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Service Delivery Innovation Profile

Comprehensive Evidence-Based Adolescent Pregnancy Prevention Program Cuts Teen Pregnancies in Half


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Snapshot

Summary

The Children's Aid Society - Carrera Adolescent Pregnancy Prevention Program, an evidence-based, primary adolescent pregnancy prevention program, takes a long-term "above the waist" approach to pregnancy prevention by addressing all aspects of teens' lives from middle school through high school and beyond. The program helps teens plan and create productive futures by combining daily academic enrichment, weekly exposure to the work world, weekly mental health services (and as needed), weekly family life and sexuality education, ongoing exposure to lifetime individual sports and self-expression, and comprehensive medical and dental services. The program is implemented both as an after-school program and as an integrated school program. The after-school version is the only 3-year fully evaluated teenage pregnancy prevention program with statistically proven effectiveness in the country yielding a 50-percent reduction in birth rates in communities served. Additional results include increased use of primary care whereas reducing reliance on the emergency department, improved academic performance and work readiness, and increased high school graduation and college enrollment.

Evidence Rating (What is this?)

Strong: The evidence comes from a 3-year, randomized controlled trial that included 941 teens between the ages of 13 and 15 years who participated in an after-school program for 12 hours a month for 3 years at 12 different sites (6 in New York City). Outcomes were measured through annual self-reported surveys, sexuality knowledge questionnaires, and interviews conducted by the research team. Pregnancy and birth outcomes were confirmed through a review of medical records.

Date First Implemented

1984
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Patient Population

Adolescents 13–18 years are included in the evaluation; the model is implemented for ages 10–18.Age > Adolescent (13-18 years)end pp

Problem Addressed

Even after experiencing declines in teenage pregnancies since the 1990s, the United States continues to have the highest rates of teenage pregnancy and births among western industrialized nations,1 which leads to substantial economic and social costs. 
  • High rates of teenage pregnancy and births: In 2008, 750,000 girls in the United States younger than 20 years became pregnant (equivalent to 67.8 pregnancies per 1,000 girls in that age range), with the majority of those teenagers giving birth. (The nationwide birth rate for girls under 20 years was 40.2 births per 1,000 in 2008.)2 In New York State in 2011, teenage girls (ages 15 to 19) gave birth to 13,718 babies,3 a rate of 21.1 births per 1,000 teenage girls.4
  • Leading to high economic and social costs: Across the United States, the annual cost associated with a child born to a teenage mother averages $1,682; in New York State, these costs are almost 13 times higher (averaging $21,482 per child). Society often ends up bearing these expenses (e.g., for medical care, housing, food, etc.); for example, in 2010, teenage childbearing cost taxpayers $9.4 billion.5 Teenage pregnancy and childbirth also create significant social costs, as teen mothers are more likely to drop out of school, remain unmarried, and live in poverty than females who delay childbearing until after age 20 years.5

What They Did

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Description of the Innovative Activity

