachusetts Tier 2 (FY2023-FY2028) State PREP State Title V SRAE No

Michigan Tier 1 (FY2023-FY2028) State PREP

PREIS State Title V SRAE Yes

Minnesota Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Mississippi Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Missouri Tier 1 (FY2023-FY2028) State PREP State Title V SRAE

Yes

Montana Tier 1 (FY2023-FY2028) State PREP

Tribal PREP State Title V SRAE No

Nebraska No State PREP State Title V SRAE No

Nevada No State PREP State Title V SRAE No

New Hampshire^a No State PREP Competitive Title V

SRAE No

New Jersey Tier 2 (FY2023-FY2028) State PREP

PREIS State Title V SRAE Yes

New Mexico^b Tier 1 (FY2023-FY2028) State PREP State Title V SRAE No

New York Tier 1 (FY2023-FY2028) Tier 2 (FY2023-FY2028) State PREP State Title V SRAE

Yes

North Carolina Tier 1 (FY2023-2028)

Tier 2 (FY2023-FY2028 State PREP State Title V SRAE No

North Dakota No Competitive PREP Competitive Title V

SRAE No

Ohio No State PREP State Title V SRAE Yes

Oklahoma Tier 1 (FY2023-2028) State PREP

Tribal PREP State Title V SRAE Yes

Oregon No State PREP

Tribal PREP State Title V SRAE Yes

Pennsylvania Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Rhode Island Tier 1 (FY2023-FY2028) State PREP No No

South Carolina Tier 1 (FY2023-FY2028) State PREP State Title V SRAE Yes

Adolescent Pregnancy: Federal Prevention Programs

Congressional Research Service 34

State or

Insular Area

Teen Pregnancy

Prevention (TPP)

Grantees

in Jurisdiction

(FY2023)

Type(s) of Personal

Responsibility

Education Program

(PREP)

Grants in

Jurisdiction

(FY2022)

Title V Sexual Risk

Avoidance

Education (SRAE)

Grant Funding

(FY2023)

GD Sexual Risk

Avoidance

Education

Grantees in

Jurisdiction

(FY2023)

South Dakota Tier 1 (FY2023-FY2028) State PREP

Tribal PREP State Title V SRAE Yes

Tennessee No State PREP

PREIS State Title V SRAE Yes

Texas Tier 1 (FY2023-FY2028) Tier 2 (FY2023-FY2028)

Competitive PREP

PREIS State Title V SRAE Yes

Utah Tier 1 (FY2023-FY2028) State PREP State Title V SRAE No

Vermont No State PREP No Yes

Virginia No Competitive PREP State Title V SRAE No

Washington Tier 1 (FY2023-FY2028) Tier 2 (FY2023-FY2028) State PREP No No

West Virginia Tier 1 (FY2023-2028) State PREP State Title V SRAE Yes

Wisconsin Tier 1 (FY2023-FY2028) State PREP

Tribal PREP State Title V SRAE No

Wyoming No State PREP Competitive Title V

SRAE Yes

American Samoa No No No Yes

Federated States of Micronesia

No State PREP State Title V SRAE No

Guam No State PREP Competitive Title V

SRAE Yes

Marshall Islands No No No

Northern Mariana Islands No State PREP No No

Republic of Palau No State PREP No No

Puerto Rico Tier 1 (FY2023-FY2028) State PREP State Title V SRAE No

U.S. Virgin Islands No State PREP Competitive Title V

SRAE No

Source: Congressional Research Service (CRS), based on U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Health (OASH), Office of Adolescent Health (OAH), Current Teen Pregnancy Prevention (TPP) Program Grantees,” https://www.hhs.gov/ash/oah/grant-programs/teen-pregnancy- prevention-program-tpp/current-grantees/index.html. See also HHS, Administration for Children and Families (ACF), Family and Youth Services Bureau (FYSB), State Personal Responsibility Education Program (PREP) Grantees FY2022, December 31, 2022; Competitive Personal Responsibility Education Program (PREP) Awards FY2022, December 30, 2022; Personal Responsibility Education Innovative Strategies (PREIS) Program Grantees FY2022,

Adolescent Pregnancy: Federal Prevention Programs

Congressional Research Service R45183 · VERSION 11 · UPDATED 35

December 30, 2022; Tribal Personal Responsibility Education Program (PREP) Grantees FY2022, December 30, 2022; Title V State Sexual Risk Avoidance Education (SRAE) Grantees FY2022, December 30, 2022; Title V Competitive Sexual Risk Avoidance Education (SRAE) Grantees FY2023, February 5, 2024; and General Departmental Sexual Risk Avoidance Education (GD SRAE) Grantees FY2023, February 8, 2024; HHS, General Departmental Management, Fiscal Year 2023 Justification of Estimates for Appropriations Committee, p. 92; and HHS, Administration for Children and Families, Fiscal Year 2023 Justification of Estimates for Appropriations Committee, pp. 296-297. a. Although New Hampshire applied for State PREP funding in FY2021 and FY2022, it opted to discontinue receiving State PREP funds for FY2023. As a consequence, for FY2023, entities within New Hampshire were eligible to apply for competitive PREP funding; two such organizations were awarded competitive funds (HHS, ACF, FYSB, “Competitive Personal Responsibility Education Program (PREP) Grantees FY2023,” February 5, 2024, https://www.acf.hhs.gov/fysb/grant-funding/fysb/competitive-personal-responsibility- education-program-prep-grantees).

b. The project period for the third cohort of eight Tribal PREP grantees (in seven states) that was awarded in FY2021 is five years. However, the FY2021 Tribal PREP grant for Tewa Women United, was not continued after FY2021 (HHS, ACF, FYSB, Tribal Personal Responsibility Education Program (PREP) Grantees FY2021, December 30, 2022, https://www.acf.hhs.gov/fysb/grant-funding/tribal-personal-responsibility-education- program-prep-grantees).

Author Information

Jessica Tollestrup Specialist in Social Policy

Acknowledgments

This report was originally authored by Adrienne Fernandes-Alcantara, former CRS Specialist in Social Policy. The most recent edition of the report received invaluable review by Alexandria K. Mickler, CRS Analyst in Health Policy, and research support from Sylvia Bryan, CRS Research Assistant.

Disclaimer

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