The Children's Aid Society - Carrera Adolescent Pregnancy Prevention Program is a long-term comprehensive youth development program for low-income boys and girls beginning in middle school and continuing through high school and beyond. Students receive daily academic assistance, job skills training, family life and sex education, self-expression, and lifetime sports, coupled with medical, dental, and mental health services. The program seeks to address all aspects of young people's lives, viewing teens as "at promise" rather than being "at risk" and uses a philosophy that emphasizes gentleness, generosity, and forgiveness. The program can be delivered either as an afterschool program in local community centers or within schools during normal or extended hours. The program's seven integrated, scientifically accurate, and age-appropriate components described below work together to foster youth development, build self-esteem, and reduce teenage pregnancies:
  • Afterschool or integrated school model: The program serves young people from low-income communities beginning in middle school and continuing through high school graduation and beyond. Services are available between 1 and 4 hours a day, 6 days a week (including Saturdays), 50 weeks per year. In the integrated school model, class time for the program components is provided through advisory and guidance periods, resource time, and other available and/or extended school day hours.
  • Education: Educational professionals guide students toward academic success by reviewing past and current test scores with teachers and then creating an individualized academic plan, as needed. Students receive daily one-on-one or small group tutoring. This includes homework help, remediation, enrichment with trained teachers, PSAT and SAT preparation, and field trips to colleges. For the in-school model, student's grades and standardized test scores are entered into a program-wide computer system; this database helps to track progress and guide planning and counseling efforts. 
  • Employment assistance, with built-in incentives: Weekly Job Club helps students learn about the world of employment and money, including how to complete job applications, interview for a position, explore career options, and open a bank account. Employment staff with bachelor or masters-level degrees and business experience run the Job Club. Students receive a monthly stipend of $3 for every hour they participate (typically 4 to 5 hours per month) in the Job Club. The money earned is deposited in accounts set up at "kid-friendly" banks that have relationships with the program. As part of this effort, many teens secure summer or part-time jobs. 
  • Family life and sexuality education classes: Master's-level professionals (often with national sexuality association certifications) teach age-appropriate, weekly, holistic sexuality education classes. The classes emphasize the importance of abstinence, increasing sexual literacy, and how to build healthy relationships. Parents are invited to attend a separate set of classes where they learn to communicate effectively with their children about sexuality issues.
  • Self-expression: Teens discover talents and build self-confidence by taking part in weekly self-expression activities, such as music, dance, writing, and drama taught by theater and arts professionals.
  • Lifetime sports and physical activities: Students learn self-discipline and impulse control by participating in an individualized sports component in which a fitness professional teaches sports such as golf, squash, swimming, and bowling on a weekly basis at nearby community centers.
  • Medical and dental services: Through partnerships with local providers, program participants have access to comprehensive medical/reproductive health and dental services with the parents' consent. This includes free contraception and testing for sexually transmitted infections. Program staff can schedule and accompany teens to their medical appointments. 
  • Mental health services: Certified social workers employed by the program lead weekly socialization groups (called Power Group) and provide individual counseling, case-management, and crisis-intervention services as needed.

Context of the Innovation

Children's Aid Society is a nonprofit organization in New York City that seeks to fill the gap between what children have and what they need to thrive. In the 1970s, the organization began providing teenage sex education workshops in four impoverished neighborhoods in New York. Based on this experience, the organization's leaders believed they needed to do more to prevent teenage pregnancies. Dr. Michael Carrera, the director of Children's Aid Society's teenage pregnancy prevention program, found that sex education alone did not change teens' risky behaviors. In his view, making the message "stick" required addressing all aspects of teens' lives, including family, education, mental health, physical activity, employment, and health care. To that end, he launched this new, expanded holistic program in 1984 in New York City with 27 teenagers and a few parents.

Did It Work?

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Results

The after-school model of this program has enhanced knowledge of sexuality; reduced risky sexual behaviors, teen pregnancies, and teen births; increased use of primary care while reducing reliance on the emergency department (ED); and improved academic performance and work readiness. Positive feedback from the integrated school model is also promising. The key program results are described below:
  • Results from after-school model:
    • Greater knowledge of sexuality: Program participants exhibited greater gains in knowledge about sexuality than did a control group of nonparticipants.
    • Less risky sexual behaviors: Participants were less likely to have sexual intercourse and more likely to use birth control. Among program participants, 15 percent (40 out of 268) reported having vaginal intercourse in the 3 years they participated, compared to 18 percent (45 out of 251) in the control group. Program participants were also more than twice as likely than members of the control group (22 vs. 9 percent) to use birth control (Depo-Provera) during their most recent intercourse.6
    • Significantly fewer pregnancies and births: Only 15 percent of program participants (40 out of 268) have ever been pregnant, compared to 25 percent of the control group (63 out of 250). Program participants were only half as likely to have ever given birth (50 percent reduction in births), with 5 percent of participants having done so versus 10 percent of the control group.6
    • More primary care, less ED use: During their 3 years in the program, roughly 90 percent of participants received health care services outside of the ED, slightly above the 82 percent in the control group who had done so. Program participants were more likely to use a private physician for medical care to have had a hepatitis B vaccine (83 vs. 77 percent) and to have had a reproductive health appointment (86 vs. 78 percent).6 
    • More academic success: At a 7-year followup with participants from six New York City locations, participants were 30 percent more likely than members of the control group to have graduated high school or obtained a general education diploma or GED (86 vs. 66 percent) and 37 percent more likely to be enrolled in college (63 vs. 46 percent). Participants also had higher PSAT scores and were more likely to have made a college visit (64 vs. 49 percent).6
    • Enhanced work readiness: Also at the 7-year followup, roughly 9 in 10 participants (89 percent) had work experience, compared with 77 percent of those in the control group. Participants were also more likely to have bank accounts (59 vs. 32 percent) and use the Internet (81 vs. 75 percent) and e-mail (58 vs. 49 percent).6
  • Positive feedback from integrated school model: Interviews with principals from four New York City schools suggest that the Integrated School program has led to calmer classrooms, better student behavior, a shift in school culture to focus more on youth development, earlier identification of student needs, faster interventions in crisis situations, better communication with parents, a stronger sense of belonging and school spirit, and increased teaching time.7,8

Evidence Rating (What is this?)

Strong: The evidence comes from a 3-year, randomized controlled trial that included 941 teens between the ages of 13 and 15 years who participated in an after-school program for 12 hours a month for 3 years at 12 different sites (6 in New York City). Outcomes were measured through annual self-reported surveys, sexuality knowledge questionnaires, and interviews conducted by the research team. Pregnancy and birth outcomes were confirmed through a review of medical records.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Soliciting input from students: The program developer asked teens about their interests, concerns, and life issues to get a better sense of how to effectively help them to prevent pregnancy and to fulfill their goals for a positive and productive future.
  • Developing program curriculum: The program developer created a comprehensive curriculum that covers seven components that touch on all aspects of teens' lives, as described earlier. Along with this curriculum, leaders implemented a program philosophy that emphasizes the creation of a gentle, generous, and forgiving environment.
  • Raising funds: The program developer raised funds from local and national foundations and corporations and used public funds, if available. Partnership sites are responsible for their own fundraising to support ongoing program implementation.
  • Hiring and training staff: Program leaders developed a staffing strategy that included hiring credentialed professional staff from diverse backgrounds (e.g., social work, employment, teaching, sports) and training them in how to deliver the seven program components.
  • Developing partnerships in the afterschool and in-school environment: The program developed partnerships with schools and community-based organizations in low-income New York City neighborhoods and across the United States. The Children's Aid Society - Carrera has partnered with public and charter schools to implement the Integrated School Model.
  • Replicating and evaluating program: To ensure fidelity to the program model, developers designed and implemented a blueprint for the successful launch and maintenance of program replication. Trained staff were sent to help community-based organizations in New York City and across the country to replicate the program. By 2001, the after-school program had been implemented and evaluated in 12 sites.

Resources Used and Skills Needed

  • Staffing: The Children's Aid Society - Carrera employs more than 100 (95 full-time and 20 part-time) staff to deliver the program components at locations in New York City as well as to provide support to partnership sites throughout the United States. Staff include licensed social workers, certified teachers, master's-level family life and sexuality professionals (some certified by national sexuality organizations), business professionals, art and sports professionals, and medical/dental advocates (with a bachelor or master's degree). At the individual site level, program staff are typically hired in May or June and then spend 2 months in training so they can start work in September. Each implementing site also needs a full-time coordinator and community organizer to oversee day-to-day program activities.
  • Costs: The after-school version of the program costs approximately $4,000 per child per year for the first year and an average of $2,500 per year over the course of the entire program (can vary based on a number of factors). The in-school version benefits from economies of scale generated by taking on additional classes of students each year; typical costs for a group of 100 students average between $3,500 and $3,700 for the first year with costs reducing to $2,300 to $2,500 by year 3 and significant declines thereafter.
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Funding Sources

The Children's Aid Society - Carrera Program was primarily privately funded during its 30-year history. Major donors have included: The Robin Hood Foundation, The Edna McConnell Clark Foundations, Atlantic Philanthropies, JPB Foundation, Charles Stewart Mott Foundation, Stern Family Foundation, Stavros Niarchos Foundation, and many more. Since 2010, the Children's Aid Society - Carrera has received funding through the White House Social Innovation Fund and partnership sites have received funding through the U.S. Department of Health and Human Services Office of Adolescent Health. The sponsoring organizations are responsible for raising funds to sustain the program's replications.end fs

Tools and Other Resources

Sex, The Facts, The Acts and Your Feelings
Michael A. Carrera, EdD

Sexual Health for Men: Your A to Z Guide 
Michael A. Carrera, EdD

Sexual Health for Women: Your A to Z Guide 
Michael A. Carrera, EdD

The Language of Sex 
Michael A. Carrera, EdD
A high school and college resource book

Working with Teens When the Topic Is Hope - Lessons for Lifeguards 
Michael A. Carrera, EdD

Adoption Considerations

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Getting Started with This Innovation

  • Identify target community or school with progressive leader: Find a school or community-based organization in a low-income neighborhood where gaps exist between what children have and what they need to thrive. Communities with high teen pregnancy rates and other social challenges will be most likely to benefit. Sponsoring organizations or schools interested in replicating a Children's Aid Society - Carrera program should have leadership that is aligned with the program's philosophy of viewing young people as "at promise" and who recognize that all children thrive in gentle, generous, and forgiving environments. A willingness to adjust hours for program activities is also necessary. If the adopting organization does not have its own source of sustainable funding, consider contacting a local "sponsoring" agency (e.g., as a community center) and help that agency apply for grants to fund the program.
  • Launching a Carrera Replication: Those interested in adopting the program should contact the national training center which provides ongoing technical assistance, training, and support needed to launch and maintain the program. Program leaders in the adopting organization spend 6 to 8 months working with the leadership and management team from the national training center to establish a program workplan and timeline that covers the following areas:
    • Hiring and training staff: The sponsoring agency hires its own staff to run the program. National training center personnel travel to the site location to screen potential hires and assist with program launch and implementation. Staff complete 2 months of training led by national training center personnel on the program philosophy and curriculum. The national training center staff continue to provide ongoing fidelity management to all sites.
    • Arranging for medical and dental services and coverage: Work with the national training center to identify and approach local medical providers and/or other community-based organizations to secure access to no cost comprehensive medical and dental services. To the extent possible, raise funds to cover specialty services not covered under typical insurance policies, such as glasses, braces, and skin care.
    • Other preparations: Work with the national training center to develop a plan for recruiting participants, preparing the program site, planning program activities, and evaluating the program's performance over time.
    • Fidelity management/quality control: To ensure fidelity to the program model locally and nationally, Children's Aid Society - Carrera works with partner agencies to deliver ongoing technical assistance, support, and general program oversight from the national training center in New York and/or locally staffed Regional Implementation Centers. This support includes the provision of preservice and ongoing professional development for local program staff. To ensure a seamless professional development process, staff also participate in monthly "maintenance" training and receive supervision and technical assistance from regional implementation managers on an as-needed basis (typically several times a week initially).

Sustaining This Innovation

  • For long-term sustainability, consider implementing the program in public domain: Implementing the program in a public or charter school puts the program in the "public domain," thus making it easier to form public-private partnerships and to apply for public subsidies.
  • Develop a fundraising and sustainability strategy: To ensure long-term survival of the program, develop a strategy for raising funds and maintaining the program over time.
  • Consider benefits of economies of scale: The inschool model may lead to lower per-student costs, because this approach virtually guarantees high participation rates, as children take part in the program from sixth grade through high school graduation. 
  • Be patient: There are no quick fixes to preventing teen pregnancies. Rather, programs must address all major aspects of the teen's lives over a long period of time. Young people need to hear repeated messages—over the course of days, months, and years—about core values, how to take care of themselves, and how to prepare for the future.
  • Track and share data on program impact: Monitor outcomes and share evidence documenting the program's positive benefits to potential donors, policy makers, government officials, and other interested stakeholders. Would-be funders will use this information to make funding decisions.

Spreading This Innovation

  • The in-school model is currently being used in the following New York City locations: the Bronx, Brooklyn, Central Harlem, and Washington Heights. This program is also being replicated in Washington, DC; Flint, MI; Tulsa, OK; and Milwaukee, WI.
  • The after-school program is being used in the following New York City locations: the Bronx, Brooklyn, Central Harlem, and the Lower East Side. This model is also being replicated in Connecticut, Delaware, Florida, Georgia, Illinois, Michigan, New Jersey, New Mexico, and West Virginia.
  • More information on these programs is available at: http://stopteenpregnancy.childrensaidsociety.org/about-us.

Additional Considerations

  • As the only initiative in the United States targeting teenage pregnancy that has been fully evaluated and shown to lead to statistically significant improvements, this program has earned "top-tier" designation by the Coalition for Evidence-Based Policy. An evidence summary of the program from the Coalition for Evidence-Based Policy is available at http://toptierevidence.org/wordpress/?page_id=172.

More Information

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Contact the Innovator

Michael A. Carrera, EdD
Vice President, Adolescence Division, Children's Aid Society
Director, Carrera Adolescent Pregnancy Prevention Program
350 East 88th Street
New York, NY 10128
Phone: (212) 876-9716
Fax: (212) 876-1482
E-mail: michaelc@childrensaidsociety.org

Innovator Disclosures

Dr. Carrera has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Carrera Adolescent Pregnancy Prevention Program. Available at: http://stopteenpregnancy.childrensaidsociety.org/.

Carrera Adolescent Pregnancy Prevention Program Components. Available at: http://stopteenpregnancy.childrensaidsociety.org/our-program.

Kristof N. “Gifts That Reflect the Spirit of the Season,” The New York Times: 11/30/13. Available at: http://www.nytimes.com/2013/12/01/opinion/sunday/kristof-gifts-that-reflect-the-spirit-of-the-season.html?partner=rss&emc=rss&_r=0.

Proven Sex-Ed Programs Get a Boost from Obama. Available at: http://www.npr.org/templates/story/story.php?storyId=127514185

The Children's Aid Society. Available at: http://www.childrensaidsociety.org/.

The National Campaign to Prevent Teen and Unplanned Pregnancy. Available at: http://www.thenationalcampaign.org/.

Footnotes

1 Demographic Yearbook 2012. New York: United Nations. Available at: http://unstats.un.org/unsd/demographic/products/dyb/dyb2012.htm.
2 Kost K, Henshaw S. U.S. Teenage Pregnancies, Births and Abortions, 2008: National Trends by Race and Ethnicity, 2012. Available at: http://www.guttmacher.org/pubs/USTPtrends08.pdf.
3 Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats: Birth Data Files. Available at: http://www.cdc.gov/nchs/vitalstats.htm.
4 Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final Data for 2011. National Vital Statistics Reports. 2013;62(1). Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf.
5 Economic data via “Counting It Up: The Public Costs of Teen Childbearing” Available at: http://www.thenationalcampaign.org/costs/default.aspx.
6 Philliber S, Kaye J, Herrling S. The National Evaluation of the Children's Aid Society Carrera-Model Program to Prevent Teen Pregnancy, May 2001. Accord, NY: Philliber Research Associates.
7 Brigham RA, Nahas J. Early Evaluation to Inform Expansion of a Teen Pregnancy Prevention Program. The Evaluation Exchange. 2010;11(1):15-22. Available at: http://www.hfrp.org/evaluation/the-evaluation-exchange/issue-archive/current-issue-scaling-impact
/early-evaluation-to-inform-expansion-of-a-teen-pregnancy-prevention-program
.
8 Brigham RA, Nahas J. Children's Aid Society/Carrera Integrated School Model: Documentation of early implementation in four schools. Cambridge, MA: Brigham Nahas Research Associates; 2008.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 08, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 02, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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